Valvular Disorders Flashcards
Heart sounds
SI, S2 (lub and dub). Extra heart sounds- S3 and S4
Types of aortic stenosis
Subvalvular, supra-valvular, and valvular
Most common cause of Aortic stenosis
Acquired- Due to calcific degeneration of valve (elderly over 70 with systolic murmur). Less common causes of aortic stenosis include rheumatic fever, endocarditis, radiation therapy, and systemic disease
Most common congenital abnormality causing aortic stenosis
Having bicuspid valve instead of 3 valves. Can also have unicuspid or quadricuspid.
Only 5% of people with bicuspid Aortic valve also have…
coartation of the aorta, but 3/4s of people with aortic coarctation also have bicuspid aortic valve
Consequences of LVH due to aortic stenosis
Compensatory adaptation, abnormal diastolic filling pattern (increase in LV filling pressure with exercise), and subendocardial ischemia
Classic AS symptoms with EXERTION
SAD- syncope, angina, dyspnea (due to heart failure)
What is the most COMMON symptom of aortic stenosis?
dyspnea
What effect does aortic stenosis have on cardiac output?
LVH- less fluid leaves ventricle due to stiff aortic valve outflow obstruction causing a decrease in cardiac output, leading to heart failure often in end stage AS
Of the 2/3rds of patients with aortic stenosis that have angina pectoris with exertion, half have…
underlying coronary artery disease, other half have angina due to reduced coronary flow reserve or increase in oxygen demand due to increased LV mass
Murmur in aortic stenosis
Systolic ejection murmur heard at aortic area with radiation to neck and apex, and delayed carotid upstroke
Difference between mild-moderate AS and severe AS
Mild-moderate AS- ejection click may precede the murmur. Severe AS- harsh ejection murmur with diminished to absent S2
How would you diagnose aortic stenosis
Echocardiography- PREFERRED, EKG, CXR, cardiac CT/MRI, cardiac catheterization
Patient aged 72 presents with systolic ejection murmur with absent S2 sound. Patient complains of angina and dizziness, and feelings of dizziness for a couple months now. The angina is most severe during exertion. Patient also has history of coronary artery disease. You order EKG and CXR- what would results show?
Suspect aortic stenosis. EKG- left ventricular hypertrophy. CXR- rounding of the left ventricular apex suggests LVH. Also see calcification of the aortic leaflets and aortic root.
When do symptoms (like SAD) begin to occur in someone with aortic stenosis?
Sx develop when aortic valve area is less than 1.0 cm. square
Serial echocardiographic studies should be ordered in AS how often?
Mild AS- 3-5 years. Moderate AS every 1-2 years. Severe AS- every year
How is physical activity and exercise affected by AS without symptoms?
Mild AS- no barrier in playing competitive sports so long as annual checks are done to evaluate aortic stenosis. Moderate AS- Low intensity competitive sports, such as cricket, golf, bowling. Depending on condition may be able to play slightly more competitive sports like volleyball, baseball, diving, and motorcycling (Bp response should be normal and no dysrhythmias or symptoms). Severe AS- no competitive sports
What kind of tx for symptomatic Aortic stenosis?
valve repair or replacement after onset of symptoms should be performed (if not, survival average is 2-3 years)
Types of valve repair in aortic stenosis
Valvotomy and balloon valvuloplasty
Types of valve replacement in AS
Mechanical and bioprosthetic, and core valve
Pros and cons between mechanical and bioprosthetic valve aortic valve replacement in AS
Mechanical requires lifelong anticoagulation, but is more durable. Bioprosthetic does not require lifelong anticoagulation, but has greater risk of infection after the first 18 months
Which aortic valve replacement type in AS is stented (smaller effective orifice area)
Bioprosthetic
St. Jude is …
most frequently used mechanical aortic valve replacement in AS
Why does aortic regurgitation occur?
Damage to aortic valve leaflets leading to dysfunction, or distortion or dilation of the aortic root and ascending aorta
Preload in AR
Increased- increased volume coming into ventricles
Causes of acute aortic regurgitation
aortic dissection, Infective endocarditis, traumatic rupture, iatrogenic
What are some signs you might pick up on in acute AR
APCDQW- Austin Flint Murmur, Pulses bisferiens, Corrigan’s pulse, DeMusset’s sign, Quincke’s pulse, Watson’s Hammer Pulse
acute AR may result in cardiogenic shock. What are signs for this?
