Valvular Heart Disease Flashcards
Ventricular anatomy and hemodynamic response to aortic stenosis
- Ventricular anatomy: aortic valve becomes fused, narrow and unable to open under normal pressures.
- Hemodynamic response: ↑end diastolic pressure ↑systolic pressure, ↓aortic diastolic pressure.
Ventricular anatomy and hemodynamic response to aortic regurgitation (insufficiency)
- Ventricular anatomy: aortic valve can not close properly to allow the build up of pressure during diastole. Vegetation may be present and causing the destruction of the valve.
- Hemodynamic response: ↑stroke volume, ↑pulse pressure,↓ aortic diastolic pressure (blood leaks back)
Causes, signs, symptoms of aortic stenosis
- Causes: bicuspid aortic valve (most common congenital heart disease), senile aortic stenosis, rheumatic heart disease
- Symptoms
- Dyspnea on exertion
- Syncope
- Angina (hypertrophy, ↑systolic pressure, ↓aortic diastolic pressure, ↑end diastolic pressure)
- Signs:
- systolic ejection murmur
- abnormal heart sounds
- Possible LV and RV failure
Qualities of heart murmur associated w/aortic stenosis
- Ejection + thrill (diamond or crescendo-decrescendo)
- Peaks later as stenosis becomes more severe.
- Radiates to neck.
Abnormal heart sounds in aortic stenosis
- S2: becomes softer as valve becomes more immobile and if myocardium deteriorates.
- Opening: sudden forceful valve opening or high pressure jet hitting aorta
- S4: LVH
- S3: if ventricle fails.
Signs/symptoms of L/R HF w/aortic stenosis
- If LV fails: narrow pulse pressure, peripheral vasoconstriction, rales, S3
- If RV fails too: ↑JVP, peripheral edema.
Cause, hemodynamic effects, signs/symptoms of aortic regurgitation
- Cause:
- Aortic leaflet disease: bicuspid valve disease, rheumatic heart disease, endocarditis.
- Aortic root disease: aortic aneurysm/dissection, marfan’s syndrome, syphilis.
- Hemodynamic effects: low aortic diastolic pressure, large stroke volume, high pulse pressure.
- Symptoms: well tolerated, symptoms of heart failure only after years.
- Signs: wide pulse pressure bounding (waterhammer) pulses, capillary pulses (quinke), diastolic decrescendo murmur (turbulence), displaced vigorous LV apex impulse.
Cause, hemodynamic effects, signs/symptoms of mitral stenosis
- Cause: rheumatic heart disease (4:1 in females)
- Hemodynamic effects: obstruction of flow from left atrium to left ventricle→↑LA pressure↑PA and RV pressure.
- Symptoms:
-
↑ Left atrial and pulmonary capillary pressures: dyspnea, cough, pulmonary edema - RV failure: ↑elevated jugular venous pressure, edema.
-
- Signs:
- Diastolic murmur: heard best in left lateral decubitus, soft, accentuated when flow is greatest; loud S1; opening snap (as mitral valve gets more severe).
- CXR: signs of ↑LA pressure→LA enlargement, Kerley B-lines and heart failure, pulmonary artery enlargement.
Characteristics of bicuspid valve disease
- common congenital heart defect
- increased risk for aortic stenosis, aortic insufficiency, endocarditis, and vascular complications
- should be monitored routinely via echo
Signs of aortic regurgitation
CXR findings in aortic stenosis, mitral stenosis
- Aortic stenosis: post-stenotic dilation of aorta, enlarged LA and LV if failure occurs.
- Aortic regurgitation: LV enlargement, dilated aorta.
- Mitral stenosis: signs of elevated LA pressure—LA enlargement, Kerley B-lines and heart failure, pulmonary artery enlargement.
ECG findings in aortic stenosis, mitral stenosis
- Aortic stenosis: LVH, occasionally L or R Bundle Branch Block.
