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Clin Med I- CARDIO > Valvular Disorders > Flashcards

Valvular Disorders Flashcards

1
Q

Heart sounds

A

SI, S2 (lub and dub). Extra heart sounds- S3 and S4

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2
Q

Types of aortic stenosis

A

Subvalvular, supra-valvular, and valvular

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3
Q

Most common cause of Aortic stenosis

A

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

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4
Q

Most common congenital abnormality causing aortic stenosis

A

Having bicuspid valve instead of 3 valves. Can also have unicuspid or quadricuspid.

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5
Q

Only 5% of people with bicuspid Aortic valve also have…

A

coartation of the aorta, but 3/4s of people with aortic coarctation also have bicuspid aortic valve

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6
Q

Consequences of LVH due to aortic stenosis

A

Compensatory adaptation, abnormal diastolic filling pattern (increase in LV filling pressure with exercise), and subendocardial ischemia

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7
Q

Classic AS symptoms with EXERTION

A

SAD- syncope, angina, dyspnea (due to heart failure)

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8
Q

What is the most COMMON symptom of aortic stenosis?

A

dyspnea

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9
Q

What effect does aortic stenosis have on cardiac output?

A

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

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10
Q

Of the 2/3rds of patients with aortic stenosis that have angina pectoris with exertion, half have…

A

underlying coronary artery disease, other half have angina due to reduced coronary flow reserve or increase in oxygen demand due to increased LV mass

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11
Q

Murmur in aortic stenosis

A

Systolic ejection murmur heard at aortic area with radiation to neck and apex, and delayed carotid upstroke

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12
Q

Difference between mild-moderate AS and severe AS

A

Mild-moderate AS- ejection click may precede the murmur. Severe AS- harsh ejection murmur with diminished to absent S2

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13
Q

How would you diagnose aortic stenosis

A

Echocardiography- PREFERRED, EKG, CXR, cardiac CT/MRI, cardiac catheterization

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14
Q

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?

A

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.

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15
Q

When do symptoms (like SAD) begin to occur in someone with aortic stenosis?

A

Sx develop when aortic valve area is less than 1.0 cm. square

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16
Q

Serial echocardiographic studies should be ordered in AS how often?

A

Mild AS- 3-5 years. Moderate AS every 1-2 years. Severe AS- every year

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17
Q

How is physical activity and exercise affected by AS without symptoms?

A

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

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18
Q

What kind of tx for symptomatic Aortic stenosis?

A

valve repair or replacement after onset of symptoms should be performed (if not, survival average is 2-3 years)

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19
Q

Types of valve repair in aortic stenosis

A

Valvotomy and balloon valvuloplasty

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20
Q

Types of valve replacement in AS

A

Mechanical and bioprosthetic, and core valve

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21
Q

Pros and cons between mechanical and bioprosthetic valve aortic valve replacement in AS

A

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

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22
Q

Which aortic valve replacement type in AS is stented (smaller effective orifice area)

A

Bioprosthetic

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23
Q

St. Jude is …

A

most frequently used mechanical aortic valve replacement in AS

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24
Q

Why does aortic regurgitation occur?

A

Damage to aortic valve leaflets leading to dysfunction, or distortion or dilation of the aortic root and ascending aorta

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25
Q

Preload in AR

A

Increased- increased volume coming into ventricles

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26
Q

Causes of acute aortic regurgitation

A

aortic dissection, Infective endocarditis, traumatic rupture, iatrogenic

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27
Q

What are some signs you might pick up on in acute AR

A

APCDQW- Austin Flint Murmur, Pulses bisferiens, Corrigan’s pulse, DeMusset’s sign, Quincke’s pulse, Watson’s Hammer Pulse

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28
Q

acute AR may result in cardiogenic shock. What are signs for this?

