Valvular Disorders - Part 1 - Exam 1 Flashcards
What are the 6 clinical classification categories based on? What are they?
based on anatomy and symptoms
What are the risk factors for valvular disease?
congenital defects: bicuspid aortic valve
previous illness: endocarditis or rhematic fever
aging: calcification and degenerative disease
What are the 2 types of aortic stenosis? When do they typically appear?
congenital and acquired
congenital: bicuspid is the MC, present prior to age 50
acquired: Rheumatic fever, valve calcification, and degenerative stenosis, present after age 50
What does aortic stenosis lead to? What is the MC type of congenital aortic stenosis?
results in left ventricular hypertrophy
bicuspid congenital is the MC
What is degenerative/calcified AS a result of? Approx. 25% of patients over 65 and 35% over 75 have evidence of _____ on echo
calcium deposits on valve leaflets, MC in elderly pts
aortic sclerosis
What are risk factors for aortic stenosis?
HTN
hyperlipidemia
smoking
**What is the MC surgical valve lesion in developed countries?
aortic valve
What are the 3 cardinal symptoms of aortic stenosis? **What is the highlighted symptom?
angina
syncope/dizziness** especially on exertion
dyspnea
**What does a aortic stenosis murmur sound like? **Where is it best heard and where does it radiate? _____ extra heart sound may be present
Midsystolic, crescendo-decrescendo, medium pitch, harsh quality, often loud with a thrill
Best heard at the right 2nd interspace with the pt sitting and leaning forward
with radiation to the carotids
S4 gallop
**What is parvus et tardus? What valve condition is it associated with?
Slow rising carotid pulse contour
aortic stenosis
What is the imaging of choice for aortic stenosis? ______ confirms the presence of severe AS and any CAD
echo
cardiac cath
The CXR shows how enlarged cardiac silhouette, calcified aortic valve, dilated ascending aorta.
What am I?
aortic stenosis
What is a gradient? What is normal?
difference in pressure of the left ventricle in systole and the aorta in systole.
normal should be less than 15mmHg
What are the components of a echocardiography? What are the values of each for mild/moderate/severe?
**Know the severe criteria for each section at the very least
What is the tx for symptomatic pts with severe AS? What do you need to give to pts after tx?
aortic valve replacement
Mechanical valve → Warfarin +/- ASA 81 mg
TAVR → Plavix x 6 months; lifelong ASA 81 mg
______ is useful for patients who are poor/intermediate candidates for open heart surgery
Transcutaneous Aortic Valve Repair (TAVR) or TAVI
______ is useful for congenital AS, but not used often for degenerative AS due to complications and high restenosis rate. What is given to help slow the rate of progression?
Balloon valvuloplasty
No medical therapies proven to slow progression!!! statins to control plaque build up and therapies aimed at s/s
What is aortic regurgitation caused by? What does it lead to?
Caused by disease of the aortic leaflets, aortic root, or both
Chronic AR leads to LVH and dilation due to the need to accommodate for the additional regurgitant volume
What are some causes of aortic root problems?
aortic dissection, aortic root dilation and Marfan’s syndrome
aortic regurgitation presentation is determined by how quickly ______. Symptoms are typically due to increase in ______ leading to CHF. What are the 2 MC s/s?
regurg occurs
LV filling pressures
Exertional dyspnea and fatigue +/- angina
**What does an aortic regurgitation murmur sound like? Where is the best place to hear it? Where does the sound radiation to?
Early diastolic, decrescendo, blowing
High pitched, best heard in the 2nd to 4th left interspaces (left sternal border) with the pt sitting and leaning forward
radiation to the apex
What is widened pulse pressure (SBP-DBP) and “water hammer pulse” associated with? What additional heart sounds can be heard?
aortic regurgitation
S3 or S4 gallops may be present
**What is an Austin Flint murmur? What cardiac dz is it associated with?
A low-pitched, diastolic mitral murmur, may be heard at the apex
aortic regurgitation
What is the imaging modality of choice for aortic regurgitation?
Echocardiography (TTE)
What is the tx for aortic regurgitation? What is the criteria? What medication is recommended? Why?
aortic valve replacement for patients with symptomatic severe AR or with LV changes
Recommend AVR prior to progression to LV dilation > 5.0 cm or reduction in EF to < 50%
vasodilators (hydralazine, minoxidil, nitrates, and nitroprusside and/or normal BP meds)
to unload the ventricle but does NOT slow down the progression of aortic regurgitation
What is a normal ejection fraction?
normal ejection fraction is greater than 50%
What is acute aortic regurgitation caused by? What is it a result of? What does it lead to?
Infective endocarditis, traumatic rupture of aortic leaflets, aortic root dissection, and acute dysfunction of a prosthetic aortic valve
Results in hemodynamic instability because the LV is unable to accommodate the increased diastolic volume
aka blood backs up into the lungs and they cant breathe then they die
cardiogenic shock (pale, cool extremities, weak, rapid pulse, low pitched early diastolic murmur)
What is the tx for acute aortic regurgitation? What is the tx of choice?
Medical treatment includes vasodilator therapy and diuretics if BP is stable. Inotropic agents and vasopressors may be necessary
need to take pressure off heart
urgent aortic valve replacement!!!
**What is the MC cause of mitral stenosis? 2/3rd of patients are _____. What does it lead to?
rheumatic fever
women!!
Fusion of the leaflet commissures and thickening, fibrosis, and calcification of the mitral leaflets and chordae
Initial hemodynamic changes with mitral stenosis include elevated ____ pressure, causing ___ enlargement. This is transmitted back to the pulmonary venous system and may result in _______. Chronic elevations in pulmonary venous pressure leads to ______
left atrial
Left atrium
pulmonary congestion
right ventricular failure
As mitral valve stenosis becomes severe, _____ filling is impaired, reducing the _____ and _____
left ventricle
stroke volume and cardiac output
When do patients with mitral stenosis start developing symptoms? What are the s/s related to?
