Valvular heart disease Flashcards
The heart valves are extremely important in the cardiac cycle because they ______
prevent backflow of blood during
ventricular contraction
What is happening with the heart valves during diastole?
During diastole, the pulmonic and aortic valves
are closed, preventing blood from flowing back
from the pulmonary artery and the aorta.
○ The AV valves are open during diastole, allowing
blood to drop from atria to ventricles
What is happening with the heart valves during systole?
During systole, the AV valves snap closed as the
pressure in the ventricles increases, preventing
blood from flowing back to the atria.
○ The increasing pressure in the ventricles pushes
the pulmonic and aortic valves open.
The _____ hold (and kind of pull) the
mitral and tricuspid valves closed
Chordae Tendineae and the Papillary Muscles
The ______ during systole pushes the tent-like valves closed
increasing pressure within the ventricles
_____ are part of the ventricle
wall and also contract, providing added
strength to keep the flaps from bulging too
far into the atria
Papillary muscles
These normal heart sounds are the sounds
made by ____ of the valves
closing
Abnormal heart sounds, such as extra sounds
(gallups), friction rubs, and murmurs generally
occur when something is _____
structurally wrong
Corresponds with closure of the atrioventricular
valves at the beginning of systole
The “lub” is also called the first heart sound, or S1
Corresponds with the closure of the Aortic and
Pulmonic valves at the beginning of diastole.
The “dub” is the second heart sound, or S2
Valvular Heart Disease is characterized by _____
damage to or a defect in
one or more of the four heart valves
Structural damage or defects can interrupt normal valvular function, which can not only result in abnormal cardiac auscultation, but can also change _____
pressure gradients within the heart
Valvular Heart Disease can produce one or both of the following:
○ Stenosis- Narrowing of the valve opening
○ Regurgitation- Incompetence or backflow leakage
In the past, most cases of
valvular disease in the US were
due to _____- especially affecting the
Mitral Valve
Rheumatic Heart Disease
Causes of valvular Heart Disease
○ Congenital heart disease
○ Coronary Artery Disease / Myocardial Infarction
○ Degenerative Calcification (product of aging)
○ Aortic Dissection
○ Infective Endocarditis
○ Cardiomyopathy
○ Some autoimmune disorders (such as Lupus)
○ Radiation exposure
What does bacterial endocarditis do to the heart valves?
Endocarditis can affect any valve,
and generally involves whichever is
most susceptible in that patient
____% of adults over the age of 65 have some
thickening of the aortic valve- “aortic sclerosis”
25
When it comes to Valvular Heart Disease, one of the most important
clinical assessments is _____
auscultation of the heart for murmurs
Systolic murmurs:
Between S1 and S2
■ Aortic Stenosis, Mitral Regurgitation, (Pulmonic Stenosis), and
(Tricuspid Regurgitation).
● “SAS MR”
Diastolic murmurs:
After S2 and before S1
■ Aortic Regurgitation, Mitral Stenosis, (Pulmonic Regurgitation), and
(Tricuspid Stenosis).
● “DAR MS”
Workup for valvular heart disease includes:
○ Chest X-ray - May reveal evidence of abnormal cardiac chamber size or
increased pulmonary vasculature (normal in mild disease).
○ EKG - May reveal evidence of ventricular hypertrophy, atrial
enlargement, ischemic disease, etc. Abnormal EKG means get Echo.
○ Cardiac Catheterization - Not always needed, but may help confirm
abnormal pressure gradients caused by valvular disease.
○ Echocardiogram - The most important diagnostic assessment for
valvular heart disease of any kind. Dx study of choice if suspecting
The most important diagnostic assessment for
valvular heart disease of any kind
Echocardiogram
_____- These should be evaluated by an Echocardiogram if
they are not a venous hum or a mammary soufflé of pregnancy
Continuous Murmurs
ALL of these murmors should be evaluated by an Echocardiogram
Diastolic Murmurs
Which systolic murmors should be evaluated by a Echo?
Early systolic murmurs, midsystolic murmurs grade 3 or more, late systolic murmurs, and holosystolic murmurs all need to be evaluated by Echocardiogram. It if is a midsystolic murmur that is grade 2 or less, it needs to be evaluated by an Echocardiogram only if the patient is symptomatic or display other signs of possible cardiac disease
Valvular disease guidelines from the AHA/ACC suggest all lesions may be
best classified into one of six categories based on anatomy and symptoms:
○ Stage A - Individuals at risk for valvular heart disease.
○ Stage B - Asymptomatic individuals with progressive valvular heart
disease (mild to moderate severity on Echo).
○ Stage C - Asymptomatic individuals with severe valvular disease.