A

profound hypotension, pallor, diaphoresis, occasional cyanosis, and weak, thready, and rapid pulse

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29
Q

Cardiac apex displacement and hyperdynamic nature in acute vs. chronic AR

A

Cardiac apex displaced and hyperdynamic in chronic AR

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30
Q

Diagnostic testing for acute AR

A

Echocardiography and CT/Transesophageal Echocardiography if suspected aortic dissection

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31
Q

Tx of acute AI

A

Emergent aortic valve replacement/repair, no intral-aortic balloon pump

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32
Q

Causes of chronic AR

A

Congenital (bicuspid aortic valve), aortopathy, acquired AR (Rheumatic heart disease, dilated aorta, CT disorder, degenerative, syphilis)

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33
Q

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..

A

Chronic AR

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34
Q

PE signs of chronic AR

A

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

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35
Q

Physical activity and exercise in AR

A

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

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36
Q

Tx of chronic AR

A

Medical- afterload reduction with vasodilators, serial echocardiograms, and surgery once LV impairment occurs

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37
Q

How often should you do echocardiogram in mild chornic AI and normal left ventricular ejection fraction

A

Clinical evaluation yearly and echocardiography every 2-3 years

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38
Q

How often should you do echocardiogram in chronic moderate AR

A

annual clinical evaluation and echo every 1-2 years

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39
Q

How often should you do echocardiogram in chornic severe AR

A

Varies with left ventricluar dimensions

40
Q

Normal Left ventricular end-diastolic diameter

A

less than or equal to 55 mm

41
Q

Normal mitral valve opening

A

4-6 cm square

42
Q

Mild mitral valve stenosis opening

A

1.5-2.5 cm square

43
Q

Moderate mitral valve stenosis opening

A

1.0-1.5 cm square

44
Q

Severe mitral valve stenosis opening

A

less than 1.0 cm square

45
Q

Causes of mitral stenosis

A

Rheumatic heart disease and congenital disease

46
Q

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.

A

Mitral stenosis

47
Q

Diagnosis mitral stenosis

A

EKG- LAE, RVH, premature contractions, atrial flutter, CXR may be normal in mild MS, catethetirization/angiogram- hemodynamic pressures, and echocardiogram

48
Q

What is the gold standard in diagnosing mitral stenosis

A

Echocardiography- assess hemodynamic severity, RV size and function, and valve morphology, serial findings

49
Q

Tx of mitral stenosis

A

Medical- diuretics for heart failure, atrial fibrillation therapy, percutaneous balloon valvuloplasty, and surgical

50
Q

Atrial fibrillation therapy tx in mitral stenosis

A

For rate control, rhythm control, and anticoagulation

51
Q

Surgeries in mitral stenosis

A

mitral commissurotomy (valvulotomy) and mitral valve replacement- mechanical and bioprosthetic

52
Q

What might the etiology of mitral regurgitation involve?

A

Valvular leaflets, chordae, annulus, papillary muscles, LV dilation, and trauma

53
Q

Chronic mitral regurgitation consequences

A

chronic LV volume overload and backflow resulting in increased LA size (atrial fibrillation, pulmonary HTN)

54
Q

Acute mitral regurgitation consequences

A

LA pressure rises abruptly, leads to pulmonary edema, and results of flailed leaflet

55
Q

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?

A

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

56
Q

Therapy for MR

A

Acute- Emergent surgery. Chronic- serial exams, afterload reduction with ACE-I, control supraventricular tachycardias with BB, Mitral valve surgery, MV repair or replacement

57
Q

What is the only truly effective treatment for MR

A

Mitral valve surgery

58
Q

MV repair vs. replacement

A

Replacement- need anticoagulation, tissue prosthetic valve degeneration, and mechanical prosthetic valve dysfunction/thrombosis. Repair- No anticoagulation needed, very feasible. PREFERRED.

59
Q

Tricuspid stenosis often seen in conjunction with

A

tricuspid valve repair or carcinoid syndrome

60
Q

Why does diastolic murmur in tricuspid stenosis increase upon inspiration?

A

Because inspiration causes lungs to compress IVC, which causes more pressure in IVC, leading to more blood output into RA, increasing murmur sound

61
Q

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..