40s-50s
pulmonary vascular congestion and right ventricle failure
What are the MC s/s of mitral stenosis?
Fatigue, exertional dyspnea, orthopnea (SOB when lying flat)
may have peripheral edema
**_____ is also common in mitral stenosis. What does it lead to?
atrial fibrillation
leads to blood clots
**What is Ortner syndrome? **What valve dz is it associated with?
Compression of the left recurrent laryngeal nerve from a severely dilated LEFT ATRIUM may result in hoarseness
mitral stenosis
**What does a mitral stenosis murmur sound like? Where is the best place to hear it? What pt position?
Low-pitched, rumbling, diastolic murmur
best heard at the apex with patient in left lateral decubitus position
______ extra heart sound is heard in mitral stenosis. Why?
opening snap following S2
valve has to push itself open
What happens in mitral stenosis if pulmonary artery pressures are elevated?
a palpable P2 (light tap felt over pulmonary artery/vein) may be detected at the upper left sternal border, also associated with a prominent pulmonic component of S2 on auscultation
**Characteristic rheumatic deformity observed is doming ______ of the anterior mitral valve leaflet. What is this due to?
“hockey stick” in mitral stenosis
This is secondary to fusion of the commissures and tethering of the leaflet tips
What is the tx for mild/moderate mitral stenosis? Give the reason why with each
Beta Blockers for HR control
Diuretics are used to relieve pulmonary congestion and signs of RV failure
BP control for afterload reduction
What is the tx for moderate/severe mitral stenosis and severe symptoms? What is considered moderate/severe s/s?
refer for sx
s/s when sitting down not moving/doing anything
Why is percutaneous balloon valvuloplasty not a common tx option for mitral stenosis?
because of the valve location. Have to go through atrial septum to access the valve
NOT a definitive tx, only used in pliable, noncalcified leaflets and chords
What is the definitive tx for mitral stenosis?
Valve Replacement Surgery is otherwise definitive treatment with bioprosthetic or mechanical valve replacement
mitral regurgitation is the result of abnormalities of the _____, _____, _____ or ______. What are some common causes?
MR results from abnormalities of the mitral leaflets, annulus, chordae, or papillary muscles
MV prolapse
LV dilation (cardiomyopathy)
Posterior wall MI
Rheumatic fever
Endocarditis
What does mitral regurgitation result in?
Results in regurgitant blood flow from the LV to the LA during systole
complication of mitral regurgitation, _____ and ______ dilate to compensate for increased volume
left atrium and left ventricle
In mitral regurgitation, what does left ventricle dilation cause? then what happens?
LV dilation continues causing elevation in diastolic filling pressures and a reduction in LV systolic function
LA pressures build and pulmonary venous pressures increase resulting in pulmonary congestion
LA and LV dilate to compensate for the increased volume
What is the presentation of mitral regurgitation?
most remain asymptomatic and well-compensated for many years
s/s will appear due to depressed left ventricle systolic function (fatigue, dyspnea on exertion, peripheral edema)
**What does a mitral regurgitation murmur sound like? Where is the best place to hear it? What can also be heard if there is mitral valve prolapse?
Holosystolic murmur
best heard at the apex and radiates to the axilla and back
Mid-systolic click may be present if mitral valve prolapse present
______ is the diagnostic modality of choice to dx mitral regurgitation. What is the monitoring recommendations? What is also recommended to asses severity?
TTE echo
TTE monitoring every 3-5 years for mild, 1-2 years for moderate, and 6 mos for severe depending on symptom severity may be useful
cardiac cath
What is the medical management of mitral regurgitation?
ACE/ARB or BB to reduce afterload
diuretics to treat pulmonary congestion and reduce overall volume
What is the definitive tx for mitral regurgitation? ______ or ______ may also indicate the need for intervention regardless of left ventricular size and function
sx BEFORE irreversible myocyte damage and left ventricular remodeling occurs
Afib or pulonary HTN
What are the different types of mitral regurgitation surgeries?
MV repair:
annuloplasty, when a prosthetic ring is sewn in
or mitral valve replacement
When is mitral valve repair NOT indicated?
Not indicated if the MV is heavily calcified or disrupted secondary to papillary muscle disease or endocarditis
Why is acute mitral regurgitation considered life threatening? What does it result in?
because the left atrium does NOT dilate to accommodate the regurgitant volume
Results in abrupt increase in LA and pulmonary venous pressures which leads to pulmonary congestion
What are the causes of acute mitral regurgitation?
Acute MI
Trauma
Endocarditis
Tachyarrhythmia in patient with chronic MR
MVP – papillary muscle / chordae tendineae dysfunction
What are the s/s of acute mitral regurgitation? What does the murmur sound like? What is the tx?
hypotension
tachycardia
syncope
pale
sweating
SOB
soft, low-pitched sound in early systole
urgent valve replacement sx
mitral valve prolapse is MC in ______. What is it defined as?
MC in women
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
Nonspecific symptoms of chest pain, palpitations, dizziness, anxiety, fatigue. Most patients are asymptomatic
What am I?
**What will auscultation reveal?
mitral valve prolapse
mid-systolic click usually followed by late-systolic murmur
What is the diagnostic imaging of choice for mitral valve prolapse? What is the tx? What if severe mitral regurgitation is present?
echo
Most patients with mild prolapse and insignificant MR are asymptomatic and require no intervention
mitral regurgitation present: MV repair or replacement is indicated
Consider looking at this flow chart again :) maybe idk idk
