Valvular Disorders 2 Flashcards
What are the 2 types of valve disorders?
Regurgitation and stenosis
What are the 6 clinical classification categories of valvular heart disease?
- Stage A: at risk for valvular heart disease
- Stage B: mild/moderate progressive valvular heart disease but asymptomatic
- Stage C severe valvular heart disease but asymptomatic
- Stage C1: severe valve lesion but asymptomatic with normal LV function
- Stage C2: severe valve lesion but asymptomatic with abnormal LV function
- Stage D: symptomatic patients due to valvular heart disease
What happens during S1?
Mitral and tricuspid valves close and aortic and pulmonic valves open
What happens during S2?
Mitral and tricuspid valves open and aortic and pulmonic valves close
What are physical exam findings for aortic stenosis?
- Midsystolic
- Crescendo-decrescendo
- best heard at 2nd interspace with radiation to carotids
- Medium pitch, harsh quality, loud with thrill
- heard best leaning forward
- laterally displaced
- sustained apical impulse
- S4 gallop may be present
- EKG may demonstrate LVH
What are physical exam findings for aortic regurgitation?
- Early diastolic
- Decrescendo
- Blowing
- High-pitched, best heard at 2nd to 4th interspaces with radiation to apex
- best heard with patient sitting, leaning forward with breath held after exhalation
- Widened pulse pressure
- S3 or S4 gallops may be present
- Low-pitched, diastolic mitral murmur may be heard at apex (Austin-Flint murmur)
What are physical exam findings for mitral stenosis?
- Low-pitched, rumbling, diastolic murmur best heard at apex with patient in left lateral decubitus position
- S1 loud in early MS and softens as leaflets become more immobile
- Opening snap following S2 usually present
- If pulmonary artery stenosis also present, palpable P2 may be present at upper left sternal border
- Also prominent pulmonary component of S2 on exam
What is the clinical presentation of mitral regurgitation?
- Holosystolic murmur best heard at apex radiating to axilla and back
- Mid-systolic click may be present if MVP present
What is the clinical presentation of mitral valve prolapse?
- Most asymptomatic
- Chest pain, palpitations, dizziness, anxiety (AKA MVP syndrome)
- Mid-systolic click followed by late systolic murmur
What is the epidemiology of tricuspid stenosis?
- Female
- Generally uncommon
- Rarely isolated disease, commonly associated with AS or MS
What are causes of tricuspid stenosis?
- Rheumatic heart disease
- MCC in US: carcinoid disease, prosthetic valve degeneration
- Congenital anomalies, leaflet tumors/vegetations
What is the pathophysiology of tricuspid stenosis causing symptoms?
- Tricuspid stenosis causes reduced RA emptying into RV
- This causes increased peripheral venous congestion leading to JVD, edema, and hepatic congestion
- It also causes reduced RV output leading to reduced LV output
What are symptoms of tricuspid stenosis?
- Right heart failure –> hepatomegaly, ascites, peripheral edema, fatigue
- Elevated JVP
What does tricuspid stenosis sound like on auscultation?
- Soft, high-pitched diastolic rumbling murmur along lower left sternal border
- Mimics mitral stenosis, except for increased sound with inspiration
- Opening snap may be heard
What is present on physical exam of tricuspid stenosis?
- Signs of right heart failure: lower extremity edema, JVD, ascites
- Palpable pre-systolic liver pulsation may be appreciated, coincides with atrial contraction
What is the diagnostic study of choice for tricuspid stenosis?
Echocardiogram
In addition to an echocardiogram, what other testing can be done for tricuspid stenosis? Why?
EKG, looking for right atrial enlargement
CXR, looking for cardiomegaly
How do you manage tricuspid stenosis?
- Loop diuretics for volume overload: torsemide or bumetanide if bowel edema
- Add aldosterone antagonist if liver congestion or ascites is present
- Surgical intervention
What is the surgical intervention of choice for tricuspid stenosis? When is this indicated?
- TV replacement
- If patient is symptomatic
What is the general cause of tricuspid regurgitation?
- Dilation of R ventricle and tricuspid annulus
What are causes of RV dilation leading to tricuspid regurgitation?
- LV failure
- PV stenosis
- Severe PV regurgitation
- Cardiomyopathy
- infiltrative processes
What are other causes of tricuspid regurgitation other than RV dilation?
- Endocarditis
- Carcinoid syndrome
- Congenital abnormality
- Chest wall trauma
What is the pathophysiology of symptoms of tricuspid regurgitation?
- Increased RA pressure
- Increased peripheral venous congestion
- Leads to JV, edema, and hepatic congestion
- At the same time, RA pressure leads to reduced RV output
- Leads to reduced LV output
What are symptoms of tricuspid regurgitation?
- If no pulonary HTN, usually well tolerated
- Progressive symptoms of RV failure
- Fatigue
- Ascites
- Peripheral edema
What is present on physical exam of tricuspid regurgitation?
- Signs of right heart failure: lower extremity edema, increased JVD, ascites
- Hepatic congestion and palpable systolic liver pulsations may be appreciated
What does the murmur of tricuspid regurgitation sound like?
- High-pitched and pansystolic, best heard at left sternal border
- Accentuated with inspiration or leg-raising by increasing venous return
What is the diagnostic study of choice for tricuspid regurgitation?
