Valvular Heart Disease Flashcards
SVC & IVC
-Brings blood back to the heart
Pulmonary Artery
only artery that has venous blood
-goes to lungs to receive oxygen
Pulmonary Vein
- bring back to LA
- oxygenated blood
LV
- Pushes blood to aorta to the rest of body
- oxygenated blood
- work horse of the heart
Atrioventricular valves
between atria and ventricles
- Tricuspid & mitral
- S1 created w/ closure
Semiulnar
- Aortic & pulmonic
- S2 w/ closure
- in ventricular outflow tracts
Aortic Valve
- Calcified and degenerates
- Most common to have issues over time
- 3 leaflet valve
S1
softer than S2 at the base; often louder at apex
S2
normal splitting of S2 with inspiration; disappears with expiration; may be normal in younger, healthy patients & children
S3
gallop; heard just after S2; ”Kentucky” or lub- dub-ta; due to extra fluid striking a compliant left ventricle
S4
heard just before S1; “Tennessee” or ta-lub-dub; associated with a thickened ventricle (hypertension) or aortic stenosis
Regurgitation or Insufficiency
benign or pathological
-Backward flow
Stenosis
- narrowing or impedence in flow
- Always pathological
Systole
-occurs between S1 & S2; feel with pulse Innocent & Physiologic murmurs Aortic stenosis Mitral Regurgitation Tricuspid Regurgitation Pulmonary Stenosis Hypertrophic Cardiomyopathy
Diastole
(always pathological) – occurs after S2 before S1
Mitral Stenosis
Aortic Regurgitation
Common Systolic murmurs: Aortic Stenosis
- Aortic stenosis (most common of aging)
- Harsh murmur
- Right, 2nd ICS
- Crescendo-decrescendo (diamond shaped)
- Intensity correlates with severity of obstruction
- Carotid upstroke may be decreased and/or delayed (parvus tardus)
Aortic Stenosis
Causes:
Aging- Degenerative calcification of aortic cusps
Congenital- Bicuspid Aortic Valve (BAV)
Rheumatic Heart Disease (RHD)
Risk Factors
Elevated LDL & lipoprotein a, DM, smoking, CKD, metabolic syndrome
Aortic Stenosis Symptoms
- Usually no symptoms until disease is severe
- Onset age 60-80s in chronic degenerative AS
- Onset age 40-50s in BAV
- Fatigue, DOE most common
- —Triad: Angina, Heart Failure, exertional Syncope for critical AS
Management of AS
- Treat heart failure with diuretics
- Treat LV dysfunction
- Cautious use of nitrates and Ace inhibitors in Severe AS
- Avoid strenuous activity when AS is moderate or greater (esp. weight lifting)
- Aortic Valve Replacement (SAVR)
- Transcutaneous Aortic Valve Replacement (TAVR)
Common systolic murmurs: Mitral Regurgitation
- Mitral valve leaflets don’t meet, allowing backflow of blood into atrium during systole in LA
- Holosystolic
- Apex
- High-pitched; blowing
- Intensity is related to pressure gradient across the valve from left atrium to left ventricle
- May radiate to axilla or into back as gradient worsens
- Intensity increases with hand grip
- Happening in systole not as harsh as AS
MR
Acute Causes
- Acute Myocardial Infarction (with papillary muscle rupture)
- Ruptured chordae tendineae
- Infective Endocarditis
- Chest trauma
Chronic causes
-RHD; MVP; calcification; congenital; HOCM; dilated CMP
MR Symptoms
Acute
-pulmonary edema
Chronic
-fatigue, DOE, orthopnea (late symptoms)
MR management
Treat heart failure with diuretics
Treat LV dysfunction
If Atrial Fibrillation, anticoagulation needed
Follow serial echocardiograms based on progression of disease and symptoms
Timing of surgical repair
MitraClip percutaneous device for severe inoperable MR
Mitral Valve Prolapse
Heard best at the apex
Systolic “click” murmur
May be followed by high-pitched late systolic crescendo-decrescendo murmur at apex
Most common in women ages 15-30 years old
Causes:
unknown
may be genetic; often associated with Marfan’s Syndrome or other connective tissue disorders
Mitral Valve Prolapse: Symptoms
Symptoms:
Often asymptomatic
Palpitations, presyncope/syncope
(with associated arrhythmias)
Chest pain
Classification/Pathophysiology:
May progress to Severe Mitral Regurgitation (MR)
Most common cause of isolated severe MR requiring surgical intervention in North America
MV prolapse management
Treat arrhythmias
In Atrial Fibrillation, anticoagulation needed
With history TIA/stroke, use Aspirin or Warfarin
Follow serial echocardiograms on patients MR or progressive symptoms
TR
-Systolic Murmur heard when severe
–Primary Tricuspid Regurgitation:
RHD
Congenital – Ebstein’s Anomaly, TV Prolapse
Endocarditis
Carcinoid tumors
Device lead impingement
Iatrogenic (RV biopsy)
-Secondary Tricuspid Valve Regurgitation:
Functional (Sev LV failure, Pulm HTN)
90% cases
TR Symptoms
PE findings / Symptoms:
-Prominent V waves, DOE, dyspnea at rest with severe HF, liver congestion, early satiety, LE edema, anasarca
Classification/Pathophysiology:
- Severe TR leads to right heart failure, venous system congestion & decreased CO.
