Valvular Disorders, Part 2 Flashcards
Two types of valve disorders
Regurgitation
Stenosis
6 clinical classification categories¹ based on anatomy and symptoms
- Stage A - at risk for valvular heart disease
- Stage B - mild/moderate² progressive valvular heart disease but asymptomatic
- Stage C - severe valvular heart disease but asymptomatic
- C1 - severe valve lesion but asymptomatic with normal LV function
- C2 - severe valve lesion but asymptomatic with abnormal LV function - Stage D - symptomatic patients due to valvular heart disease
Pt comes in with
1. Murmur
- Midsystolic, crescendo-decrescendo
- Medium pitch, harsh quality, often loud with a thrill
2. Laterally displaced, sustained apical impulse
3. S4 gallop (may be) present
4. EKG may demonstrate LVH
what are you suspecting?
aortic stenosis
Pt comes in with
Murmur
Early diastolic, decrescendo, blowing, High pitched
with radiation to the apex
Widened pulse pressure
S3 or S4 gallops present
A low-pitched, diastolic mitral murmur, may be heard at the apex (Austin Flint murmur)
what is this presenting
aoritic regurgitation
where and how is aortic regurgitation best heard?
best heard in the 2nd to 4th left interspaces, radiation to apex
Best heard with the patient sitting, leaning forward with breath held after exhalation
Pt comes in with
Low-pitched, rumbling, diastolic murmur
S1 is loud in early MS. S1 softens as the leaflets become more calcified and immobile
An opening snap following S2 is usually present
what are they presenting
mitral stenosis
how is mitral stenosis best heard
best heard at the apex with patient in left lateral decubitus position
how does MVP present?
Most are asx
Nonspecific sx include chest pain, palpitations, dizziness, anxiety (AKA MVP syndrome)
PE - Auscultation reveals a mid-systolic click, usually followed by a late-systolic murmur
tricuspid stenosis is MC in who?
women
Generally an uncommon valvular disorder
tricuspid stenosis is MC associated with other conditions
AS or MS
rarely isolated dz
causes of tricuspid stenosis
Rheumatic heart disease (worldwide)
MCC in US: Carcinoid disease¹, prosthetic valve degeneration
Congenital anomalies, leaflet tumors/vegetations
RHF → hepatomegaly, ascites, peripheral edema, fatigue
Elevated JVP
Soft, high-pitched, diastolic rumbling murmur along lower left sternal border
Mimics mitral stenosis, except for increased¹ sound with inspiration
Opening snap may be heard
what is this presenting
tricuspid stenosis
What can we expect to happen physiologically and clinically when we see a patient with tricuspid stenosis?
reduced RA emptying into RV –> peripheral venous congestion –> JVD, edema, hepatic congestion
–> reduced RV output –> reduced LV output
pt presents with Lower extremity edema, JVD, ascites
what are you suspecting
RHF
diagnostic study for tricuspid stenosis?
echo
other testing for evaluation of tricuspif stenosis
EKG → right atrial enlargement
CXR → cardiomegaly
management of tricuspid stenosis
- Treat the resulting HF
- Diuretics - Loops
— Torsemide or bumetanide if bowel edema
- Add aldosterone antagonist if liver congestion or ascites is present - TV replacement = surgery of choice
- Indicated if symptomatic
Typically results from any dilation of the right ventricle and tricuspid annulus (due to anatomic placement of chordal attachments)
Tricuspid Regurgitation
TV annulus is ______, so as the valve collapses and becomes ____ with RV failure/dilation, regurg worsens
saddle shaped
elliptical
MCC of RV dilation in Tricuspid Regurg
- Pulmonary HTN, LV failure, PV stenosis, severe PV regurgitation, cardiomyopathy, infiltrative processes (sarcoidosis)
- other: Endocarditis, carcinoid syndrome, congenital abnormality, chest wall trauma
In the absence of pulmonary HTN, TR is _____ by the patient
well tolerated
As it progresses patients develop and present with symptoms of RV failure
presentation of progressed tricuspid regurg
- signs of RHF: Fatigue, ascites, and peripheral edema, JVD
- Hepatic congestion and palpable systolic liver pulsation may be appreciated
- Murmur - high-pitched, pansystolic, best heard at L sternal border
- Accentuated with inspiration or leg-raising by increasing venous return
diagnostic study of choice for tricuspid regurg? other testing?
echo
EKG → afib/flutter possible
Cardiac cath can confirm elevated RA pressure
Tricuspid Regurg - Management
Treat underlying cause & HF symptoms!
when to replace or repair for tricuspid regurg?
