Valvular Heart Disease Flashcards
What are possible causes of valve disease?
Rheumatic fever, IE, Congenital malformations (pediatric/bicuspid), calcification, Rupture/dysfunction of the papillary muscles (MI), Aortic dissection, Syphilis
What is the pathophysiology of tricuspid regurgitation?
functional rather than organic (MS, MR, AS, AI or left-sided failure). Pulmonary hypertension leads to right ventricular dilation. the tricuspid annulus dilates, and chordal papillary muscle complex becomes functionally shortened. Prevents leaflet apposition
What is the clinical presentation of tricuspid regurgitation?
pulmonary HTN, fatigue and weakness related to reduced CO. DOE and SOB.
What is seen on physical exam and EKG with tricuspid regurgitation?
right sided failure, abnormal pulse in jugular vein, high pitched systolic murmur. Right axis deviation
What is the pathophysiology of tricuspid stenosis?
Most commonly rheumatic (fusion and shortening of chordae & leaflet thickening). As the right atrial pressure increases, venous congestion. Right atrial wall thickens and chamber dilates
What would expect on physical exam and EKG with tricuspid stenosis?
Diasystolic murmur at LLSB. Tall P waves, RAE on EKG
What is Ebstein’s anomaly?
Atrialization of RV, sail-like TV, TR. 50% ASD/PFO
50% EKG evidence of WPW.
What is the common causes of mitral stenosis?
rheumatic fever. Scarring & fusion of valve apparatus. Two-thirds of all patients with MS are female
What is the pathophysiology of mitral stenosis?
pulmonary interstitial edema, pulmonary HTN. LA stretch and atrial fib- increased HR decreases LV filling, decreased atrial kick, atrial thrombus and embolus
What are symptoms of mitral stenosis?
Fatigue, Palpitations, Cough, SOB (DOE), Left sided failure, Orthopnea, PND, Palpitation, Hoarseness
What would you hear on auscultation of mitral stenosis?
Loud S1- as loud as S2 in aortic area. Diastolic murmur: length proportional to severity
What are complications of mitral stenosis?
atrial dysrhythmias, systemic embolization, right sided CHF, massive hemoptysis secondary to ruptured bronchial veins (pulm HTN), pulmonary edema or recurrent bronchitis
What would you see on EKG of a patient with mitral stenosis?
LAE, RVH, PVCs, aflutter/fib
What are treatment options for mitral stenosis?
diuretics for LHF/RHF. Digitalis/Beta/ca blockers for rate control in afib. anticoagulation for afib. balloon valvuloplasty. Surgical-mitral commissurotomy, MVR repair usually not possible
What morphological patterns are seen with mitral regurgitation?
RVD-annular dilatation and leaflet thickening. MVP-leaflet redundancy and thickening. Ischemic papillary muscle dysfunction or chordal rupture. IE-perforation or destruction of cusps or chordae
What is the pathophysiology of mitral regurgitation?
Chronic LV volume overload leads to compensatory LVH initially maintaining cardiac output. Decompensation (increased LV wall tension) leads to CHF. LVH leads to annulus dilation and increased MR. Backflow –» LAE, Afib, Pulmonary HTN
What are symptoms of mitral regurgitation?
Dyspnea, Orthopnea, PND, Fatigue, Pulmonary HTN, right sided failure, Hemoptysis, Systemic embolization in A Fib
What are the valve areas and mean gradients for mild, moderate, and severe mitral stenosis?
mild: area >1.5 and gradient < 5. moderate: area 1.0-1.5 and gradient 5-10. severe: area < 1.0 and gradient >10
What might you find on physical exam for mitral regurge?
apex will be hyperdynamic, laterally displaced, palpable S3 thrill, late parasternal lift. systolic murmur.
Name the valve diseases that have systolic murmurs
Aortic stenosis, Mitral insufficiency, Mitral valve prolapse,Tricuspid insufficiency
Name the valve diseases that have diastolic murmurs
Aortic insufficiency and Mitral stenosis
What will an EKG and CXR show for mitral regurge?