■ C1: Severe valve lesion (on Echo), asymptomatic, normal LV function
■ C2: Severe valve lesion (on Echo), asymptomatic, abnormal LV function
○ Stage D - Symptomatic individuals as a result of valvular heart disease
Aortic Stenosis
● Narrowed, thickened, stiffened, and
roughened valve secondary to several
possible causes.
○ Most common is calcific,
degenerative changes
Common risk factors for Aortic
Stenosis include ______
aging, hypertension, hyperlipidemia, and smoking
Aortic Stenosis Pathophysiology
○ The narrowing/stiffening of the valve
makes it more difficult for the left
ventricle to eject blood during systole.
○ Ventricular systole becomes
prolonged as the heart struggles to
overcome the increased resistance.
○ Left ventricular hypertrophy can
develop due to the pressure overload,
eventually resulting in LV failure
Aortic Stenosis clinical presentation
○ Left ventricular failure, anginal chest pain, and/or syncope may be the presenting signs and symptoms in significant AS
○ In patients with calcific aortic stenosis, 50% have associated coronary artery disease as well.
○ Exertional dyspnea is also a common presentation
○ Harsh, medium-pitched, crescendo-decrescendo systolic murmur.
○ May have a sustained, significant, and heaving PMI.
○ There may be a systolic thrill over the aortic area or carotids.
○ Delayed carotid upstroke (large delay between S1 & carotid pulse).
○ A prominent S4 may be heard in late, severe disease
Long-Term Sequelae of Aortic Stenosis
○ Because of the stress placed on the
heart with AS, complications
include angina, exertional syncope,
heart failure, and sudden death.
○ Symptomatic AS has a poor
prognosis with a 25% annual
mortality risk
Aortic Stenosis Diagnosis
○ EKG often reveals LVH or secondary repolarization abnormalities.
○ CXR can show a normal or enlarged cardiac silhouette, calcifications of the aortic valve
○ Echocardiogram/Doppler is the most useful for AS
Aortic Stenosis treatment
○ Treatment of underlying/comorbid cardiovascular disease is important.
○ Medications do not seem to reduce the progression of AS (even statins).
○ Medical Tx may stabilize patients in heart failure, but intervention is indicated for all symptomatic patients with significant AS.
○ Aortic Valve Replacement (AVR) is the treatment of choice when warranted/recommended;
Aortic Valve Replacement (AVR) is indicated in these patients:
■ Symptomatic patients (stage D)
■ Asymptomatic patients with Severe AS and LVEF < 50%
■ Patients with Severe AS undergoing other cardiac surgery
____ is an effective approach to aortic valve replacement
TAVR
SAVR vs. TAVR for aortic valve replacement
■ SAVR can be considered anytime AVR is indicated.
■ TAVR should be reserved only for those patients with symptoms.
■ SAVR and TAVR are equivalent in RCTs of symptomatic patients.
If the patient receiving an AVR is over the age of 70, what type of valve is indicated? What about under 50?
A bioprosthetic valve is preferred in those over 70 YOA, while a
mechanical valve is preferred in those under 50 YOA (either if 50-70).
T/F all diastolic murmors are considered pathologic
T
Aortic Regurgitation
AR is characterized by the reflux of blood back through the “closed”
aortic valve during diastole.
○ This generally occurs because of structural abnormalities in the
valve itself, or in the aortic root
The most common causes of AR are
Congenital bicuspid valves, infective endocarditis, and hypertension
● Less common causes include Marfan-related aortic root dilation, aortic dissection, and widespread inflammatory conditions
Aortic Regurgitation Pathophysiology
○ Regurgitation secondary to any cause
results in abnormally rapid filling of the
left ventricle, increasing the intraventricular pressure.
■ Can be acute or chronic
○ Chronic AR results in substantial LVH,
even more than in aortic stenosis
Aortic Regurgitation presentation
○ The murmur of AR is a holodiastolic, somewhat decrescendo murmur that is often loud and blowing in early diastole.
■ This is generally heard best along the lower left sternal border.
○ Patients who develop sudden, acute AR present with LV failure manifested primarily as pulmonary edema (life-threatening).
○ In chronic AR, patients may be asymptomatic
○ The heart gradually compensates for the increased LV pressure and
volume, resulting in a large stroke volume.
○ The chronic increased LV pressure eventually results in LV dilation and
failure, with symptoms of dyspnea on exertion, etc.
“water-hammer pulse” refers to:
Wide Pulse Pressure (pulse is a rapid rise and fall, with elevated systolic BP and low diastolic BP;
What is a “Musset Sign”?
