Valvular Disorders, Pt 1 Flashcards
risk factors for valvular heart disease
- Congenital defects
- Aortic stenosis
- Pulmonic stenosis
- Bicuspid aortic valve - Aging
- Degenerative valve disease
- Valve calcification
- Mediastinal radiation therapy - Other illnesses / disease
- Infective endocarditis
- Rheumatic fever
Aortic Stenosis occurs in 2 settings
- Congenital
- Unicuspid, bicuspid, or quadricuspid valve
- Sx classically present prior to age 50 - Acquired
- Rheumatic fever, valve calcification, and degenerative stenosis
- sx typically present after age 50
Congenital and acquired Aortic Stenosis leads to _____ and ______ of the valve leaflets, which results in a _____ _____ ______.
This ultimately results in ___, which then leads to diastolic dysfunction and eventually into systolic dysfunction
thickening and calcification
narrowed valve opening
LVH
Results from calcium deposition on valve leaflets
MC in elderly patients
MC surgical valve lesion in developed countries
what type of AS?
Degenerative or calcified AS
risk factors for calcified AS
HTN, HLD, Smoking
types of congenital abnormalities of AS
- bicuspid
- acommissural
- unicommissural
cardinal sx of AS? Prognosis?
- Most are ax for yrs, despite severity (defined by imaging)
- Cardinal sx:
- Angina - underperfusion of endocardium
- Syncope - ↑LV pressure stimulates baroreceptors to induce peripheral vasodilation
- CHF - Once sx occur, prognosis drops to 2-5 yrs unless surgical correction is made
PE findings of AS
-
Murmur
- Midsystolic, crescendo-decrescendo
- Best heard at the right 2nd interspace, with radiation to carotids
- Medium pitch, harsh quality, often loud with a thrill
- Heard best sitting and leaning forward - Laterally displaced, sustained apical impulse
- S4 gallop may be present
EKG may demonstrate LVH
diagnostic studies for AS
- CXR
- Echo
- Cardiac catheterization - Confirms presence of severe AS and any CAD
which diagnostic study Could show enlarged cardiac silhouette, calcified aortic valve, dilated ascending aorta
CXR
which diagnostic study Can measure the mean transvalvular pressure gradient and the valve area
echo
managements for AS
- Symptomatic pts w/ severe AS → aortic valve replacement
- Open AVR through sternotomy or TAVR
- requires anticoagulation
— Mechanical valve → Warfarin +/- ASA 81 mg
— TAVR → Plavix x 6 months; lifelong ASA 81 mg - Transcutaneous Aortic Valve Implantation (TAVI/TAVR)
- Balloon valvuloplasty
- No medical therapies proven to slow progression
- +/- statins
- Medical therapies for sx include afterload reduction and volume reduction - refer!!
useful for congenital AS, but not used often for degenerative AS due to complications and high restenosis rate
what type of AS management
balloon valvuloplasty
useful for patients who are poor candidates for open heart surgery
indicated for those of intermediate risk
which AS management?
Transcutaneous Aortic Valve Implantation (TAVI) / replacement (TAVR)
Caused by disease of the aortic leaflets, aortic root, or both
what type of valvular disorder?
Aortic Regurgitation
causes of Aortic Regurgitation of leaflets
rheumatic fever
congenital abnormalities (bicuspid valve)
infective endocarditis
HTN
causes of aortic regurg of root
aortic dissection or root dilation, Marfan’s
chronic AR leads to __ and ___ due to the need to accommodate for the additional regurgitant volume
LVH and dilation
presentation (sx) of AR
- May remain asx for yrs
- determined by how quickly regurg occurs
- Sx are typically due to increase in LV filling pressures, leading to CHF - Exertional dyspnea and fatigue MC
- Angina may occur
- Similar mechanism to AS in that coronaries are not getting the perfusion they need d/t aortic insufficiency
Physical Exam Findings of AR
- Murmur
- Early diastolic, decrescendo, blowing
- High pitched, best heard in the 2nd to 4th left interspaces, with radiation to the apex
- Best heard sitting, leaning forward - Widened pulse pressure
- S3 or S4 gallops may be present
- A low-pitched, diastolic mitral murmur, may be heard at the apex (Austin Flint murmur)
diagnostic study for AR
Echocardiography (TTE)
Helps monitor progression of disease to determine timing for surgery
tx for AR?
any recommendations?
