Valvular Heart Disease

Question 1

hx: of rheumatic heart disease. She presents with fever, fatigue and neck throbbing. She complains of abdominal fullness. Examination shows peripheral edema and ascites. There is a 1/6 systolic blowing murmur at the lower left sternal border with a 3/6 diastolic rumble. Both murmurs are increased with inspiration. A split first heart sound is present.

Answer 1

tricuspid valve: systolic murmur due to insufficiency, diastolic murmur due to stenosis.

• see Carvallo’s sign: indicates tricuspid regurgitation

Question 2

Carvallo’s sign?

Answer 2

deep inspiration –> more blood goes into right atrium and right ventricle, will result in increased murmur on right side of heart.

= a clinical sign found in patients with tricuspid regurgitation. The pansystolic murmur found in this condition becomes louder during inspiration;

Question 3

wave seen in tricuspid insufficiency/stenosis?

Answer 3

high canon A wave: atrial contraction wave

Question 4

most common cause of tricuspid failure in US?

Answer 4

carcinoid tumor

Carcinoid metastasis can lead to carcinoid syndrome. This is due to the over-production of many substances, including serotonin, which is released into the systemic circulation, and which can lead to symptoms of cutaneous flushing, diarrhea, bronchoconstriction, and right-sided cardiac valve disease.

Question 5

what are the waves?

Answer 5

a wave = atrial contraction
c wave = ventricular contraction
x wave= atrial relaxation
v wave = atrial filling
y wave = atrial emptying

Question 6

causes of canon A wave?

Answer 6

• tricuspid failure/stenosis (canon wave is very high due to stenosis and having to contract atrium to large degree)
• complete heart block (atrium contracts while ventricles are not relaxed)

Question 7

look at jugular venous tracings!!!

Answer 7

now.

Question 8

blunted y descent

Answer 8

atrial empyting, impaired with stenosis/regurgitation of the tricuspid valve

Question 9

tx for tricuspid stenosis?

Answer 9

1. diuretics: esp. torsemide (absorbed better from gut)
   - spironolactone is used for ascites
   * diuretics will reduce blood volume, preventing atrial stretching and CHF
2. balloon valvotomy (used to increase the opening of a narrowed (stenotic) valve.), open comissurotomy, bioprosthetic valve (b/c of low flow velocity and tendency to clot with mechanical valves)

Question 10

history of a prior right ventricular MI presents with fatigue and abdominal fullness. Examination shows peripheral edema and ascites. There is a 3/6 systolic blowing murmur at the lower left sternal border with an audible S3. The murmur is increased with inspiration.

Answer 10

tricuspid insufficiency due to inferior right ventricular infarction, which involves tricuspid valve

audible S3 heard when AV valves open and blood rushes in and there is already blood in there, it meets other blood and creates a vibritory sound – if there is an S3 it means there is a bad regurgitaiton

Question 11

what is third heart sound associated with?

Answer 11

heart failure

It occurs at the beginning of diastole, approximately 0.12 to 0.18 seconds after S2 (floppy atria)

associated with:
1. rapid ventricular filling: mitral regurg, tricuspid regurg, dilated cardiomyopathy, poor left ventricular function

Question 12

what wave is seen with primary tricuspid insufficiency?

Answer 12

larve CV wave… due to there being no X wave (no atrial relaxation) and no low pressure in the atria, because there is flow back into the atria constantly

large cV wave also seen any time that the RV is dilated: ex. pulmonary HTN, pulmonic regurg, left ventricular failure where PA or RV systolic pressure is high

anything effecting right ventricle results in large CV wave

Question 13

COPD and pulmonary hypertension presents with a split P2 and a diastolic 2/6 murmur at the left 2nd intercostal space that increases with a deep breath. what type of murmur is this?

