Valvular Heart Disease

Question 1

Mitral Stenosis Pathology

Answer 1

Rheumatic Fever is primary cause (2 year development)
Females predominate
Thickened leaftlets that cannont open or shut
Reduced S1
Enlargement of LA and elevation of left main stem bronchus
Hockey Stick Deformity

Question 2

Clinical Manifestations of Mitral Valve Stenosis

Answer 2

Dyspnea, cough
Pulmonary edema (when CO is increased
Thromboembolism
Infective endocarditis
Compression of left recurrent laryngeal nerve by dilated LA (causes hoarseness)

Question 3

Medical Treatment of Mitral Valve Stenosis

Answer 3

Penicillin prophylaxis
Digitalis if a-fib is present
Beta blocker can increase exercise capacity
Mitral valve replacement or baloon valvuloplasty

Question 4

Causes of Acute Mitral Regurgitation

Answer 4

Infectious endocarditis
Trauma
Myxomatous Degeneration
Libman-Sacks lesions
Systemic Lupus Erythematosus
CAD, MI, ischemia
LV dyfunction (this is harder to fix)
Myocarditis
Prosthetic valve dysfunction

Question 5

Causes of Chronic Mitral Regurgitation

Answer 5

Inflammatory (rheumatic, lupus)
Degenerative (mitral valve prolapse, marfans, MAC)
Infective subacute endocarditis
Structural (ruptured chords, CAD, LV dilation, hypertrophic CM, prosthetic valve dysfunction)
Congenital

Question 6

Mitral Regurgitation Findings

Answer 6

Holosystolic Murmur: “All of systole”, starts at S1 and persists to S2
Same frequency along the entire duration
Heard best at axilla
Prolapse is heard as mid-systolic click

Question 7

Clinical Course of MR

Answer 7

Symptoms usually do not occur until LV fails
Development of symptoms tends to be longer than with MS, 2 decades
Acute pulmonary edema is less frequent in chronic MR than MS
Don’t wait to treat! Symptoms develop when LV is beyond repair

Question 8

Mitral Regurgitation Treatment

Answer 8

Afterload reduction (reduces volume of blood regurgitating into LA)
Angiotensin inhibitor or hydralazine
Is better to repair the mitral valve than replace it

Question 9

Aortic Stenosis Causes

Answer 9

Congenital commissural fusion - Bicuspid valve
Senile degenerative calcific stenosis
Rheumatic fever (mitral stenosis occurs first), often regurgitant
Diabetes mellitus
Hypercholesterolemia
Atherosclerosis

Question 10

Aortic Stenosis Findings

Answer 10

Systolic ejection murmur
Snapping or clicking heard right after S1
Louder than S1
Cooing or musical murmur
Best heard at base of heart or suprasternal notch
Crescendo/decrescendo
A2 is heard less, softer than P2

Question 11

Clinical Course of Aortic Stenosis

Answer 11

Asymptomatic and benign until symptoms develop
Angina, syncope, heart failure
Wait to fix the valve until patient gets symptoms

Question 12

Treatment of Aortic Stenosis

Answer 12

Balloon Aortic Valvuloplasty (but major complication is re-stenosis)
Valvuloplasty is bridge until aortic valve replacement (standard of care)
St. Jude Valve

Question 13

Aortic Regurgitation Causes

Answer 13

Rheumatic Fever
Aortic wall disease (ehlers-danlos, marfans)
Usually due to some sort of aortic insufficiency

Question 14

Clinical Course of Aortic Stenosis

Answer 14

Early diastolic murmur, occurs right after A2
High frequency murmur
Heard best at the base of the heart

Question 15

Treatment of Aortic Stenosis

Answer 15

Symptomatic Patients: AVR

Asymptomatic Patients: Depends on end-systolic diameter

Question 16

Tricuspid Regurgitation

Answer 16

Caused by dilation of RV and RV failure
Usually from left-sided disease
Murmur augmented during respiration (Carvallo’s sign)

Question 17

Tricuspid Regurgitation Tx

Answer 17

In absence of pulmonary hypertension does not require treatment
Can totally excise valve (if RV systolic pressure is normal)
Surgical: suturing annulus to prosthetic ring