profound hypotension, pallor, diaphoresis, occasional cyanosis, and weak, thready, and rapid pulse
Cardiac apex displacement and hyperdynamic nature in acute vs. chronic AR
Cardiac apex displaced and hyperdynamic in chronic AR
Diagnostic testing for acute AR
Echocardiography and CT/Transesophageal Echocardiography if suspected aortic dissection
Tx of acute AI
Emergent aortic valve replacement/repair, no intral-aortic balloon pump
Causes of chronic AR
Congenital (bicuspid aortic valve), aortopathy, acquired AR (Rheumatic heart disease, dilated aorta, CT disorder, degenerative, syphilis)
Patient presents with high pitched diastolic murmur at RSB, widened pulse pressure, hypotension, diaphoresis, pallor, sense of pounding heart/beat, palpitations, atypical chest pain, left sided heart failure (shortness of breath), angina, and displaced cardiac apex. You suspect..
Chronic AR
PE signs of chronic AR
ACDQMW- Austin Flint Murmur, Corrigan’s Sign, DeMusset’s Sign, Quincke’s sign, mueller’s sign, watson’s water hammer pulse, widened pulse pressure, high pitched diastolic murmur at RSB, apical impulse
Physical activity and exercise in AR
Asymptomatic with mild or moderate chronic AI and normal LVEDd- can play competitive sports
If LVEDd 60-65 mm- exercise testing
Significant dilation of ascending aorta greater than 45 mm- only low intensity competitive sports
Tx of chronic AR
Medical- afterload reduction with vasodilators, serial echocardiograms, and surgery once LV impairment occurs
How often should you do echocardiogram in mild chornic AI and normal left ventricular ejection fraction
Clinical evaluation yearly and echocardiography every 2-3 years
How often should you do echocardiogram in chronic moderate AR
annual clinical evaluation and echo every 1-2 years
How often should you do echocardiogram in chornic severe AR
Varies with left ventricluar dimensions
Normal Left ventricular end-diastolic diameter
less than or equal to 55 mm
Normal mitral valve opening
4-6 cm square
Mild mitral valve stenosis opening
1.5-2.5 cm square
Moderate mitral valve stenosis opening
1.0-1.5 cm square
Severe mitral valve stenosis opening
less than 1.0 cm square
Causes of mitral stenosis
Rheumatic heart disease and congenital disease
Patient presents with dyspnea and hemoptysis, probably from pulmonary edema, enlarged LA seen on CXR. S1 loud, low pitch diastolic rumble at the apex, pre-systolic accentuation, and opening snap after aortic valve closure. Atrial fibrillation present on EKG. Hoarseness in voice also present.
Mitral stenosis
Diagnosis mitral stenosis
EKG- LAE, RVH, premature contractions, atrial flutter, CXR may be normal in mild MS, catethetirization/angiogram- hemodynamic pressures, and echocardiogram
What is the gold standard in diagnosing mitral stenosis
Echocardiography- assess hemodynamic severity, RV size and function, and valve morphology, serial findings
Tx of mitral stenosis
Medical- diuretics for heart failure, atrial fibrillation therapy, percutaneous balloon valvuloplasty, and surgical
Atrial fibrillation therapy tx in mitral stenosis
For rate control, rhythm control, and anticoagulation
Surgeries in mitral stenosis
mitral commissurotomy (valvulotomy) and mitral valve replacement- mechanical and bioprosthetic
What might the etiology of mitral regurgitation involve?
Valvular leaflets, chordae, annulus, papillary muscles, LV dilation, and trauma
Chronic mitral regurgitation consequences
chronic LV volume overload and backflow resulting in increased LA size (atrial fibrillation, pulmonary HTN)
Acute mitral regurgitation consequences
LA pressure rises abruptly, leads to pulmonary edema, and results of flailed leaflet
Patient presents with dyspnea on exertion, fatigue, hemoptysis, pulmonary HTN, right sided heart failure, and brisk pulse. Hyperdynamic pulse, S1 soft, S2 has wide split, systolic murmur-pansystolic apex to axilla. What do you suspect and what would diagnostic studies show?
Mitral Regurgitation. ECG- LA enlargement, atrial fibrillation, LVH or RVH may be present, CXR- LA enlargement, may have LV enlargement, increased pulmonary vascularity, CHF, Echocardiography, TEE
Therapy for MR
Acute- Emergent surgery. Chronic- serial exams, afterload reduction with ACE-I, control supraventricular tachycardias with BB, Mitral valve surgery, MV repair or replacement
What is the only truly effective treatment for MR
Mitral valve surgery
MV repair vs. replacement
Replacement- need anticoagulation, tissue prosthetic valve degeneration, and mechanical prosthetic valve dysfunction/thrombosis. Repair- No anticoagulation needed, very feasible. PREFERRED.