- Aortic regurgitation: LV enlargement, dilated aorta
- Mitral stenosis: left atrial enlargment, RVH
Echo findings in aortic stenosis, aortic regurgitation, mitral stenosis
- Aortic stenosis: abnormal valve structure, ventricular hypertrophy, dilated aorta, pressure gradient, aortic valve area.
- Aortic regurgitation: valve or root pathology, ventricular enlargement, amount of aortic insuffiency.
- Mitral stenosis: abnormal valve, pulmonary pressures, mitral valve area.
General course of aortic stenosis
- can occur early in life due to a congenital malformation (bicuspid aortic valve) or late in life (senilar aortic stenosis, or somewhere in between (rheumatic heart disease).
- Good health and youth can mask the symptoms making younger people more at risk for sudden death.
- After the onset of symptoms however, there is a sharp decrease in survival, thus, treatment and therapeutic interventions should take place right away
General course of aortic regurgitation
- generally well tolerated until symptoms of heart failure appear (generally takes years).
- quick response to treat the ventricular hypertrophy associated with aortic insufficiency via replacement of the valve can result in the ventricle returning back to its near normal state.
Course/tx of mitral stenosis
- can cause heart failure and atrial fibrillation
- treat urgently
Components of mitral valve anatomy (4)
- annulus
- leaflets (2)
- chordae
- papillary muscles
Mitral valve annulus characteristics
- fibrous structure that supports valve @ AV groove
- saddle-shaped
Causes of mitral valve regurgitation
- primary valve disease (e.g. myxomatous, endocarditis, chordae rupture)
- mitral valve prolapse
- fxnl mitral valve disease
- primarily a LV problem
Mitral valve prolapse disease course
- long, asymptomatic @ first
- L atrial enlargement (–> arrhytmias)
- LV volume overload (LV dilation/dysfxn)
- HF symptoms
- risk of endocarditis
Mitral valve physical exam findings
– Mid systolic click
– Late diastolic or holosystolic murmur; Classically @ apex
– Maneuvers that Decrease LV size intensify
and prolong the Murmur: Valsalva, dehydration
– Maneuvers that Increase LV size decrease
murmur: Squatting, Hydration
Primary Mitral valve disease tx
- surgical repair, replacement
- afterload reduction (reduce BP)
- treat CHF (diuretics)
Fucntional mitral regurgitation characteristiscs (physical exam)
– Holosystolic murmur a apex: Quiet S1
– Signs of LV dysfunction:
S3, S4
Loud P2 – associated with Pulmonary
Hypertension
Lateral displacement of the apical impulse
Edema, crackles, Jugular venous distension
Functional mitral regurgitation treatment
- treat underlying cardiomyopathy: ACEi, beta-block, spironolactone, revascularization, bi-ventricular pacing, transplant
- primary mitral valve surgery is controversial
Main causes of mitral valve stenosis
– Rheumatic Heart Disease
Rheumatic fever produces antibodies
Attack the valve many years later
– Rarely senile Calcification
Age
Renal disease
Mitral stenosis disease course
Long asymptomatic period
Left atrial enlargement (can be massive)
– Atrial arrhythmias
– Clots, strokes
Heart failure symptoms
– Dyspnea, edema, orthopnea
Pulmonary Hypertension
– Right ventricular dysfunction
– Tricuspid regurgitation
Mitral stenosis physical exam findings
Loud S2
– Opening snap
S2-OS time shorter with more severe stenosis
– Diastolic rumble
At apex
– Signs of pulmonary hypertension
Loud P2
RV thrill or lift
Jugular venous distension
Tricuspid regurgitation murmur
Mitral stenosis tx
Valvuloplasty
Surgical replacement
Medical treatment
– Not curative
– Beta blockers
– Diuretics (to treat heart failure)
– Anticoagulation
– Antibiotics
Tricuspid valve anatomy
- 3 leaflets
- 3 papillary muscles
Characteristics of tricuspid valve disease
Tricuspid Regurgitation is almost always secondary to Right heart failure or
pulmonary Hypertension
Primary Tricuspid Valve disease is rare
– Congenital heart disease
– Endocarditis
– Carcinoid
– Rheumatic (less common than mitral valve)