- Repair is considered (annuloplasty) to restore TV function for pts with persistent sx
- Replacement must be considered for underlying primary leaflet pathology
- Anticoag not needed unless Afib present
Typically isolated, congenital defect
Can occur as a result of genetic syndromes → Noonan, Trisomy 13
what is this condition
pulmonic stenosis
Stenosis usually a result of fused pulmonary leaflets, creating ____
pressure-overloaded state that results in RVH
Neonates with critical PS present with ?
central cyanosis at birth
presentation of pulmonic stenosis in adolescence/young adults
Most patients are usually asymptomatic until adolescence or young adulthood otherwise
1. Mild to moderate PS is usually asx
2. Moderate to severe stenosis results in progressive fatigue and dyspnea on exertion
- This can further lead to RV dysfunction and RV failure
Systolic ejection murmur best heard at ?
left upper sternal border
Increases with inspiration
Radiates to left shoulder
pt presents with
Systolic ejection murmur
S1 followed by opening click that is louder with expiration
RV lift on palpation of precordium
what could this be?
pulmonic stenosis
management for pulmonic stenosis
- Mild PS (<36 mmHg peak gradient)
Asx and require no intervention - Moderate PS (peak gradient 36-64 mmHg)
- If asx, require balloon valvuloplasty or surgical valve replacement - Moderate to severe PS (peak gradient >64 mmHg)
- Require balloon valvuloplasty or surgical valve replacement
Typically due to dilation of the PV annulus secondary to pulmonary HTN
Symptoms are related to primary disease and secondary to RV failure
Pulmonic Regurg
murmur of pulmonic regurg
diastolic, high-pitched, blowing quality, best heard at second left intercostal space
diagnosing pulmonic regurg
- Everyone gets an ECHO!
- Cardiac MRI and CT can be helpful
- Give detailed info on size of PA
- Help exclude other causes of pulmonary HTN - EKG typically not helpful, although RBBB is common
management for pulmonic regurg
1.Treat the cause of the pulmonary HTN!
2. Valvular intervention
- PV replacement is rare for PR patients
— for cases of intractable RV failure
types of prosthetic heart valves
Mechanical & Tissue
which Prosthetic Heart Valve
Extremely durable
High thromboembolic risk and require lifelong anticoagulation
mechanical
what is the only approved anticoagulant for mechanical heart valve
goal INR
coumadin
INR 2.3-3.5
which prosthetic heart valve
Lower risk for thromboembolic event
Less durable (about 10 years of life)
tissue
what med can reduce risk of thromboembolism development for tissue prosthetic heart valvemultifactorial consideration
ASA 81 mg
Valve chosen requires ___
multifactorial consideration
Patient age, compliance for anticoagulation, and valve position
caused by infection with group A beta-hemolytic strep
what type of heart disease?
Acute rheumatic fever (ARF)
RHD develops secondary to abnormal immunologic response
ARF typically affects who? (no gender disparity)
children 4-9 y/o
why has rheumatic heart disease decreased in the US?
a result of antibiotic access, RHD continues to be a major health issue in resource-limited countries
in RHD myocardium is infiltrated with ____ and areas of necrosis may occur
lymphocytes
rheumatic heart disease is characterized by __, diffuse inflammation of the heart
pancarditis
Aschoff body is associated with what?
Characteristic histologic finding in myocardium of RHD
Collection of myocytes and macrophages surrounded by fibrous tissue
Valvulitis is characterized by ___ on leaflet edge
verrucous lesions
what valves are MC affected by verrucous lesions?
MV, then AV
presentation of rheumatic heart disease
an acute, febrile illness 2-4 wks following strep pharyngitis infection
No lab test is a “stand alone” for diagnosis
criteria used for diagnosing RHD?
Jones Criteria
1. Major Criteria
- Carditis (pleuritic chest pain, friction rub, HF)
- Polyarthritis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
2. Minor Criteria
- Fever
- Arthritis
- Previous rheumatic fever or known RHD
diagnostic criteria of RHD
- 2 major criteria met
- 1 major and 2 minor criteria met
- AND if criteria are present following a recent, documented strep infection
2015 REVISED RECOMMENDATION: 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
tx for RHD
PCN - eradicate strep infection
Salicylates - for fever and arthritis
are recurrent attack in RHD common?
yes
Especially during first 5-10 years after initial infection
tx for recurrent RHD
Prophylaxis be continued for up to 10 yrs
- PCN G 1.2 million units IM monthly
- Oral PCN or erythromycin may be used but be mindful of compliance