-
AVR surgery for symptomatic severe AR or with LV changes
- Recommend AVR prior to LV dilation > 5.0 cm or reduction in EF to < 50% - Medical tx - vasodilators to unload the ventricle
- does not slow progression
Acute Aortic Regurgitation is caused by: (4)
Infective endocarditis
traumatic rupture of aortic leaflets
aortic root dissection
acute dysfunction of a prosthetic aortic valve
Acute Aortic Regurgitation results in ____ ____ because the LV is unable to accommodate the increased diastolic volume
hemodynamic instability
Leads to increased LV size → LA → lung vasculature pressure → pulmonary congestion → pulmonary edema
presentation of acute aortic regurgitation
- s/s of cardiogenic shock
- Pale, cool extremities
- Weak, rapid pulse - Murmur
- Low-pitched, early diastolic - SHOCK
diagnostic studies for acute aortic regurg
- STAT Echocardiography
- Can also see moderate/severe LVH on EKG
- cardiomegaly with LV prominence on CXR
tx for acute aortic regurg
-
vasodilators + diuretics if BP is stable
- Inotropic agents and vasopressors may be necessary - Treatment of choice remains urgent aortic valve replacement
Occurs when thickening and immobility of the mitral leaflets impede flow from the left atrium to the left ventricle
what type of valvular disorder?
Mitral Stenosis
causes of Mitral Stenosis
- Rheumatic fever (MC)
- Congenital abnormalities
- connective tissue disorders
- left atrial tumors
- overly aggressive surgical repair of MR rarely occur
mitral stenosis is MC in who?
women - 2/3 pts
pathophys of mitral stenosis
- The pathologic changes of MS d/t rheumatic dz occur over many yrs before dysfunction becomes hemodynamically important
- Gradually leads to:
- Fusion of the leaflet commissures and thickening, fibrosis, and calcification of the mitral leaflets and chordae
Initial hemodynamic changes with MS include elevated left atrial pressure, causing ____
LA enlargement
This is transmitted back to the pulmonary venous system and may result in pulmonary congestion
Chronic elevations in pulmonary venous pressures → increase in pulmonary vascular resistance and pulmonary arterial pressures → ?
RV failure
LV filling pressures are __ or __ with mild to moderate MS
As the stenosis becomes severe, LV filling is impaired, which leads to what? (2)
normal or low
reducing the stroke volume and cardiac output
sx of mitral stenosis
- Pts w/ rheumatic MS don’t develop sx until at least the 4th or 5th decades of life (approx. 20 to 40 yrs following illness)
- sx related to pulmonary vascular congestion and RV failure
- Fatigue, exertional dyspnea, orthopnea MC
- A-fib also common
- Sudden hemoptysis d/t rupture of the dilated bronchial veins
- Blood-tinged sputum associated with pulmonary edema
additional findings of mitral stenosis
- Peripheral embolism from left atrial thrombus
- Peripheral edema
- Compression of the left recurrent laryngeal nerve from a severely dilated LA may result in hoarseness (Ortner syndrome)
PE of mitral stenosis
- Low-pitched, rumbling, diastolic murmur best heard at the apex in left lateral decubitus
- S1 is loud in early MS. S1 then softens as the leaflets become more calcified and immobile
- opening snap following S2
- If pulmonary artery pressures are elevated, a palpable P2 may be detected at the upper left sternal border, also associated with a prominent pulmonic component of S2 on auscultation
use bell of stethoscope!
LA abnormality
A. Fib is possible
RV hypertrophy pattern is possible
this EKG is closely associated with which valvular disorder?
mitral stenosis
diagnostic tool of choice for mitral stenosis
-
echo
- TTE
- TEE
Characteristic “hockey stick” of the anterior MV leaflet is seen in which valvular disorder?
mitral stenosis
rheumatic deformity
This is secondary to fusion of the commissures and tethering of the leaflet tips
can measure the extent of the valvular calcification and severity of stenosis in mitral stenosis?
criterias?
