Valvular dz Flashcards
Valvular heart disease incidence
2.5% in US
Valve associated with stenosis and regurg
aortic stenosis = also regurgitant
What increases the mortality in pts with regur?
CAD w/ mitral or aortic valve disease
Mitral regurgitation d/t ischemic heart disease
New York Heart Association Functional Classification of Patients with Heart Disease
class 1
asymtomatic
New York Heart Association Functional Classification of Patients with Heart Disease
class 2
symptoms with ordinary activity but comfortable at rest
New York Heart Association Functional Classification of Patients with Heart Disease
class 3
symptoms with minimal activity but comfortable at rest
New York Heart Association Functional Classification of Patients with Heart Disease
class 4
symptoms at rest
Murmurs cause
-Turbulent blood flow across abnormal valves
-Increased flow across normal valves
Functional murmur
innocent/physiologic murmur due to a condition outside the heart
pregnancy
Pahtologic murmur
seomthing going on inside the heart itself
Identifying characteristics of the murmur
Timing of the murmur in the cardiac cycle is most important
location, radiation and intensity.
Midsystolic vs holosystolic and diastolic murmurs
midsystolic murmur
can be fucntional murmur
Occur between distinct S1 and S2 heart sounds
Crescendo–decrescendo pattern
hear at R sternal border, if goes to the carotids = aortic stenosis
Systolic murmur
Stenosis of the aortic or pulmonic valves
Incompetence of the mitral or tricuspid valves
Midsystolic or holosystolic
Holosytolic murmur
merges with S1 and S2
best heard at apex and radiates to the axilla = mitral regur
Diastolic murmur
Stenosis of the mitral or tricuspid valves
Incompetence of the aortic or pulmonic valves
follows s2.
aortic stenosis murmur location
R sternal border
radiates to cartoids, ejection clock, also diastolic murmur if aortic regur is present
Aortic regurg murmur location
L sternal border
may also have systolic murmur due to increased SV
mitral stenosis murmur location
apex.
opening snap after S2, loud S1, radiation to L axilla
mitral regurg murmur location
apex
radiates to the L axila
Common auscultatory sites
Aortic: 2nd ICS RSB
Pulmonic: 2nd ICS LSB
Tricuspid: 5th ICS LSB
Mitral: 5th ICS MCL
Valve disease ekg dx
Left atrial enlargement (notched p wave)
Left or right axis deviation (hypertrophy)
Dysrhythmias (afib)
Possible ischemia/previous MI
Valve dz cxray
Cardiomegaly
Left mainstem bronchus elevation
Valvular calcifications
aortic abnormalities
Mechanical valves
Metal or carbon alloy
Very durable… 20-30 years
Highly thrombogenic
Young pts
hemolysis
Bioprosthetic valve
Porcine or bovine
Shorter lasting… 10-15 years
Low thrombogenic potential
Elderly pts
DC warfarin
Discontinuation of warfarin
for Minor vs major surgery
bridge therapy
Rebound hypercoagulable state
Anticoagulation during pregnancy
Continue but warfarin can lead to spont termination of pregnancy in 2st trimester
ASA or lmwh
Mitral stenosis
Rare in the US
Rheumatic heart disease
Primarily affects women
Asymptomatic for 20-30 years
Normal mitral valve orifice area
Normal mitral valve orifice area is 4–6 cm2
Symptoms develop - < 2 cm2
LV contractility remains normal in….
Mitral stenosis
MS symptoms
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary HTN
Atrial fibrillation
MS CXR
Mitral calcification
Pulmonary edema or vascular congestion
Elevated left main bronchus
Straightening of left heart border
MS EKG
Notched P waves
AFib
MS Treatment
Rate control; β-blockers, calcium channel blockers, digoxin
Left atrial pressure; Diuretics
Anticoagulation - risk of stroke 7-15% per year
Arterial thromboembolism vs venous thrombosis
surgical correction
MS maintains svr and bp using….
