valvular disorders part 1 Flashcards
what are the 2 types of valve disorers
regurgitation and stenosis
what are teh 6 clinical classification categories based on anatomy and symtpoms of valvular heart disease
what are the valvular heart disorders associated with congenital defects
- aortic stenosis
- pulmonic stenosis
- bicuspid aortic valve
what are the valvular heart disorders associated with aging
- degenerative valve disease
- valve calcification
- mediastinal radiation therapy
what are the risk factors for valvular heart disorders associated with other illnesses/disease
- infective endocarditis
- rheumatic fever
what are the 2 ways aortic stenosis typically occurs
congenital or acquired
what occurs with congenital aortic stenosis and when does it present.
- unicuspid, bicuspid, or quadricuspid valve
- symptoms classically present prior to age 50
what typically causes acquired aortic stenosis and when does it present
- rheumatic fever, valve calcification, and degenerative stenosis
- symptoms presenting after age 50
what do both congenital and acquired causes of aortic stenosis lead to
thickening and calcification of the valve leaflets which result in narrowed valve opening
this further leads to LVH which then leads to diastolic dysfunction then to systolic dysfunction (i gotta draw this out)
what is the cause of degenerative or calcified AS
results from calcium deposition on valve leaflets
who is degenerative or calcified AS MC in
elderly patients
what percent of patients over 65 and 75 have aortic sclerosis on echo? why is this so bad
25% over 65
35% over 75
10-20% can further progress to aortic stenosis in the next 10-15 years
what are risk factors for calcified AS
HTN
HLD
Smoking
what is the MC surgical valve lesion in developed countries
aortic stenosis
what are the cardinal symptoms of aortic stenosis
- angina (underperfusion of endocardium)
- syncope (↑LV pressure stimulates baroreceptors to induce peripheral vasodilation)
- CHF
once cardinal symptoms of aortic stenosis occur, what happens to the prognosis of the patient
it drops 2-5 years unless surgical correction is made
what are PE findings for aortic stenosis
- murmur
- laterally displaced, sustained apical impulse
- S4 gallop may be present
what does the murmur for aortic stenosis present like
- medium pitch, harsh quality, loud with a thrill
- midsystolic, crescendo-decrescendo
- best heart at right 2nd interspace w radiation to carotids
- heard best w patient sitting and leaning forward
what would an EKG demonstrate in a pt with aortic stenosis
may see LVH
what are the three diagnostic studies used for aortic stenosis
CXR
echo
cardiac catheterization
what would a CXR show in aortic stenosis
- enlarged cardiac silhouette
- calcified aortic valve
- dilated ascending aorta
what would a echo show in aortic stenosis
honestly not sure whats happening here… plz interperet this as you will until i figure it out haha
what does cardiac catheterization show in aortic stenosis
confirms presence of severe aortic stenosis and any CAD
what can reduce transvalvular pressure gradient in an enchocardiography
reduced LV function due to low output
what is the treatment for symptomatic aortic stenosis patients
open aortic valve replacement
or
transcutaneous aortic valve replacement/implantation
what anti-coagulant would a patient who underwent an open AVR with a mechanical valve recieve
warfarin +/- aspirin
what anti-coagulant would a patient who underwent a TAVR recieve
plavix and aspirin
when would you use a TAVR (transcutaneous aortic valve implantation)
in patients who are poor candidates for open heart surgery or are of intermediate risk
when is balloon valvuloplasty used in aortic stenosis management
congenital AS but not degenerative AS due to high “restenosis” rate
what medication therapies have been proven to slow progression of aortic stenosis
NONE!!
what is included in medical therapies for sympotms of aortic stenosis
+/- statins
medications to reduce afterload and volume reducton (BB i think)
what is aortic regurgitation caused by
disease of the aortic leaflets, aortic root, or both
what are diseases that can affect aortic leaflets
- rheumatic fever
- congenital abnormalities
- infective endocarditis
- HTN
what are diseases that can affect the aortic root
- aortic dissection
- root dilation
- marfan’s
what does chronic AR lead to?
LVH and dilation due to ned to accommodate for the additional regurgitant volume
what are the symptoms of aortic regurgitation
- may be asymptomatic for years
- exertional dyspnea
- fatigue
- angina (d/t low perfusion)
what are the symptoms determined and caused by in aortic regurgitation?