Answer 13

• pulmonic valve murmur that increases with deep breath, diastolic murmur represents pulmonic insufficiency

“Graham Steele murmur” relates now to pulmonic regurgitation from any cause of pulmonary hypertension

Question 14

high pressure pulmonary insufficiency

Answer 14

• due to pulmonic regurgitation from pulmonary hypertension
• prolonged RV systole, also see mitral stenosis problems or COPD
• called “graham steell murmur”

high pressure from pulmonary HTN –> difficulty ejection through pulmonic valve = high pressure PI

Question 15

low pressure pulmonary insufficiency

Answer 15

there is very little murmur here, it results from pulmonary valve being damaged and blood leaking back

ex. trauma, dilated pulmonary annulus, carcinoid plaque, bicuspid valve, repaired tetrology

Question 16

tx for pulmonic regurgitation?

Answer 16

high pressure: tx pulmonary HTN

low pressure: watch, not much that can be done

Question 17

pregnant female from Iran presents with exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Auscultation with the patient in the left lateral decubitus position reveals a loud M1 and an early diastolic sound at the mitral area.

EKG shows right atrial enlargement (negative P wave), and large waves indicating RVH

Xray: shows left atrial enlargement

Echo: shows large LV and LA

Answer 17

Mitral stenosis (loud first heart sound)

• see “hockey stick sign” on echo: doming of anterior mitral valve due to mitral stenosis during diastole- atrium tries to empty into ventricle, but its obstructed and the anterior leaflet domes
• see straight border of heart due to left atrium being enlarged

Question 18

auscultory findings in mitral stenosis?

Answer 18

Loud M1 (unless calcificed): due to mitral valve closing against lots of pressure, it slaps back

• opening snap (unless calcified): occurs after S2, with worsening LA pressure - due to all the blood present in LA that didn’t get in last diastole
• rumbling diastolic murmur: can be heard if bell placed lightly over chest, heard after second heart sound
• presystolic accentuation of diastolic rumble (just before systole the rumble increases)

Question 19

two syndromes assoc. with mitral stenosis?

Answer 19

in mild/moderate stenosis: (valve surface area of 1.5cm) results in pulmonary edema

in severe stenosis (<1cm)
see pulmonary HTN and right sided CHF, AF, and low CO (this is due to vessels clamping down, due to all of the edema)

Question 20

Graham Steel murmur?

Answer 20

heard at the left sternal border from relative pulmonary insufficiency

• if mitral valve stenosis is severe enough, causes back up into lungs, resulting in pulmonary insuffieicny and murmur

Question 21

What are ECG findings of mitral stenosis?

Answer 21

see negative P wave and RAD???

Question 22

two reasons why there would be mitral stenosis?

Answer 22

thickened immobile leaflets due to rheumatic heart disease, or could be annular calcium deposits (degenerative changes)

Question 23

tx of mitral stenosis?

Answer 23

based on echo evaluation -

score of 8 or less: use valvuloplasty (balloon is inflated to widen the narrowed mitral valve)

score 8-10: needs mechanical (INR 2.5 - 3.0) or bioprosthetic valve (lasts 10-15 years)

(if young use mechanical valve b/c won’t have to replace it often) - will have to be on Warfarin (coumadin) in order to prevent clotting on valve

Question 24

male with long standing mitral regurgitation presents with new onset palpitations, orthopnea and Paroxysmal nocturnal dyspnea. There is a high pitched pan systolic murmur with an S3* at the apex. The patient is on a beta blocker and an ACE inhibitor.

Answer 24

mitral regurgitation –> causes left heart failure –> results in edema in lungs/HTN –> right heart failure

high pitched pan systolic murmur with S3 at apex is severe marker, due to mitral insufficiency (blood flowing back into atria –> floppy dilated atria)

if S3 is in the tricuspid then it is severe regurgitation

Question 25

what would see on CXR for mitral regurg?

Answer 25

see increased left side of heart size - see straightened left border

Question 26

what would see on EKG for mitral regurg?

Answer 26

see left atrial and ventricular enlargement on the EKG

Question 27

reasons why you could get mitral regurgitation?