Tricuspid stenosis often seen in conjunction with
tricuspid valve repair or carcinoid syndrome
Why does diastolic murmur in tricuspid stenosis increase upon inspiration?
Because inspiration causes lungs to compress IVC, which causes more pressure in IVC, leading to more blood output into RA, increasing murmur sound
Loud S1, increase in right atrial and jugular venous pressure, lungs clear, low frequency diastolic murmur heard along LSB with increase upon inspiration. You suspect..
Tricuspid stenosis
Diagnosis of Tricuspid Stenosis
Echo shows Doppler echo- high velocity turbulent diastolic flow, diastolic doming of the valve, leaflets stiff, and reduced separation of leaflet tips
Tx of tricuspid stenosis
Diuretics for volume control, surgical replacement-usually bioprosthetic valve used
What kinds of causes can TR arise from?
RV dilation and congenital anomalies
Examples things causing RV dilation that lead to TR
Pulm HTN, RV infarct, infiltrative diseases
Examples of tricuspid anomalies causing TR
CREEP(t)- Collagen disease, RV pacemaker injury, endocarditis, Ebstein’s anomaly, and tricuspid valve prolapse
What is Ebstein’s anomaly?
Displacement of one of more Tricuspid valve leaflets into the RV
Patient presents with jugular venous distention, right-sided third sound gallop, RV heave, holosystolic murmur. You are suspicious of a valve dysfunction. What is it and what tests would you order?
Tricuspid Regurgitation. MRI- gold standard, ECG and CXR- Right atrial or RV enlargement, Echo, Right heart catheterization- hemodynamics, PVR, exclude chronic thromboembolic disease as a cause of R heart failure
Tx of TR
Treat cause. Surgery- tricuspid annuloplasty
Gold standard in diagnosing TR
MRI
What valve is associated with heroin addicts?
Tricuspid valve with endocarditis, causing TR
Patient presents with increased pulmonary pressure. What would you be worried about?
Pulmonic regurgitation-most often secondary to increased pulmonary pressures. or could be caused by mitral stenosis or regurgitation
What are the types of prosthetic heart valves
Mechanical, bioprosthetic, homograft
Mechanical valve types
Ball and Cage, Bileaflet Tilting Disc, Caged Disc, and Single Tilting Disc
What characteristics do mechanical valves have?
Cage, strut, or frame, moving component, and sewing ring. They are made from a compressed carbon material
Describe the positions that Ball and Cage method offers
Open- blood flows across sewing ring and around the ball occluder on all sides. Closed position- small amount of regurgitation, circumferentially around the ball
Disadvantages of ball and cage
Bulky, small internal orifice, stimulated thrombus formation
St. Jude is a type of…
Bileaflet mechanical valve
What is the most frequently used mechanical valve?
St. Jude- has 3 orifices and is least stenotic mechanical prosthetic valve
Types of Bioprosthetic valves
Heterograft, auto-graft, homograft
Heterograft/xenograft
Transfer from animal to human
Auto-graft
Transfer from set to seft
Homograft/allograft
Transfer from one human to another
Mechanical valves vs. bioprosthetic valves
Mechanical- low rate of structural failure, but requires long-term coumadin and greater risk of bleeding. Bioprostheitc- High rate of structural failure, but don’t require warfarin therapy and have less risk of bleeding. also have greater risk of infection though.
All heart murmurs usually evaluated with…
ECG, CXR, most require echocardiography. For diagnosis and severity confirmation
When would you hear mid-late systolic heart murmur?
Mitral valve prolapse?
When would you hear holosystolic heart murmur?
MR, TR, ventricular septal defect, ebsteins anomaly
Aortic and pulmonic obstruction would have heart murmur timing at…
mid systolic
Aortic regurgitation would have heart murmur timing at
Early diastolic
When would you hear early diastolic heart murmur?
AR and PR
When would you hear mid diastolic heart murmur?
MS and TS
When would you hear continuous heart murmur?
Patent ductus arteriosus, coarctation, pulmonary artery branch stenosis, fistulas
Systolic murmurs include…
Aortic stenosis, pulmonic stenosis, mitral insufficiency, mitral valve prolapse, and TR
Diastolic murmurs include
Aortic insuffienciency, PR, TS, mitral stenosis
Heart murmurs intensity Grade 1-6
1-barely audible, 6- loud with no contact between stethoscope and chest
Manuevers that aid in diagnosis of murmurs
Inspiration, valsalva maneuver, release of valsalva maneuver, isometric handgrip, squatting, amyl nitrite
What is the classic finding for rheumatic mitral stenosis?
Hockey stick appearance