- Presentation is determined by how quickly regurg occurs
- due to increase in V filling pressures which leads to CHF
what are the PE findings associated with aortic regurgitation
- murmur
- widened pulse pressure
- S3 or 4 gallop
- Austin flint murmur
what does an austin flint murmur sound like and when is it heard
heard in aortic regurgitaiton
a low pitched, diastolic mitral murmur, heard at apex
what is the description of the murmur for aortic regurgitation
- early diastolic decrescendo blowing in nature
- high pitched, best hear in the 2nd to 4th left interspaces with radiation to the apex
- best heard with the patient sitting and leaning forward
what causes widened pulse pressure in aortic regurgitation
Due to elevated stroke volume during systole and falling diastolic pressure as a result of the incompetent aortic valve
( in notes at the bottom of 28)
what causes the austin flint murmur in aortic regurgitation?
As a result of the incomplete opening of the mitral leaflets due to increased LV pressures or impingement of the AR jet on the anterior mitral leaflet
(at bottom of slide of 28)
didagnostic modality of choice for AR
echooooo
what is the tx for aortic regurgitation
- AVR surgery for patients with symptomatic severe or LV changes (LV dilation >5cm or EF<50%)
- medical tx with vasodilator (BB) to unload ventricle (does NOT slow progression)
what may be seen on EKG in aortic regurgitation
- LVH
(notes on slide 30)
what may be seen on CXR for aortic regurgitation
cardiomegaly w LV prominence
(notes on slide 30)
what might a CT or MRI be used for when assessing aortic regurgitation
aortic root size and severity
(notes under 30)
in patients with marfans syndrome that have aortic regurgitation, what medication is preferred for vasodilation
ARBs instead of BBs
(slide 30 notes)
what is acute aortic regurgitation caused by
- infective endocarditis
- traumatic rupture of aortic leaflets
- aortic root dissection
- acute dysfunction of prosthetic aortic valve
what does acute aortic regurgitation result in?
Results in hemodynamic instability because the LV is unable to accommodate the increased diastolic volume
this is an emergency!!!!!
What are s/s of cardiogenic shock
- pale, cool extremities
- weak, rapid pulse
- low pitched, early diastolic murmur
what is the diagnostic study used for acute aortic regurgitation
STAT echo
what is seen on EKG for acute aortic regurgitation
LVH
what is seen on CXR in acute aortic regurgitation
cardiomegaly with LV prominence on CXR
what is medical treatment for acute aortic regurgitation
vasodilator therapy and diuretics if BP is stable
inotropic agents and vasopressors may be necessary
what is the teratment of choice for acute aortic valve regurgitation
urgent aortic valve replacemet
what is occuring during mitral stenosis
thickening and immobility of the mitral leaflets impede the flow from the left atrium to the left ventricle
what are the causes of mitral stenosis
- rheumatic fever (MC)
the following are rare:
* congenital abnormalities
* connective tissue disorders
* left atrial tumors
* overly aggressive surgical repair MR
what is the MC group affected by mitral stenosis
2/3 women
what is the pathophysiology of MS due to rheumatic fever
- pathologic changes occur over many years before dysfunction becomes hemodynamically important
- gradually leads to fusion of leaflets and thickening, fibrosis, and clacification of mitral leaflets and chordae
what are initial hemodynamic changes in MS
elevated left atrial pressure causing LA enlargement
(may result in pulmonary congestion)
what occurs with chronic elevations in pulmonary venous pressures in MS
- increase in pulm vascular resistance and pulm arterial pressures
- this further leads to RV failure
compare mild/moderate MS to severe MS in relation to LV impairement
- mild/mod - LV filling pressures may be normal or low
- severe - LV filling is impaired reducing SV and CO!!!