Phenylephrine, vasopressin
Prevention and treatment of decreased cardiac output or pulmonary edema in MS pts by….
avoiding Excessive pre-op IV fluid or Trendelenburg position
Mitral regurgitation
More common than MS
2% of the US population
Mitral regurgitation associated with
IHD
Ruptured papillary muscle
Endocarditis
Mitral valve prolapse
Cardiomyopathy
MR pathophysiology
Left atrial volume overload and pulmonary congestion
Transforms LV
Eccentric hypertrophy
Compliance of left atrium
Mr Symptoms
History of IHD, endocarditis, papillary muscle dysfunction
Holosystolic murmur at apex
Radiates to axilla
Cardiomegaly
Atrial fibrillation
MR EKG
Left atrial and LV hypertrophy
Atrial fibrillation
MR CXR
Cardiomegaly
Left atrial and LV hypertrophy
Mr treatment
Asymptomatic vs symptomatic pts
MV repair > MV replacement
EF < 30% little improvement with surgery
Transcatheter mitral valve repair; MitraClip
Vasodilators, biventricular pacing; ACE-I, β-blockers (carvedilol)
HR for MR
Normal to slightly increased HR
avoid Bradycardia – LV volume overload
Avoid increased SVR
Vasodilators (nitroprusside)
Aortic stenosis associated with
Calcific aortic stenosis- leaflets calcify/ get stenotic
Bicuspid aortic valve- seen in younger patients (30-50)
Develops earlier in life with BAV than with tricuspid aortic valve
most common congenital valvular abnormality
bicuspid aortic valve in 1-2% of population
normal aortic valve area
Normal valve area 2.5 - 3.5 cm2
Severe AS valve area < 1cm2
As pathophysiology
Obstruction to ejection of blood into the aorta
Increased LV pressure
Always associated with AR
Concentric LV hypertrophy- subendocaridal compression
As symptoms
Systolic or midsystolic murmur – right upper sternal border
Crescendo–decrescendo pattern
Radiates to neck, mimics carotid bruit
Critical AS
Angina pectoris; Increased risk of peri-op mortality and MI
Syncope
Dyspnea on exertion - diastolic dysfunction = elevated LV filling pressures
AS Symptoms correlate with…..
Symptoms correlate with an average time to death of 5, 3, and 2 years
75% of symptomatic pts die w/in 3 years w/o valve replacement
AS cxr
Prominent ascending aorta
Aortic valve calcification
AS ECG
LV hypertrophy
ST Depression
T wave inversion
AS echo
Tri-leaflet vs bi-leaflet valve
Thickened and calcified leaflets
Valve area and transvalvular pressure gradients
balloon valvotomy done with….
for adolescents/young adults with AS
> 65 do TAVR
CPR is typically not effective with….
aortic stenosis
Fluids with AS
Intravascular fluid volume - normal levels
Preload dependent
tx of hypotension with AS
Hypotension - α-agonists (phenylephrine)
tx of Junctional rhythm or bradycardia with AS
- ephedrine, atropine, or glycopyrrolate
Tx of tachycardia with AS
Tachycardia - β-blockers (esmolol)
Aortic regurgitation caused by
Endocarditis
Rheumatic fever
Bicuspid aortic valve (BAV)
Anorexigenic drugs
Acute aortic regurgitation caused by
Endocarditis or aortic dissection
AR pathophysiology
Decreased CO d/t regurgitant SV
Combined LV pressure and volume overload
Usually slow onset
Magnitude of aortic regurgitation depends on:
Time available for regurgitant flow (HR)
Pressure gradient across the aortic valve (SVR)
(Austin-Flint murmur) heard in….
AR
Low-pitched diastolic rumble
Hyperdynamic circulation causes
Widened pulse pressure
Decreased DBP
Bounding pulses
s/s of LV failure
Dyspnea, orthopnea, fatigue and coronary ischemia
AR on EKG/cxr / echo
LV enlargement and hypertrophy
Echocardiogram
Leaflet prolapse or perforation
Associated aortic abnormalities
treatment for AR
Decrease systolic HTN, LV wall stress, and improve LV function; Diuretics, ACE-I, CCB
Surgical ; AVR, Aortic root replacement
AR avoid….
Avoid bradycardia, HR: > 80 bpm
Avoid increased SVR
Minimize myocardial depression; Inotrope to increase contractility
