Valvular Heart Disease

Question 1

Semilunar valves

Answer 1

Aortic and pulmonary valves
3 cusps
Function depends on integrity and coordinated movements of cusps and attachments

Question 2

Atrioventricular valves

Answer 2

Tricuspid and mitral
Competency depends on integrity of valve “apparatus”
• Leaflets + annulus, chordae tendinae, papillary muscles, ventricular wall

Question 3

Valve histology/structure

Answer 3

Connective tissue core:
varies in density
• (spongiosa, fibrosa, reticularis)
• Collagen
• Elastic fibers (each varies in amount of collagen and elastin)

lined on both sides by endocardium

Question 4

stenotic

Answer 4

valve is unable to open normally, leads to volume or pressure overload

Question 5

regurgitant/insufficient

Answer 5

valve leaflets don’t close completely leading to backflow of blood

Question 6

Bicuspid Aortic Valve

Answer 6

Prevalence 1% (one of the most common)

2 cusps
• One larger with midline raphe*
• Incomplete embryonic separation

increased risk of Aortic Stenosis (50’s-60’s)
• Infective endocarditis

Underlying aortopathy (has higher risk of dissections and aneurysms)

Question 7

most common valvular abnormality

Answer 7

Valvular Degeneration 
due to Calcification

Question 8

Valvular Degeneration 
due to Calcification is caused by

Answer 8

“wear and tear” small injuries heal with a little fibrosis and a little calcification and begins to add up over time
Dystrophic calcification

Question 9

Valvular Degeneration 
due to Calcification affects which valves

Answer 9

can affect any of the valves

aortic valve calcification is the most serious and can lead to aortic stenosis

Question 10

Valvular Degeneration 
due to Calcification risk factors

Answer 10

Chronic injury – hyperlipidemia, HTN, inflammation

similar to atherosclerosis risks

Question 11

progression of aortic calcification

Answer 11

Calcified masses within aortic cusps
Prevent cusp opening 
Outflow obstruction
Increased pressure gradient across valve
Concentric LVH

Question 12

symptoms of aortic calcification

Answer 12

• Congestive heart failure
• Myocardial ischemia
• Syncope

Question 13

Mitral Valve Prolapse
 aka

Answer 13

Myxomatous Degeneration of Mitral Valve

Question 14

mitral valve prolapse characteristics

Answer 14

Enlarged, redundant, floppy leaflets
Balloon into atrium during systole
 (may cause damage to atrium)

• histologic: Thinning of fibrosa
• Expansion of spongiosa* via deposition of myxomatous (mucoid) material) (makes the valve rubbery)

Question 15

Mitral Valve Prolapse is more commonly seen in patients with what syndrome

Answer 15

marfan syndrome

Question 16

signs and symptoms of mitral valve prolapse

Answer 16

Majority asymptomatic, incidental finding (no long term complications)
Midsystolic click

Minority with nonspecific symptoms
Chest pain, dyspnea, fatigue, depression, anxiety

Question 17

mitral valve prolapse is most commonly found in

Answer 17

young women (3% of the population)

Question 18

complications of mitral valve prolapse

Answer 18

Rare, serious complications (3% of patients)
Infective endocarditis
Mitral insufficiency
Stroke/systemic infarct (due to Embolism of leaflet or atrial thrombi)
Arrhythmias

Question 19

why is endocarditis commonly found with valve injuries

Answer 19

any time there is injury to the endocardium, there is some fibrin deposits creating a place for bacteria to atttach

Question 20

Infective Endocarditis definition

Answer 20

Destructive inflammation of cardiac valves and endocardium

Infection (Bacterial most common)

Question 21

hallmark finding of infective endocarditis

Answer 21

vegetation - an abnormal outgrowth upon a body part; specifically : any of the warty excrescences on the valves of the heart that are composed of various tissue elements including fibrin and collagen and that are typical of endocarditis

Question 22

characteristics of Vegetations of 
Infective Endocarditis

Answer 22

Thrombotic debris, fibrin,  inflammatory cells, microorganims
Large, bulky
Destructive (acute inflammation) 
Erosive
Friable (weakly attached can Embolize)

Question 23

characteristics of acute infective endocarditis

Answer 23

Highly virulent micro-organisms
Usually previous normal valve
Rapid, severe destruction of valve
50% mortality
Staphylococcus aureus

Question 24

characteristics of subacute endocarditis

Answer 24

Low virulence organism
Affect previously deformed valve
Recovery with appropriate treatment
Streptococcus viridans
less severe symptoms
may have a new murmur

Question 25

patients at higher risk for infective endocarditis

Answer 25

``` Valvular disease Prosthetic valves Immune deficient Diabetic Intravenous drug abusers Alcoholics ```

Question 26

portals of entry of infective endocarditis

Answer 26

Infection elsewhere Dental or surgical procedures with bacteremia Injection of contaminated material into bloodstream Occult source (gut, oral cavity, trivial injury)

Question 27

Infective Endocarditis diagnosis

Answer 27