- Poor outcomes and high mortality
TR Management
Manage Right HF with diuretics
Treat LV dysfunction
Anticoagulate patients with Atrial Fibrillation
Often requires frequent hospitalizations
May be surgically repaired in some cases
Device lead impingements
FORMA percutaneous device
Common Systolic murmurs: Hypertrophic Cardiomyopathy
- Harsh, systolic murmur
- Through precordium
- Worsens with Valsalva
- Lessens with standing or squatting
- Due to thickened ventricular septum restricting ventricular outflow track
- Genetic disease < 200,000 cases/year
Common Diastolic murmurs: Aortic Regurgitation
- High pitched
- Decrescendo
- Left 4th ICS
- Intensity related to amount of blood that reflexes back into left ventricle during diastole
- Instruct patient to lean forward & hold breath
- Intensifies with hand grip
AR Symptoms
Symptoms:
Fatigue, dyspnea, syncope
PE Findings:
Increased arterial pulse pressure; “Water hammer” pulse; head bobbing
Thrill and heave may be palpable
Thrill may radiate into carotids
AR Management
Follow with echocardiogram every 3-12 months
Treat heart failure
Treat LV dysfunction
Surgery
Consider symptoms, LV function, assessment of end-diastolic and systolic dimensions, response to exercise
Patients are not usually symptomatic until LV function deteriorates
Operate in asymptomatic patients when severe AR with LV dysfunction < 50% and LV end SD > 55 mm & end DD > 75 mm.
Delayed surgical treatment often does not restore LV function
Common Diastolic Murmurs: Mitral Stenosis
-Low-pitched Rumble -Use Bell of stethoscope applied lightly at apex -Turn patient on left side -May be accompanied by opening snap -Intensifies with light exercise
Guidelines for anticoagulation
WARFARIN ONLY – NO DOACS
Bioprosthetic Valves:
Typically for 4-6 weeks post-operatively
Mechanical Valves:
Dependent upon position
Mitral position is most thrombogenic
Consider other comorbid conditions
Mitral Stenosis classifcation
-Normal valve area 4 - 6 cm2
- Mild - Valve area < 2 cm2
- –causes an increased atrioventricular pressure gradient to maintain CO
- –PVP and PAP increase (dyspnea)
- Moderate - Valve area 1 - 1.5 cm2
- —LVEF normal at rest & rises suboptimally with exertion
- Severe - Valve area < 1 cm2
- —-LVEF may be suboptimal at rest and fail to rise with exertion
Mitral Stenosis Management
Treat heart failure with diuretics
Anticoagulate patients with Atrial Fibrillation
Balloon Valvotomy or Repair before LVEF can increase with exertion
Valve Replacements
Bioprosthetic:
Traditionally for patients > 65 yo
Technology is improving
Mechanical:
Traditionally for patients < 65 years old
Require life-long anticoagulation with Warfarin (Coumadin)
-ABX treatment before dental procedures (SBE prophylaxis)
Spontaneous Bacterial Endocarditis (SBE) Prophylaxis: Oral
Amoxicillin
Ampicillin
or Cefazolin or Ceftriaxone
Allergic to penicillin’s or ampicillins: Cephalexin or Clindamycin or Azithromycin or clarithromycin