May see head bob with each pulse with an aortic regurgitation
Long-Term Sequelae of AR
○ Because the reflux of blood back into the left
ventricle causes significant distress to the
ventricle, complications of long-term AR include
heart failure, mitral valve regurgitation, and left
ventricular hypertrophy
Aortic Regurgitation treatment
○ Medications that decrease afterload can reduce regurgitation severity, although there is no convincing evidence that this alters mortality
■ Only treat with these medications if the patient has systolic HTN.
○ Asymptomatic patients can be monitored with periodic echocardiogram
(approx q 6 months) to watch for progression to severe AR.
Patients with one or more of the following should have AVR surgery
■ Symptoms attributable to AR
■ LV ejection fraction less than 50%
■ LV end-systolic diameter at > 50 mm or end-diastolic at > 65 mm
■ Having cardiac surgery for other indications
■ Moderate AR and undergoing other heart surgery
○ In addition, those with aortic root dilation of greater than 55 mm should undergo surgery for AVR and aortic root replacement.
Mitral Stenosis
Mitral stenosis is narrowing of the mitral valve occurring secondary to leaflet thickening, commissural fusion, and/or shortening and fusion of the chordae tendineae
Most common cause of mitral stenosis
worldwide is _____
rheumatic heart disease
Pathophysiology of Mitral Stenosis
○ The thickened, stiff leaflets of the mitral valve prevent normal, quick
flow of blood from the left atrium into the left ventricle
○ In more severe disease, LA pressure can be
increased, causing increased hydrostatic
pressure in the pulmonary vasculature, and may result in RV dilation.
○ Dilation of the LA dramatically increases the risk of developing Atrial Fibrillation
Mitral Stenosis Presentation
○ Patients with mild disease may be asymptomatic.
○ When symptoms develop, the classic presentation is that of dyspnea on
exertion, fatigue, and/or symptoms of RV failure
○ Classic findings include an early diastolic Opening Snap and/or a late
diastolic, low-pitched grumble at the apex in left-lateral position
○ 50-80% of mitral stenosis patients will develop either paroxysmal or chronic atrial fibrillation
Long-Term Sequelae of Mitral Stenosis
Atrial Fibrillation is one of the most common
complications
○ Other important complications include:
■ Heart failure, right-sided
■ Pulmonary hypertension
■ Pulmonary edema
■ Thromboembolism
Mitral Stenosis diagnostic studies
○ As is the case with the other valvular disorders, Echocardiogram is the
most valuable diagnostic technique for assessing mitral stenosis
○ Echo can also measure the effective mitral valve area
Mitral Stenosis treatment
○ Indications for intervention focus on symptoms such as pulmonary
edema, decline in exercise capacity, or evidence of Pulmonary HTN
■ Percutaneous Balloon Valvuloplasty
■ Mitral Valve Replacement
Mitral Regurgitation
Also commonly called Mitral Insufficiency, mitral regurgitation is the
systolic retrograde flow of blood from the left ventricle through the
mitral valve into the left atrium
There are several known causes of Mitral regurgitation:
○ Endocarditis
○ Myocardial Infarction
○ Trauma
○ Chronic degenerative (primary)
○ Chronic functional (secondary
Mitral Regurgitation pathophysiology
○ This increases LV preload and decreases
afterload, resulting in an enlarged LV and
LA with an increased LV ejection fraction.
○ Over time, the stress of the volume
overload reduces LV contractile strength.
Mitral Regurgitation Presentation
○ In acute severe MR, patients present with sudden symptoms of left heart failure (such as dyspnea at rest) and may have cardiac shock.
○ Chronic cases may be asymptomatic (even for life). When symptoms do develop, the patient presents with left-sided heart failure.
○ The murmur of MR is a pansystolic murmur heard best at the apex.
○ EKG and Echo in moderate-to-severe disease generally show left atrial enlargement, left ventricular hypertrophy, and commonly A-Fib.
Long-Term Sequelae of Mitral Regurgitation
■ Heart failure
■ Pulmonary Hypertension
■ Atrial Fibrillation
Mitral Regurgitation treatment
○ Mitral Valve Surgery (replacement or repair)
○ Medical therapy for heart failure should be initiated as well, including
ACEi/ARBs, Beta Blockers, and/or Aldosterone Antagonists if no
contraindications (more on HF Tx in future units)
Mitral Valve Surgery (replacement or repair) is indicated for.
■ Acute severe mitral regurgitation (emergent surgery).
■ Chronic degenerative (primary) if LV EF is < 60%, LV end-systolic
diameter is > 40 mm, and/or Sxs with LV EF greater than 30%.
