Valvular heart disease

Question 1

Classification of stenosis and regurgitation

Answer 1

• Mild: 1.5-2cm
• Moderate: 1-1.5cm
• Severe: <1cm
• Severity of regurg: based on imaging and hemodynamic parameters, semiquantitative (mild/moderate/severe)

Question 2

Aortic stenosis 1

Answer 2

• Etiology: bicuspid (congenital, most common, manifests around early life and 4th decade), rheumatic fever sequelae (Sx manifest decades after infection usually 4-5th decade, very often theres mitral valve involvement as well), degenerative (most common in older pts, >65)
• Sx: angina, dyspnea, syncope (HF Sx), once any of these Sx appear the prognosis goes way down (<2 yrs)

Question 3

Aortic stenosis 2

Answer 3

• PE: sustained LV impulse (hypertrophic LV), reduced amplitude and delayed carotid pulse (+/- carotid thrill), harsh systolic (after S1) ejection murmur diamond shaped (crescendo-decrescendo)
• ECG: LVH, LBBB, secondary ST-T abnormalities
• CXR: cardiomegaly, post-stenotic dilatation, Ao calcification, laterally/inferiorly displaced apex

Question 4

Aortic stenosis 3

Answer 4

• Echo: valve morphology, calcification, valve area and gradient abnormalities
• Cardiac cath: very high LVP (200), with low systolic Ao pressure (100), meaning very large difference btwn max ventricular pressure and max Ao pressure
• Rx: no medical Rx, must have surgery (bioprosthetic, mechanical) to replace or valvuloplasty (via catheter)

Question 5

Aortic regurg (AR) etiology

Answer 5

• Depends if its chronic or acute (usually chronic)
• Chronic valve problem: congenital bicuspid, rheumatic, endocarditis, myxomatous degeneration
• Chronic Ao root problem: marfan’s, erdheim’s medial necrosis, ankylosing spondylitis, syphilis
• Acute: endocarditis, trauma, dissection, rupture of prosthetic valve
• Acute is usually endocarditis, w/ resultant increase in LVP, LAP, pulmonary edema, weakness and reduced CO resulting in death if not Rx

Question 6

Chronic AR Sx, signs, and findings 1

Answer 6

• Sx: pounding pulse (water hammer), wide pulse pressure (systolic HTN from increased SV), orthopnea, PND, volume overload, LVH (from increased LVEDP- HF Sx), chest pain and inadequate coronary perfusion
• Signs: increased LV SV and Ao pulse pressure, S2 (diastolic) decrescendo murmur, to and fro femoral murmur, head bobbing

Question 7

Chronic AR Sx, signs, and findings 2

Answer 7

• ECG: LVH, LBBB
• CXR: cardiomegaly, laterally/inferiorly displaced apex (LVH)
• Echo: abnormal Ao root and valve morpholgy, LVH
• Cath: high systolic Ao pressure (due to greater SV/FoC) and low diastolic Ao pressure (due to regurg) leads to wide pulse pressure
• Rx: no real med Rx, surgery is needed but timing is important for valve repair/replacement

Question 8

Differences btwn AR and AS

Answer 8

• The high Ao resistance in AS leads to high LVP but low SV, thus CO goes down even though there is muscular hypertrophy of LV
• In AR, the regurgitation in to LV causes higher EDV thus increasing SV and leading to dilation hypertrophy of the LV
• Main difference: AR is volume overload, AS is pressure overload

Question 9

Mitral stenosis 1

Answer 9

• Almost always due to rheumatic fever sequelae
• Sx: dyspnea, orthopnea, decreased exercise capacity, sometimes palpitations
• Signs: loud S1 (late diastole when LA contracts), high-pitched opening snap (after S2- early diastole) followed by diastolic rumble (low-pitched) murmur (decrescendo)
• Often see RV lift, loud P2 (due to pulm HTN), may see atrial fibrillation

Question 10

Mitral stenosis 2

Answer 10

• Will not see LVH, but can see LAE (often) and RVH
• ECG: LAE, RVH, afib
• CXR: LAE, double contour R lower border, prominent main pulm artery, RVH
• Echo: hockey-stick valve +/- fish-mouth deformity
• Cath: perpetually high LA pressure, with markedly high diastolic LA pressure
• Rx: BBs to slow rate, anticoagulants (for afib), antiobio prophylaxis (endocarditis), valvuloplasty (#1), surgery

Question 11

Chronic mitral regurg 1

Answer 11

• Etiology (primary): rheumatic (most common), SLE, valvulitis, anorectic drugs, marfan’s, ehlers-danlos, degenerative myxomatous, ischemia
• Secondary etiologies: dilation of the LV annulus leading to leaflets unable to seal together
• Sx: dyspnea, decreased exercise capacity, fatigue

Question 12

Chronic mitral regurg 2

Answer 12

• Signs: Laterally displanced PMI (LVH), holosystolic murmur (constant volume) w/ max at apex radiating to axilla, occasional S3
• ECG: LAE, LVH, repolarization abnormalities
• CXR: cardiomegaly, pulm congestion
• Echo: various mechanisms of MR (prolapse, ruptured chord, rheumatic, etc)

Question 13

Chronic mitral regurg 3

Answer 13

• Cath: large “V wave” which is a peak in LAP during late systole due to blood regurg, high LAP and low systolic pressure (due to low SV)
• Rx: can Rx CHF Sx using digoxin, diuretics, ACEIs, anticoagulants for afib, antibio endocarditis prophylaxis
• But only way to Rx the valve is surgical repair/replacement

Question 14

Acute MR

Answer 14

• Etiology: endocarditis, chordae tear, papillary muscle rupture, infarction/ischemia
• Sx: severe DOE
• Rx: vasodilator (nitroprusside), need urgent MV repair/replacement

Question 15

Mitral valve prolapse

Answer 15

• Leaflets fall back into LA
• Sx: atypical chest pain, palpitations, lightheadedness, fatigue, anxiety
• Signs: mobilar mid systolic click, late systolic murmur, tall/thin, hyperdistensible joints, thoracic cage abnormalities
• Rx: most are benign and do not require Rx, some may need BBs to control Sx, some my need endocarditis prophylaxis

Question 16

Choice of prosthetic valves

Answer 16

• Mechanical: very durable (pro) but prothrombotic (con- must be on anticoagulant for life)
• Pts younger than 65, already on warfarin
• Bioprosthetic: non-coagulable, but deteriorates
• For pts 65, those unable to take anticoagulants, women of child-bearing age