EKG will show LAE, afib, and LVH w/severe MR. CXR will show larger LA, LV, pulmonary vascularity, and CHF
What is non surgical tx for mitral regurge?
low sodium diet, reduce preload w/diuretics, reduce afterload with ACE inhibitors, digoxin
What is the pathophysiology of aortic stenosis?
Left ventricular outflow obstruction increases. LV hypertrophies to sustain high LV pressures eventurally results in impaired LV diastolic compliance and LA hypertrophy and enlargement.
What is concentric hypertrophy?
it is the compensatory mechanism in aortic stenosis that reduces wall stress, reduces ventricular compliance, increases LVEDP and LAP
What are the etiologies of aortic stenosis?
Congenital bicuspid aortic valve. Rheumatic aortic valve disease. Calcific (senile) aortic stenosis
What are the cardinal symptoms of severe aortic stenosis?
dyspnea, angina, syncope
What is the pathophysiology of dyspnea for aortic stenosis?
LVH causes diastolic dysfunction that progresses to LV dilation and contractile failure resulting in systolic dysfunction
What is the pathophysiology of angina for aortic stenosis?
Increased wall stress increases myocardial O2 demand, exceeds ability of coronary flow to meet demand
What is the pathophysiology of syncope for aortic stenosis?
these patients have fixed CO. When they vasodilate they have inability to augment CO leading to a drop in cerebral perfusion pressure
What are key physical findings in severe aortic stenosis?
Carotids: may hear transmitted murmur (bruits). Heart: SEM. Lungs: Rales (Failure). Extremities: Cold and decreased pulses
What will you see in diagnostic studeis with aortic stenosis?
EKG: LVH with repolarization changes “strain pattern” CXR: Aortic root dilation and failure
Echo: Aortic valve thickening and restricted motion. Doppler: increased flow velocity across aortic valve.
What are the valve areas and mean gradients for mild, moderate, and severe aortic stenosis?
mild: area >1.5 gradient 50
What is the pathophysiology of acute aortic regurgitation?
Sudden diastolic volume overload without LV dilation: Acute elevation in left ventricular diastolic pressure leads to pulmonary edema. Acute LV systolic failure leads to hypotension
What is the pathophysiology of chronic aortic regurgitation?
Slowly progressive diastolic volume overload. Increased systolic pressure with low diastolic pressure: wide pulse pressure.Progressive left ventricular dilatation, some hypertrophy. Increased diastolic compliance with maintenance of normal diastolic pressures initially. Late systolic failure with reduced ejection fraction and CHF
What are the most important predictors of survival after surgery for aortic regurgitation?
LV systolic function and ESD
Why is there a widened pulse pressure with aortic insufficiency?
The force of systolic contraction during aortic insufficiency (AI) elevates the systolic blood pressure (SBP) and the failure of the valve to close decreases the diastolic blood pressure (DBP)
What type of murmurs are you likely to hear with aortic regurgitation?
Early diastolic murmur-Upper RSB with root dilation
and Mid to lower LSB with leaflet dysfunction. Systolic murmur at base (similar to aortic stenosis). Austin Flint murmur: mid to late diastolic “rumble” at apex
What causes the Austin Flint murmur in aortic regurge?
the vibration of the anterior leaflet of the mitral valve as it is buffetted simultaneously by the blood jets from the left atrium and the aorta.
How is aortic regurgitation treated?
follow up of left ventricular size and function with serial echocardiograms (Every few years with mild AR, every 6-12 months with severe AR). Endocarditis prophylaxis. vasodilators, digoxin, diuretics. valve replacement
What is mitral valve prolapse?
congenital (Marfans), RHD, sequelae of cardiomyopathy/MI. Valve leaflet has redundant tissue. Extra tissue balloons into LA, click sound
What are symptoms of mitral valve prolapse?
Palpitations, Arrhythmias, Atypical Chest Pain
What are the physical exam and diagnostic findings of mitral valve prolapse?
Thin, young females. Mid-systolic click. Arrhythmias-SVT, WPW
What is the treatment for mitral valve prolapse?
SBE prophylaxis and Beta blockers
