Valvular Heart Disease 1.25.18 Flashcards
How many cusps does the mitral valve have?
2 (posterior cusp -smaller, and anterior cusp - bigger)
S1 is created by the closing of what?
mitral and tricuspid (AV valves)
S2 is created by the closing of what?
semilunar valves
How many phases of diastolic filling are there?
2
Describe the two phases of diastolic filling
- Passive rapid filling as ventricles relax (80% of ventricular filling)
- Atria contract
Name 5 causes of Left Ventricular diastolic dysfunction
- Longstanding HTN
- Ventricular hypertrophy
- Fibrosis
- Infiltrative cardiomyopathy
- Pericardial constriction
S3, or ventricular gallop, is most commonly associated with what?
Left ventricular failure/overload
blood from the left atrium slams into an enlarged ventricle during early diastole
When can S3 be heard?
early diastole
S4, or atrial gallop, is most often associated with what?
left ventricular hypertrophy
blood trying to enter a stiff, non-compliant left ventricle during atrial contraction
Which murmurs increase with inspiration?
right-sided murmurs
What murmur is harsh, systolic, best heard at left sternal border?
Ventricular septal defect (VSD)
Dyspnea (exertional, postural, nocturnal paroxysmal) rales, pleural effusion (diminished breath sounds) pallor/cyanosis, fatigue, tachycardia are signs of what?
Left heart failure
JVD, peripheral edema, hepatomegaly, ascites, hepatojugular reflex, weight increase are signs of what?
Right heart failure
What type of murmur is heard in a quiet room by an expert examiner?
Grade I
What type of murmur is heard by most examiners?
Grade II
What type of murmur is loud without thrill?
Grade III
What type of murmur is loud with thrill?
Grade IV
What grade of murmur has a thrill with a VERY loud murmur audible with stethoscope placed lightly over the chest?
Grade V
Grade of murmur with thrill and very loud murmur audible even with stethoscope slightly away from chest?
Grade VI
When can a continous murmur be heard?
throughout systole and diastole
What diagnostic test/eval is indicated for systolic murmur greater than grade II and any diastolic murmur?
Echocardiogram
Most common cause of aortic stenosis
calcified valve
also caused by rheumatic fever
What is the initial compensatory response of the heart with aortic stenosis?
Left ventricular hypertrophy
Describe the changes in the left atrium with aortic stenosis
the left atrium will also hypertrophy in attempt to overcome the increased resistance due to the hypertrophy of the left ventricle
Where can a murmur radiate with aortic stenosis?
carotids
Where can a murmur radiate with aortic regurgitation?
left sternal border
Classic triad of aortic stenosis (usually severe AS)
- Angina
- Syncope
- Heart Failure
What type of murmur is associated with aortic stenosis?
- mid systolic,
- crescendo-decrescendo
- harsh
- radiating to neck
Aortic stenosis exam
- Delayed carotid upstroke
- Sustained apicial impulse
- Split S2, S3, if heart failure.
S4 due to stiff LV
What type of test is contraindicated in patients with severe aortic stenosis?
Exercise stress test
What is the medical therapy for severe aortic stenosis?
ineffective, need surgery or TAVR (transcatheter AV replacement)
Indications for surgical intervention for aortic stenosis
- severe AS with symptoms
- LV dysfunction as result of AS
- Moderate aortic stenosis when the patient needs CABG (class IIa recommendation)
Balloon valvuloplasty is a safe and effective treatment for AS in what population?
pediatric with congenital stenosis
What are the two types of valves?
- Bioprosthetic
2. Mechanical
Bioprothetic valves
- Shorter lifespan than mechanical (10-15 years)
2. usually used in elderly
Mechanical valve
- Longer lifespan (should last lifetime of patient)
- Life long anticoagulation (Warfarin only!)
- Usually used in younger populations
Name 3 issues/complications with a TAVR (transcatheter aortic valve replacement)?