A

Tricuspid stenosis

62
Q

Diagnosis of Tricuspid Stenosis

A

Echo shows Doppler echo- high velocity turbulent diastolic flow, diastolic doming of the valve, leaflets stiff, and reduced separation of leaflet tips

63
Q

Tx of tricuspid stenosis

A

Diuretics for volume control, surgical replacement-usually bioprosthetic valve used

64
Q

What kinds of causes can TR arise from?

A

RV dilation and congenital anomalies

65
Q

Examples things causing RV dilation that lead to TR

A

Pulm HTN, RV infarct, infiltrative diseases

66
Q

Examples of tricuspid anomalies causing TR

A

CREEP(t)- Collagen disease, RV pacemaker injury, endocarditis, Ebstein’s anomaly, and tricuspid valve prolapse

67
Q

What is Ebstein’s anomaly?

A

Displacement of one of more Tricuspid valve leaflets into the RV

68
Q

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?

A

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

69
Q

Tx of TR

A

Treat cause. Surgery- tricuspid annuloplasty

70
Q

Gold standard in diagnosing TR

A

MRI

71
Q

What valve is associated with heroin addicts?

A

Tricuspid valve with endocarditis, causing TR

72
Q

Patient presents with increased pulmonary pressure. What would you be worried about?

A

Pulmonic regurgitation-most often secondary to increased pulmonary pressures. or could be caused by mitral stenosis or regurgitation

73
Q

What are the types of prosthetic heart valves

A

Mechanical, bioprosthetic, homograft

74
Q

Mechanical valve types

A

Ball and Cage, Bileaflet Tilting Disc, Caged Disc, and Single Tilting Disc

75
Q

What characteristics do mechanical valves have?

A

Cage, strut, or frame, moving component, and sewing ring. They are made from a compressed carbon material

76
Q

Describe the positions that Ball and Cage method offers

A

Open- blood flows across sewing ring and around the ball occluder on all sides. Closed position- small amount of regurgitation, circumferentially around the ball

77
Q

Disadvantages of ball and cage

A

Bulky, small internal orifice, stimulated thrombus formation

78
Q

St. Jude is a type of…

A

Bileaflet mechanical valve

79
Q

What is the most frequently used mechanical valve?

A

St. Jude- has 3 orifices and is least stenotic mechanical prosthetic valve

80
Q

Types of Bioprosthetic valves

A

Heterograft, auto-graft, homograft

81
Q

Heterograft/xenograft

A

Transfer from animal to human

82
Q

Auto-graft

A

Transfer from set to seft

83
Q

Homograft/allograft

A

Transfer from one human to another

84
Q

Mechanical valves vs. bioprosthetic valves

A

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.

85
Q

All heart murmurs usually evaluated with…

A

ECG, CXR, most require echocardiography. For diagnosis and severity confirmation

86
Q

When would you hear mid-late systolic heart murmur?

A

Mitral valve prolapse?

87
Q

When would you hear holosystolic heart murmur?

A

MR, TR, ventricular septal defect, ebsteins anomaly

88
Q

Aortic and pulmonic obstruction would have heart murmur timing at…

A

mid systolic

89
Q

Aortic regurgitation would have heart murmur timing at

A

Early diastolic

90
Q

When would you hear early diastolic heart murmur?

A

AR and PR

91
Q

When would you hear mid diastolic heart murmur?

A

MS and TS

92
Q

When would you hear continuous heart murmur?

A

Patent ductus arteriosus, coarctation, pulmonary artery branch stenosis, fistulas

93
Q

Systolic murmurs include…

A

Aortic stenosis, pulmonic stenosis, mitral insufficiency, mitral valve prolapse, and TR

94
Q

Diastolic murmurs include

A

Aortic insuffienciency, PR, TS, mitral stenosis

95
Q

Heart murmurs intensity Grade 1-6

A

1-barely audible, 6- loud with no contact between stethoscope and chest

96
Q

Manuevers that aid in diagnosis of murmurs

A

Inspiration, valsalva maneuver, release of valsalva maneuver, isometric handgrip, squatting, amyl nitrite

97
Q

What is the classic finding for rheumatic mitral stenosis?

A

Hockey stick appearance

Clin Med I- CARDIO (10 decks)

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