■ Chronic functional (secondary) if large regurgitant volume and LV
EF is greater than 30%
Biventricular pacing for patients with symptomatic, _____ may improve symptoms
of heart failure
chronic
severe secondary MR
Mitral Valve Prolapse
Mitral valve prolapse syndrome is when a flap of the mitral valve bulges up and into the left atrium during systole
Primary causes of MVP
Marfan Syndrome and other Connective Tissue Disorders
● Secondary causes include CAD, rheumatic heart disease, and cardiomyopathies.
Severe MVP can result in significant ____
mitral regurgitation
MVP itself is clinically suspected when auscultation
reveals a ____
Mid-Systolic Click
Treatment of MVP
● Beta Blockers
● Mitral Valve Repair
Tricuspid Valve Disease includes
● Tricuspid Regurgitation may be due to an acute event, such as endocarditis or
trauma. It can also be chronic and secondary to congenital deformity,
rheumatic heart disease, etc
● Tricuspid Stenosis is often secondary to rheumatic heart disease or congenital
deformity. Bacterial endocarditis is a possible cause as well.
○ Considered rare, affecting less than 1% of the population
Tricuspid Valve Disease pathophysiology
○ Whether it be due to stenosis or regurgitation, an overload of right-sided pressure develops
○ Sometimes the pressure overload is too much and results in right-heart failure with right-sided cardiomegaly, enlarged right atria, decrease in right ventricular function, peripheral edema, and possible Atrial Fibrillation
Tricuspid Valve Disease presentation
○ Tricuspid stenosis murmur: Not much of a murmur most of the time. If
present, it may be increased with inspiration, heard best along the left
sternal border, and has a quiet, late diastolic rumble.
○ Tricuspid regurgitation murmur: May have pansystolic murmur heard
best at the lower left sternal border that may radiate to the left clavicle.
○ When symptoms do develop, they are consistent with right-sided heart
failure, which includes: Fatigue, JVD, palpable liver pulsations,
peripheral edema, ascites.
○ A right Parasternal Lift and/or Thrill may be felt in RV enlargement.
Tricuspid Valve Disease treatment
○ Consider diuretics to control volume status in symptomatic patients.
○ A percutaneous balloon valvuloplasty may be attempted in patients with symptomatic tricuspid stenosis (although not often helpful)
○ Open tricuspid valve surgery is
recommended for some patients with
symptoms of right heart failure
○ Referral to cardiothoracic surgery for
evaluation is always appropriate
Pulmonic Valve Disease include
● Pulmonic Regurgitation may be due to pulmonary hypertension (often
from pulmonary conditions), bacterial endocarditis, iatrogenic after
pulmonary balloon valvuloplasty, or congenital causes.
● Pulmonic Stenosis is almost always congenital and a disease seen in
infants. Rubella has been associated in some cases.
Pulmonic Valve Disease pathophysiology
○ Whether it be due to stenosis or
regurgitation, an overload of right-sided
pressure develops.
○ Sometimes the pressure overload is too
much and results in right-heart failure with
right-sided cardiomegaly, decrease in right
ventricular function, and signs and
symptoms of right-heart failure
Pulmonic Valve Disease presentation
○ Severe pulmonic stenosis may present as heart failure in the neonatal
period. Or it may also progress to heart failure later in childhood
○ Pulmonic Stenosis murmur: Harsh mid-systolic crescendo-decrescendo
murmur, heard best at upper left sternal border; can radiate to neck.
○ Pulmonic Regurgitation murmur: Decrescendo early to mid-diastolic
murmur heard best at the upper left sternal border.
Pulmonic Valve Disease treatment options
○ Diuretics should be considered in patients with pulmonic valve disease and
right-heart failure.
○ Cardiothoracic surgery referral for other possible interventions, which include:
The ____ valves are the most commonly replaced valves
aortic and mitral
There are several valvuloplasty options:
○ Mechanical valve- Long-lasting and made of durable material
○ Bioprosthetic “tissue” valve- Made of mammal donor tissue
○ Ross Procedure- Moving pulmonic valve to replace aortic valve
○ TAVR- Transcatheter Aortic Valve Replacement
How long do valves last?
● Bioprosthetic heart valves last about 10-15 years, where mechanical
heart valves last decades (usually for the rest of the patient’s life)
Risk of thromboembolism with heart valves
● The risk of thromboembolism is much higher with a mechanical heart
valve than it is with a bioprosthetic heart valve.
○ For this reason, patients with mechanical heart valves should be
anticoagulated with Warfarin
Pregnancy and heart valve replacement
● Because pregnancy is a prothrombotic state, the risk of morbidity and
mortality is high for pregnant patients with mechanical heart valves
● When patients with mechanical heart valves and systemic
anticoagulation need to undergo noncardiac surgery, the risk of
thrombosis from stopping warfarin versus the risk of excessive
bleeding from continuing warfarin must be weighed