``` Clinical suspicion (chest pain, SOB, new murmur) Blood cultures (will be bacteremic) Echocardiogram (ultrasound of heart valves) ```

Question 28

Infective Endocarditis Complications

Answer 28

Cardiac - Valve insufficiency or stenosis - Abscess - Valve dehiscence or paravalvular leak in prosthetic valves Emboli (Brain, Kidney, Spleen, Lungs) Immunologic - Glomerulonephritis

Question 29

clinical signs of infective endocarditis

Answer 29

splinter hemorrhage osler nodes (painful on palms and soles) Conjunctival petechiae Janeway lesion

Question 30

treatment for infective endocarditis

Answer 30

Treatment IV antibiotics Surgery Prophylaxis with antibiotics for those at high risk

Question 31

list the 3 types of NONINFECTED Vegetations

Answer 31

Nonbacterial Thrombotic Endocarditis (Marantic Endocarditis) Endocarditis of System Lupus Erythematosus (Liebman-Sacks Endocarditis) Acute Rheumatic Fever

Question 32

characteristics of the vegetations in Nonbacterial Thrombotic Endocarditis 
(Marantic Endocarditis)


Answer 32

``` sterile thrombi (vegetations) small non-destructive loosely attached (easier to embolize) ```

Question 33

which patients get nonbacterial thrombotic endocarditis

Answer 33

pts who are very sick Marantic - Greek marantikos = “wasting away” Patients prone to hypercoagulable states -Sepsis, Cancer (Mucinous adenocarcinomas) Burns Indwelling catheters (Lead to endocardial trauma)

Question 34

clinical affects of a nonbacterial thrombotic endocarditis

Answer 34

Local - Little effect on valve itself Systemic Emboli Infarcts

Question 35

describe the vegetations in Endocarditis of System Lupus Erythematosus 
(Libman-Sacks Endocarditis)

Answer 35

Sterile mitral and tricuspid valves, chords small

Question 36

what causes Endocarditis of System Lupus Erythematosus 
(Libman-Sacks Endocarditis)

Answer 36

immune complex deposition and associated inflammation “Valvulitis” leads to subsequent fibrosis, valve deformity

Question 37

Rheumatic Fever occurs after what infection

Answer 37

Few weeks (10days to 6 weeks) after Group A (B-hemolytic) streptococcal pharyngitis (treatment of strep throat can prevent)

Question 38

pathogenesis of acute rheumatic fever

Answer 38

Immune response to group A Streptococi which CROSS-REACT with host tissues • Antibodies directed against M proteins of strep cross-react with self-antigens in the heart • CD4+ T cells specific for streptococcal peptides react with cardiac self proteins (Produced cytokines activate macrophages)

Question 39

Acute Rheumatic Fever major manifestations

Answer 39

``` Migratory polyarthritis, large joints Carditis (Pancarditis) Subcutaneous nodules Erythema marginatum of skin Sydenham chorea (involuntary purposeless, rapid movements, St. Vitus’ dance) ```

Question 40

acute rheumatic fever minor manifestations

Answer 40

Fever Arthralgia (joint pain w/o inflammation) Elevated acute-phase reactants

Question 41

what is needed to diagnose acute rheumatic fever

Answer 41

Jones criteria: Preceding group A Strep infection
 + 2 Major Manifestations
 or 1 Major and 2 Minor Manifestations

Question 42

acute rheumatic fever affects which layers of the heart

Answer 42

its pancarditis therefore it affects all the layers Pericarditis Myocarditis Endocarditis

Question 43

Aschoff Bodies

Answer 43

unique to rheumatic fever ``` T lymphocytes plasma cells macrophages Anitschkow cells (caterpillar cells, macrophages with nuclei that look like caterpillars) Multinucleated cells ``` similar to a mini granuloma

Question 44

vegetations in rheumatic fever endocarditis are mostly seen where

Answer 44

on the left sided heart valves

Question 45

what happens after the initial acute rheumatic fever endocarditis

Answer 45

Organization of inflammation Fibrosis Obliteration of normal leaflet structure 
Turbulence induced by ongoing valve deformities additional fibrosis

Question 46

Chronic Rheumatic Valvular Disease

Answer 46

results from rheumatic fever Valve leaflet fibrosis, fusion Fish mouth or buttonhole stenosis Cords short, thick, fused Mitral valve most commonly involved Alone in 65-70% Aortic and mitral valves - 25% Tricuspid, pulmonary valves - rare

Question 47

Carcinoid Tumor

Answer 47

Neuroendocrine tumor most commonly in the GI tract, tracheobronchial tree Secretes bioactive products *Serotonin (5-hydroxytryptamine) Kallikrein, Bradykinin, Histamine, Prostaglandins, Tachykinins Episodic flushing of skin, cramps, nausea, vomiting, diarrhea

Question 48

Carcinoid Heart Disease

Answer 48

Right side of heart Plaque-like thickening of endocardium and valves Muchopolysacharide matrix - coats tricuspid valve and RV marked intimal thickening of endocardium Correlation of serotonin levels with right sided heart disease