Answer 27

mitral valve can be defective at papillary mm (dilated CM, MI)

• problems with chordae (too long, too short, or ruptured as in MVP) - marfan syndrome or EDS
• leaflet problems (perforation in endocarditis)
• annulus (could be calcified or problematic in cardiomyopathy)

Question 28

volume load due to MR?

Answer 28

THERE IS A VOLUME LOAD ON THE HEART: increased preload= enlarged LV = increased EF (due to increased volume)

• decreased afterload (in order to get mitral valve to empty forward into ventricle, rather than backward into atria)
• eventually the LV will fail and the EF starts to drop

at first will have 90% EF, b/c stretch is pushing it out and ventricles are almost all emptied, but as it wears out the EF starts to drop (this is a marker of mitral valve needing to be replaced)

Question 29

EKG changes seen on mitral stenosis vs. mitral regurg?

Answer 29

mitral stenosis = right ventricular enlargement

mitral regurg = left ventricular and left atrial enlargement

Question 30

lab tests ordered to show onset of CHF in mitral regurg pt?

Answer 30

• Increased BNP (esp >105) indicates LV dysfunction

Question 31

what is effect of handgrip and squatting on mitral regurg murmur?

Answer 31

handgrip = increased peripheral pressure = results in large afterload with back pressure into heart, causes mitral regurg to blow more blood into atrium making the murmur larger

squatting = increases pressures as well, increases backpressure and murmur gets louder. squatting also increases preload by sending more blood into the right side of the heart, which increases the murmur

• the murmur is decreased with amyl nitrate (decreased afterload) and valsalva (less blood coming back, less blood to regurgitate)

Question 32

ECG changes expected in mitral regurg?

Answer 32

LVH, LAH or atrial fibrillation

Question 33

how can you differentiate b/w sudden onset MR and chronic MR?

Answer 33

sudden onset MR: see high pressure in LA and pulmonary edema (seen in IHD, MVP with ruptured chordae or infective endocarditis with valve perforation) = see pulmonary edema and tall cV wave in LA (but not LA enlargement), low CO

chronic MR: see dilated LA and LV (seen on CXR) with normal pressure

Question 34

cV wave seen in neck v? vs. capillary wedge pressure?

Answer 34

represents tricuspid regurgitation if wave is seen in neck v.

represents mitral regurgitation if wave is seen in capillary wedge pressure

note: cV wave is seen during systole- is due to no true low pressure in the atria, blood is always in there….

Question 35

tx of mitral regurgitation?

Answer 35

• failing heart yields a decreased EF (< 60%) with increased end systolic dimension(> 40 mm) = needs surgery even when asymptomatic.
• asymptomatic pt. with severe MR tend to have effective regurgitant orifice (ERO) > 40 mm2. In the sedentary patient, severe MR may show as exercise inducible pulmonary hypertension on ECHO.

** tx is repair if there is NO calcification in annulus or valve and ERO>40 and chordae tendinae can be maintained

*** if chordae tendinae can’t be maintained and/or the EF is between 40-60% then need to replace the valve

Question 36

female presents with complaints of chest pain and palpitations. Exam reveals a mid systolic click with a late systolic murmur which shortens with lying down, handgrip and squatting. The patient has joint laxity and skin changes

Answer 36

= Mitral valve prolapse

• anxiety is also a problem, hypermobility, laxity of skin

*** NOTE: MVP acts opposite with maneuvers than expected

Question 37

how does MVP act with maneuvers? standing/valsalva/amyl nitrate?

Answer 37

standing/valsalve/amyl nitrate: make murmur louder (normally this results in less blood getting back to heart and softer murmur in mitral regurg - however here MVP results in prolaspse and the valve leaflets are sticking up - when you put less blood back into the heart, the prolapsed valves don’t meet and causes a louder murmur)

• when do valsalve in MVP there is less blodd going to heart, the MVP shows louder murmur b/c there is less blood and reuslts in worse approximation of valves

Question 38

squatting and handgrip in MVP?