(must give BB or this will eventually kill the patient. said in notes on 43)
when do patients with MS typically develope symptoms
the 4th-5th decade of life
(approx 20-40 years following illness)
what are the symtpoms a result of in MS
pulmonary vascular congestion and RV failure
what are the symptoms seen in MS
- Fatigue, exertional dyspnea, orthopnea (MC)
- afib
- hemoptysis (d/t rupture of bronchial veins)
- blood tinged sputum (d/t pulm edema)
what are additional findings that could be seen in MS
- peripheral emolism from Left atrial thrombus
- peripheral edema
- compression of left recurrent laryngeal nerve from a severely dilated LA may result in hoarsness (ortner syndrome)
what is the murmur description for MS
- low-pitched, rumbling, diastolic murmur best heard at apex in LLD position
- S1 loud in early MS, then softens as leaflets become more calcified and immoble
- opening snap heard following S2
what are EKG findings assocaited with MS
- LA abnormality
- Afib
- RV hypertrophy pattern
what does the echo show for MS
characteristic rheumatic deformity is doming “hockey stick” of the anterior MV leaflet
what type of echo may be used in MS? what does it interperet
TTE or TEE to measure extent of valvular calcification and severity of stenosis.
normal MV is 4-6cm
critical is <1cm
what is measured during cardiac catheterization in evaluation of MS
measurement of cardiac output and transvalvular gradient
what is the treatment for MS
- mild/mod - medically managed for symptom control, not reversible. use BB for HR and diuretics for pulm congestion and RV failure
- mod-severe = percutaneous or surgical intervention
when is percutaneous balloon valvuloplasty recommended in MS
- pliable, noncalcified leaflets and chords
- minimal MR
- no evidence of LA thrombus
NOT A DEFINITIVE TX. only definitive is valve replacement
what is the cause of mitral regurgitation
- LV dilation (cardiomyopathy)
- Posterior wall MI
- Rheumatic fever
- Endocarditis
- MV prolapse
what does mitral regurgitation result in
regurgitant blood flow from the LV to the LA during systole
this eventually can lead to pulm congestion due to inceased LA pressure
what are symptoms for mitral regurgitation
- fatigue
- dyspnea on exertion
- peripheral edema
note: MR remains asymptomatic for many years, once symtpoms occur its due to depressed LV systolic function
what is the murmur description for mitral regurgitation
- Holosystolic murmur best heard at the apex and radiates to the axilla and back
- Mid-systolic click may be present if MVP present
what would an EKG present as for mitral regurgitation
- LA abnormality, LVH pattern
- Afib may be present
what can be used to assess severity of MR and LV function
echo and cardiac cath
when is a coronary angiography reccommended in mitral regurgitation
if male patient >40 or menopausal female w/RF
what is pharmalogical treatment for mitral regurgitation
- afterload reduction with vasodilators (ACEI or hydralazine)
- diuretics also for pulm congestion/edema and to reduce volume overall
what is surgical treatment for mitral regurgitation
- MV repair
- MV replacement (only if repair not feasible)
when is surgery indicated for mitral regurgitation
- development of afib or pulm HTN
- BEFORE irreversible myocyte damage and LV remodeling occurs
when is MV repair NOT indicated
if MV is heavily calcified or disrupted secondary to papillary muscle disease/endocarditis
what is acute mitral regurgitation
A life-threatening condition that may result from abnormalities with the papillary muscles, chordal structures or leaflets
LA does not dilate to accommodate the regurgitant volume
Results in abrupt increase in LA and pulmonary venous pressures
leads to pulm congestion!!!!!!
what are causes of acute mitral regurgitation
- Acute MI
- Trauma
- Endocarditis
- Tachyarrhythmia in patient with chronic MR
- MVP – papillary muscle / chordae tendineae dysfunction
what are symptoms of acute mitral regurgitation
- signs of cardiogenic shock such as:
- hypotension
- tachycardia
- syncope
- pale
- diaphoresis
- SOB
what is the description of the murmur for acute mitral regurgitation
soft, low-pitched sound in early systole
what is the treatment for acute mitral regurgitation?
Urgent valve replacement surgery
what is MVP?
Defined as superior displacement in ventricular systole of one or both mitral valve leaflets across the plane of the mitral annulus toward the left atrium
what is the epidemiology of MVP
present in 1-3% of population, more common in women.
can be inherited as autosomal dominant trait!!
what are the symptoms of MVP
- Most patients asymtpomatic
- Nonspecific symptoms include:
- chest pain
- palpitations
- dizziness
- anxiety
- fatigue
(AKA MVP syndrome)
what are PE findings in MVP
auscultation reveals mid-systolic click, followed by late systolic murmur
what can help with MVP syndrome
SSRI/SNRIs and BBs (in notes)
what is the treatment for MVP
- most patients with mild prolapse and are asymptomatic require no treatment
nicceeeeee
okay bye!:)