Echocardiogram
Why is an echocardiogram helpful for tricuspid regurgitation?
`
- Provides info on RV systolic pressure, RV size, and RV function
What is other testing for tricuspid regurgitation? What are findings?
- EKG: afib/flutter possible
- Cardiac cath–> confirms elevated RA pressure
How is tricuspid regurgitation managed?
- Treatment of underlying cause and HF symptoms
- Surgery
When would you repair vs replace valve for tricuspid regurgitation?
- Repair to restore TV function if persistent symptoms
- Replacement for underlying primary leaflet pathology
Anticoagulation not needed unless afib present
What is the usual cause for pulmonic stenosis?
- Isolated, congenital defect
- Rarely rheumatic disease
- can occur due to genetic syndrome: Noonan, Trisomy 13
What usually happens to the pulmonic valves in pulmonic stenosis?
- Fused pulmonary leaflets
What do the fused pulmonary leaflets cause in pulmonic stenosis?
Pressure-overloaded state resulting in RVH
What is the clinical presentation of pulmonic stenosis (not physical exam)?
- Neonates with critical PS have central cyanosis at birth
- Usually asymptomatic until adolescence or young adulthood
- Mild to moderate = asymptomatic
- Moderate to severe = progressive fatigue and dyspnea on exertion, can lead to RV dysfunction and failure
What is present on physical exam of a patient with pulmonic stenosis?
- Systolic ejection murmur best heard at left upper sternal border
- Increases with inspiration
- Radiates to L shoulder
- S1 followed by opening click that is louder with expiration
- RV lift on palpation of precordium
How would you evaluate pulmonic stenosis?
Echocardiogram
How is pulmonic stenosis managed?
- Mild PS: asymptomatic and require no intervention
- Moderate PS: if symptomatic, balloon valvuloplasty or surgical valve replacement
- Moderate to severe PS: require balloon valvuloplasty or surgical valve replacement
What is typically the cause of pulmonic regurgitation?
- Dilation of PV annulus secondary to pulmonary HTN
What is the cause of symptoms in pulmonic regurgitation?
- Primary disease and secondary to RV failure
What is heard on auscultation of a pulmonic regurgitation murmur?
- Diastolic murmur
- High-pitched
- Blowing quality
- Best heard at second left intercostal space
How is pulmonic regurgitation diagnosed?
- Echocardiogram
- Cardiac CT and MRI can be helpful
- EKG typically not helpful, although RBBB is common
Why might a cardiac MRI and CT be helpful in pulmonic regurgitation?
- Give detailed info on size of PA
- Help exclude other causes of pulmonary HTN
What is management of pulmonic regurgitation?
- Treat cause of pulmonary HTN
- Valvular intervention: PV replacement is rare for PR patients (reserved for cases of intractable RV failure
What are the 2 types of prosthetic heart valves?
- Mechanical and tissue
What should be considered with a mechanical heart valve?
- Extremely durable
- High thromboembolic risk and require lifelong anticoagulation
What medication is the only approved anticoagulant for patients with prosthetic heart valves?
Coumadin (Warfarin)
What is the goal INR with coumadin and mechanical heart valves?
2.5-3.5
What are considerations with a tissue prosthetic heart valve?
- Lower risk for thromboembolic event
- Less durable
- ASA 81 mg may be sufficient to reduce risk of thromboembolism development
What should you consider when deciding on valve?
- Patient age
- Compliance for anticoagulation
- Valve position
What causes acute rheumatic fever?
- Infection with group A beta-hemolytic strep with a abnormal immunologic response
Who typically gets acute rheumatic fever?
Children age 4-9
How has rheumatic fever changed over time?
- decreased prevalence in US due to antibiotic access
What conditions occur in rheumatic heart disease?
- pancarditis
- exudative pericarditis
- myocardium infiltrated with lymphocytes and areas of necrosis
- valvulitis
what is pancarditis?
diffuse inflammation of the heart
what is the characteristic histologic finding in myocardium?
- Aschoff body
What is an Aschoff body?
Collection of myocytes and macrophages surrounded by fibrous tissue
What characterizes valvulitis in rheumatic heart disease? Which valves are most commonly affected by rheumatic heart disease?
- verrucous lesions on leaflet edge
- MV most commonly affects, followed by AV
What is the presentation of rheumatic heart disease?
- Acute, febrile illness 2-4 weeks following streptococcal pharyngitis
What are major Jones criteria for rheumatic heart disease?
- Carditis (pleuritic chest pain, friction rub, HF) (myOcarditis)
- Polyarthritis (Joint involvement)
- Chorea (Sydenham chorea)
- Erythema marginatum (E)
- Subcutaneous nodules (Nodules)
JONES
What are minor criteria for Rheumatic Heart disease?
- Fever
- Arthritis
- Previous rheumatic fever or known RHD
How would you make the diagnosis of rheumatic heart disease?
- 2 major criteria met
- 1 major and 2 minor criteria met
- AND if criteria are present following a recent, documented strep infection
RHD must be confirmed with an echo showing BOTH morphological valvular involvement of mitral and/or aortic valves AND doppler evidence of pathologic valvular regurg
How is rheumatic heart disease treated?
- PCN to eradicate strep
- Salicylates for fever and arthritis
- Prophylaxis continued for up to 10 years with PCN G, oral PCN or erythromycin can also be used (recurrent attacks common)