Answer 38

squatting/handgrip increase the afterload (iincreased pressure on the heart) - this results in more blood getting back to heart (right atrium/RV/LA/LV) - which causes the valves to approximate better and the murmur to become softer

Question 39

what are associations of MVP?

Answer 39

1. aortic root disease
2. may be part of hyperadrenergic syndrome in young females
3. myxomatous degeneration of mitral valve (Marfans, Ehlergs Danlos syndrome) - associated with aortic regurgitation and skeletal changes
4. mid-systolic clicks, late systolic murmurs
5. atrial and ventricular arrythmias

Question 40

what murmur is heard in MVP?

Answer 40

hear mid-systolic clics with late systolic murmurs which worsen with a smaller ventricle - murmur lengthens with standing, valsalva and amyl nitrate

Question 41

tx for mitral valve prolapse?

Answer 41

• beta blockers (may be due to it being a hyperadrenergic state)
• mitral valve repair (wedge resection, chordae shortening, mitral annular ring insertion) — ** better to do repair if there is NO calcification **
• mitral valve replacement

Question 42

male presents with syncope (fainting). History is positive for a “murmur” since childhood. He reports recent onset of PND and exertional dyspnea and chest pain. There is an ejection sound with a diamond shaped harsh systolic murmur at the base and a high pitched systolic murmur at the apex. The former murmur increases after an ectopic beat and decreases with squatting.

Answer 42

congenital bicuspid aortic valve –> aortic stenosis get a coarse murmur that is diamond shaped rather than a soft murmur that is

“gallaverdin phenomenon” : in aortic stenosis the high pitched component is referred to the apex, so you could get fooled and think pt. has two different heart problems – it is due to the high pitch at the apex (they just have aortic valve that is stenosed that is referred to apex)

Question 43

bicuspid aortic valve

Answer 43

• hear “gallaverdin phenomenon”
• get stenosed/hardened aortic valve
• the more the pt. ages the more the valve is prone to calcification and atherosclerosis –> aortic stenosis due to calfication
• ** note: must check coronary aa. before operating on aortic calcification b/c they probably have atherosclerosis of those vessels as well

Question 44

why syncope with bicuspid aortic valve?

Answer 44

Peripheral vasodilation from high ventricular pressures stimulating baroreceptors in the LV. The reduced afterload calls for increased stroke volume which can’t occur due to the aortic stenosis, thus BP falls and the patient “passes out”.

THE MORE aortic stenosis, the harder the ventricle contracts, the more the aorta dilates so that ventricle can empty better  dilation of aorta results in it no longer being able to be filled, thus the patient passes out – thus can’t do catheterization on these patients, will have a cardiac arrest

Question 45

what does carotid palpation reveal?

Answer 45

• late and slow pulse due to aortic stenosis - limits flow of blood and thus results in LVH and LAH

Question 46

genetics of bicuspid aortic valve?

Answer 46

(Vit D and Notch1 may be involved in cell-cell communication for valve development).

Question 47

How is the pressure gradient across the aortic valve measured in pt with aortic stenosis? What is the critical valve area?

Answer 47

Peak doppler gradient = measurement of the flow velocity through the valve orifice squared x 4. Thus a 4 m/s flow = 64 mm Hg peak gradient. (42 x 4).

***LV failure, angina or syncope occur when the peak valvular gradient reaches 64 mmHg (mean gradient of 40 mmHg). – means valve needs to be replaced (know the numbers!!!)

Valve area < 1 cm2 = critical.

Question 48

What are the dangers in heart cathertization

and the treatment of AS?

Answer 48

Crossing the aortic valve at heart cath for CAD can induce cardiogenic shock, pulmonary edema, stroke or death. Nitrates are also dangerous. (will make them pass out, nitrates dilate aorta, heart can’t make up for decreased afterload, can’t pump out the blood and pt. passes out)

Question 49

what is critical Aortic stenosis?

Answer 49

*critical AS = mean gradient > 50 mmHg, valve area < 0.75 cm2, severe calcification density, pulmonary
hypertension > 50 mmHg, and elevated C-terminal BNP.