- CVA
- Complete heart block
- Paravalvular leak
Chronic causes of aortic regurgitation
- Degenerative valve disease
- Root dilation
- Rheumatic fever
- Endocarditis
- Collagen vascular diseases
Acute causes of aortic regurgitation
- Aortic dissection
- Endocarditis
- Post valve replacement
- Valvuloplasty
Aortic regurgitation physical exam findings
- Widened pulse pressure
- Water hammer pulse - rapid upstroke, quick collapse
- Blowing diastolic decrescendo murmur (LUSB)
- Austin Flint Murmur - mid-late diastolic rumble heard at apex in severe AR
What might be found on a CXR of aortic regurgitation?
- Cardiomegaly
- Dilated aortic knob
- Pulmonary edema (maybe)
What is medical management of patients who are nonsurgical candidates with aortic regurgitation?
- Vasodilators
- Calcium channel blockers
- ACE -inhibitors
What type of patient with aortic regurgitation would benefit from Beta blocker?
- Marfan syndrome
2. Bicuspid aortic valves
What should you think with acute aortic regurgitation?
AORTIC DISSECTION!
What physical exam findings would you expect in acute aortic regurgitation?
- Signs of hemodynamic compromise
- Diastolic murmur is softer than chronic
- Thready weak pulse
- Soft or absent S1
Are Beta blockers indicated in acute aortic dissection?
yes, beta blockers help reduce force from LV ejection to the arterial wall
What is the most common cause of mitral regurgitation?
mitral valve prolapse
What is the classic finding of mitral valve prolapse?
mid systolic click
also, holosystolic blowing murmur of mitral regurg
How does the heart compensate for chronic mitral regurgitation?
the heart increases inotropy (or contraction strength) to keep flow going forward
What type of murmur is classic in mitral regurgitation?
holosystolic, apical, blowing murmur
- radiation to the axilla
- often with thrill
Which heart sound is associated with mitral regurgitation?
pansystolic murmur
Why is repair better than replacing the valve in mitral regurgitation?
repair has less morbidity and mortality (need to anticoagulate for 3 months)
What is the treatment for acute mitral regurgitation?
- IV nitro (afterload reduction)
- IABP implant as bridge to urgent surgery
What is the cause for nearly all mitral valve stenosis?
rheumatic fever
High thromboembolic risk if patient has Afib and ______
mitral valve stenosis
Enlarged left atrium from mitral stenosis impinges on recurrent laryngeal nerve causing _____
hoarseness
The opening snap followed by low pitched rumbling mid-diastolic murmur of mitral stenosis is best heard with _______
Bell while patient is in left lateral decubitus position
What 3 tests would you consider for a tricuspid stenosis?
- EKG
- Echocardiogram
- Cardiac cath (if concern for other valve abnormalities or open repair planned)
Which type of valve is preferred in the tricuspid postion? Why?
bioprothesis is preferred as mechanical prothesis have high thrombotic risk in tricuspid position
Most common cause of Tricuspid regurgitation
dilated right ventricle dilating the annulus of the valve
what murmur is associated with tricuspid regurgitation?
- pansystolic
- 3rd to 4th intercostal space
- increases with inspiration
what murmur is associated with pulmonic stenosis
- harsh
- systolic
- crescendo-decrescendo
- best heard at 3-4 ICS
What might pulmonic stenosis show on EKG?
right axis deviation and Right ventricular hypertrophy
A brief low pitched diastolic murmur heard at the 3rd and 4th ICS
pulmonary regurgitation murmur
Name the 4 defects of Tetralogy of Fallot
- Ventricular septal defect
- Pulmonic stenosis
- Overriding aorta (over the ventricular septal defect)
- Right ventricular hypertrophy
What does squatting accomplish in tetralogy of Fallot?
Squatting decreases right to let shunt
Describe the murmur associated with Tetralogy of Fallot
Harsh and systolic. Largely due to the ventricular septal defect
What antibiotic is the go to for prohylaxis before a dental proceedure?
Amoxicillin