TTE
Normal MV area is 4 to 6 cm²
Critical MS is <1 cm²
allows for measurement of the cardiac output and transvalvular gradient in mitral stenosis
what diagnostic tool?
cardiac catheterization
tx for mitral stenosis
- Mild-moderate MS
- Managed medically for sx control - HR control - Beta blockers
- Diuretics - for pulmonary congestion and signs of RV failure
- Mod-Severe MS and severe sx (NYHA class III or IV) - percutaneous or surgical intervention → Refer
which surgical intervention for mitral stenosis is recommended for patients with:
Pliable, noncalcified leaflets and chords
Minimal MR and
No evidence of LA thrombus
-
Percutaneous balloon valvuloplasty
- not definitive tx
- Not common d/t location of valve
what is the definitive tx for mitral stenosis
Surgery is otherwise definitive treatment, with bioprosthetic or mechanical valve replacement
results from abnormalities of the mitral leaflets, annulus, chordae, or papillary muscles
what type of valvular disorder?
mitral regurg
causes of MR (5)
MV prolapse
LV dilation (cardiomyopathy)
Posterior wall MI
Rheumatic fever
Endocarditis
MR results in regurgitant blood flow from the ____ to the ____ during systole
LV
LA
pathophys of MR
- LA and LV dilate to compensate for the increased volume
- Mitral annulus stretches, which prevents closure, leading to worsening the MR and LV dilatation
- 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
sx of MR
- Most with chronic MR remain asx and well-compensated for many yrs
- When sx occur, likely d/t depressed LV systolic function
- Fatigue
- Dyspnea on exertion
- Peripheral edema
Murmur of MR
- Holosystolic murmur best heard at the apex and radiates to the axilla and back
- Mid-systolic click may be present if MVP present
diagnostic studies for MR
findings?
- EKG
- LA abnormality, LVH pattern
- Afib may be present -
Echocardiography
- Defines MV pathology and severity of MR, and assesses LV size and function - Cardiac catheterization - assess severity of MR and LV function
– Filling pressures can be measured and coronary anatomy can be defined
what is recommended if male patient >40 or menopausal female w/ RF (MR)
coronary angiography
tx/management for MR
- Medical
- Afterload reduction with vasodilators (ACE / hydralazine)
- Diuretics - for pulmonary congestion, pulmonary edema, and to reduce overall volume - Surgical - definitive
- Timing is difficult
- Surgery before irreversible myocyte damage and left ventricular remodeling occur
- known MR should have at least annual echos to monitor LV size and function
- Afib / pulmonary HTN - indication of surgery regardless of LV size and function
- MV repair is possible - Annuloplasty (a prosthetic ring is sewn in)
- MV replacement - if repair is not feasible
Preserves the mitral apparatus which helps maintain normal LV geometry and function
what type of surgical intervention for MR?
MV repair - Annuloplasty
annuloplasy is Not indicated if ?
the MV is heavily calcified or disrupted secondary to papillary muscle disease or endocarditis
A life-threatening condition that may result from abnormalities with the papillary muscles, chordal structures or leaflets
Acute Mitral Regurg
pathophys of Acute Mitral Regurg
- LA does not dilate to accommodate the regurgitant volume
- Results in abrupt increase in LA and pulmonary venous pressures
- Leads to pulmonary congestion
causes of acute mitral regurg
- Acute MI
- Trauma
- Endocarditis
- Tachyarrhythmia in chronic MR
- MVP – papillary muscle / chordae tendineae dysfunction
s/s of acute mitral regurg? describe the murmur
- Cardiogenic shock
- Hypotension
- Tachycardia
- Syncope
- Pale
- Diaphoretic
- SOB - MR murmur is a soft, low-pitched sound in early systole
- No pressure compensation
plan for acute mitral regurg
Urgent valve replacement surgery is needed
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 type of valvular disorder
Mitral Valve Prolapse
MVP may be inherited as an what type of trait? MC in who?
autosomal dominant trait
women
May also be associated with systemic or connective tissue disorders
s/s of MVP
- Clinical Presentation
- most asx
— Nonspecific sx include chest pain, palpitations, dizziness, anxiety, fatigue (AKA MVP syndrome) - Physical examination
- Auscultation reveals a mid-systolic click, usually followed by a late-systolic murmur
diagnostic tool and tx for MVP?
- echo
- mild prolapse and insignificant MR are asx and require no intervention
- MR can worsen
- If severe MR, MV repair or replacement
