Valvular heart disease Flashcards
What is the most common cause of mitral stenosis
Chronic rheumatic valve disease - valve scarring from repeated acute rheumatic fever attacks
What size is the mitral valve for patients to become symptomatic
1.5 cm2 (normal is 4 to 5)
What are the complications of mitral stenosis
Dilitation of left atrium1.) Risk of Afib2.) Pulmonary congestion3.) Pulmonary HTN4.) Right-sided heart failure
What are some symptoms of mitral stenosis
1.) Exertional dyspnea, orthopnea, PND (pulmonary congestion2.) Hemoptysis - ruptured anastomoses of small bronchial veins3.) Thromboembolism with Afib4.) Ascites and dependant edema - RVF
What are the physical exam signs seen in mitral stenosis
1.) Mitral stenosis murmur - opening snap with diastolic rumble, followed by loud S12.) RVF - Right ventricular heave, JVD, hepatomegaly, ascites
What two things makes the symptoms of mitral stenosis worse
1.) Exercise2.) Pregnancy
What two things can be used to diagnose mitral stenosis
1.) CXR - enlarged atrium (early)2.) Echo - most important, shows everything
What is the medical treatments used for mitral stenosis
Only for symptoms, treat pulmonary congestion and edema with diuretics, treat heart rate and cardiac output with beta blockers, give infective endocarditis prophylaxisAlso put these patients on chronic anticoagulation with warfarin
When is surgery indicated for mitral stenosis, and what are the best procedures
When severePercutaneous balloon valvuloplasty works for mitral stenosisOpen commissurotomy and mitral valve replacement if other is contraindicated
How should you manage asymptomatic patients with mitral stenosis
You don’t, could give diuretics for mild symptoms
What area must the aortic valve be in order to see decreased cardiac output
0.7cm2, cardiac output doesn’t increase with exercise, causing angina/syncope
What are the consequences of aortic stenosis on the heart muscle
First left ventricular hypertrophy, then eventually dilation pulling the mitral valve apart and causing mitral regurgitation
What are the causes of aortic stenosis
Wear and tear via calcification - in elderly (happens sooner if bicuspidRheumatic heart disease - causes fusion of commissures rather than calcification
What are symptoms of aortic stenosis
Dyspnea, angina and syncope on exertionClassic end disease triad: Angina (35%) - survival 3 yearsSyncope (15%) survival 2 yearsHeart failure (50%) - survival 1.5 years - orthoponea, PND, dyspnea on exertion
What are the physical exam signs of aortic stenosis
1.) Systolic murmur - crescendo/decrescendo murmur in right intercostal space that radiates to carotid arteries2.) Soft S23.) S44.) Parvus et tardus - diminished/delayed carotid upstrokes5.) Sustained PMI
What are four diagnostic modalities used for aortic stenosis
1.) CXR - calcified aortic valve2.) ECG - LVH, LA abnormality3.) Echo - diagnostic in most cases4.) Cardiac cath - definitive test, measures valve gradient and valve area, to do before surgery too
What is the treatment for aortic valve stenosis
Asymptomatic - no treatmentSymptomatic - Surgery only (replacement)
What is the mortality rate for aortic stenosis at 3 years without replacement
75%
What is the effect of aortic regurgitation on the heart muscle
LV dilation and eccentric hypertrophy (volume overload), eventual increased left sided and pulmonary pressure
What are two main causes of aortic regurgitation
1.) Aortic root dilation - syphilis aneurysm, aortic dissection, osteogenesis imperfecta, Reiters2.) Valve disease - Infective endocarditis most common, rheumatic fever, marfans, ehler-danlos, and more
What are the four causes of acute aortic regurgitation (rest would be chronic)
1.) Trauma2.) Infectious endocarditis3.) Failed iatrogenic replacement surgery4.) Aortic dissection
What are teh symptoms are aortic regurgitation
1.) LVH failure - dyspnea on exertion, PND, orthopnea2.) Palpitations worse when lying down3.) De Mussett’s sign - head bobbing4.) Pulsating nail bed (quincke pulse)5.) Cyanosis and shock if acute
What do you see on physical examination for aortic regurgitation
1.) Widened pulse pressure2.) Diastolic descrescendo murmur at left sternal border3.) Water hammer pulse - rapidly increasing pulse that collapses immediately, at wrist or femoral arteries4.) Displaced PMI down and to the left
What increases the intensity of aortic regurgitation
Handgrip
What 4 modalities can we use to diagnose aortic regurgitation
1.) CXR - LVH, dilated aorta2.) ECG - LVH3.) Echo - perform serially in stable patients to assess need for surgery, can see dilated aortic root too, if acute then look for early closure of mitral valve4.) Cardiac catherization - to assess severity and LV dysfunction severity
Who should receive treatment for aortic regurgitation
Stable and asymptomatic - medicalAcute AR - medical emergency, immediate replacementSymptomatic - surgery (valve replacement)
What treatments can you offer to stable and asymptomatic patients with aortic regurgitation?
Free the fluids - Salt restriction, avoid exercise, diuretics, vasodilators for sure, digoxin, afterload reduction (ACE and arterial dilators)
When should you give endocarditis prophylaxis for patients with mitral regurgitation
Before dental and GI/genitourinary procedures