Question 50

How is it possible for a patient with severe aortic stenosis to present
with a valve gradient of < 30 mmHg?

Answer 50

valve gradient that is low is due to heart starting to fail – ventricle can’t contract hard enough to keep flow up – thus is called low gradient low flow aortic stenosis with reduced EF (low gradient, low flow aortic stenosis means that heart is getting weak)

if replace valve in this situation, it might not help b/c their heart is already shot.

Question 51

low gradient, low flow aortic stenosis with reduced EF - how is it ddx?

Answer 51

patient has failure as a result of increased afterload or another cardiac contractility problem as from ischemic heart disease, MI, fibrosis of another CM

** diagnosed with dobutamine ECHO: if see <20% increase in SV then there is no residual mm. reserve, and aortic valve replacement will not help, need a whole new heart

Question 52

how to know if you replace an aortic valve?

Answer 52

1. Diagnose with a dobutamine ECHO: < 20% increase in SV = no muscle reserve.
2. BNP may be used in this situation of poor LV function and aortic stenosis, ie if > 550 pg/mL = poor prognosis regardless of result of dobutamine.

Question 53

tx of aortic stenosis?

Answer 53

Often needs CABG as well

young: percutaneous valvuloplasty
elderly: bovine valve

middle age: mechanical plus anticoagulation

• may need aortic root replacement, esp. w/ bivuspid valve, and aortic root diameter >50 mm

Trancutaneous Aortic Valve Replacement (TAVR) is in vogue for comorbid patients, but is associated with strokes. – replace valve through using a catheter

• statins

Question 54

o male with history of a biscuspid aortic valve and hypertension presents with new onset PND. Upon exam he has a 2/6 systolic murmur at the base with a 3/6 descrendo diastolic murmur at the base and a 1/6 late diastolic low pitched murmur at the apex.

Answer 54

= aortic insufficiency

Question 55

response of basal diastolic murmur of aortic insufficiency upon squatting/handgrip?

Answer 55

the murmur would get louder - more blood into heart and increased regurg.

Likewise it will be decreased with standing or valsalva

Question 56

what is the characteristic pulse of pt. w/ aortic insufficiency and what else can cause this?

Answer 56

AI results in horrible CO, thus they will have lots of blood in their ventricles, resulting in high systolic pressure due to hypertrophied LV, with
Wide pulse pressure ( ie. 140/50)

Will see- Corrigan’s and Quincke’s (nailbed) pulse, De Musset sign : Atherosclerosis, AV fistula, thyrotoxicosis, anemia, fever, heart block

Question 57

Corrigan’s pulse

Answer 57

large carotid pulse - seen in AI

Question 58

Quincke’s pulse?

Answer 58

pulsatile and reddening of nail when slight pressure is applied

Question 59

when do you see parvus et tardus?

Answer 59

small and weak pulse = aortic stenosis

Question 60

when do you see large and bounding pulse?

Answer 60

aortic insuffieincy

Question 61

when to do surgery for AI?

Answer 61

with sx of: of exertional dyspnea , orthopnea and PND. (SOB, C/P or syncope )

LV dysfunction with contractility failure (EF < 55%, end systolic LV dimension > 50 mm) (AR = 55/50)

. BNP > 130 pg/mL = progression to surgery.

Question 62

What other type of acute aortic insufficiency might present with an
absent M1, Austin Flint murmur, 1/6 aortic diastolic murmur and
acute CHF?

Answer 62

. Aortic dissection (marfan’s, Ehlers Danlos), endocarditis , hypertension, inflammatory disease (syphilis, giant cell arteritis, Takayasu’s), seronegative spondyloarthropathies.

Question 63

tx of aortic insufficiency?

Answer 63

Afterload reduction: Beta blockade versus ARBs (the latter reduce aortic stiffness by blocking TGF beta). These are not to be used in the absence of hypertension.

**BNP evaluation as surgical indication.

**Root replacement with valve replacement.