Valvular heart disease Flashcards
what grade of murmurs is loud, and associated with a thrill
Grade 4/6
function of echocardiography
- evaluate chamber size and valve abnormalities, including pressure gradients
function of angiography
- provides detailed info preoperatively
- evaluate for CAD
aortic stenosis
narrowing of aortic outflow tract
aortic stenosis can occur at what 3 levels
- aortic valve: 75% of cases
- supravalvular: congenital or post-operative
- subvalvular: congenital or hypertrophic cardiomyopathy
etiology of aortic stenosis below age 30
congential, unicuspid valve
etiology of aortic stenosis age 30-65
- congenital bicuspid valve which becomes calcified and stenotic
rheumatic valve disease account for what percentage of aortic stenosis between ages 30-70
6-27%
etiology of aortic stenosis over age 65
degeneration of sclerosis of valve
when does mortality become significant in patients with aortic stenosis
- after symptoms develop
- average survival without valve replacement is 2-3 years with a high risk of sudden death
early symptoms of aortic stenosis
- dyspnea on exertion
- fatigue
- decreased exercise tolerance
later symptoms of aortic stenosis
- dyspnea with normal activity
- angina
- syncope
- heart failure
aortic stenosis is associated with what murmur? where would you hear the murmur
- systolic ejection murmur
- high pressure to high pressure
- 2nd RICS or apex
what type of pulse pressure indicates severe aortic stenosis disease
small pulse pressure
CXR findings of aortic stenosis
- LVH
- calcification may be seen in valve
management of mild asymptomatic aortic stenosis
- follow, educate regarding sxs
management of moderate asymptomatic aortic stenosis
- annual ECG, echo, cxr
management of severe asymptomatic aortic stenosis
- cardiolgoy evaluation and f/u
patient education regarding aortic stenosis
- avoid strenuous physical activity
- avoid dehydration
- signs of worsening disease
- exertional dizziness, dyspnea, palpitations
what is the definitive technique for evaluating severity and site of stenosis
cardiac catheterization
normal aortic valve area
3-4 cm2
classification of severe aortic stenosis
severe < 1.0
which patients with aortic stenosis are candidates for valve replacement
- severe, symptomatic aortic stenosis
differentiate clinically between prosthetic valves and tissue valves (in aortic vavle replacement)
- prosthetic valves last longer but require lifelong anticoagulation
- warfarin
- tissue valves do not last as long but do not require lifelong anticoagulation
hypertrophic cardiomyopathy
- a form of subvalvular aortic stenosis
- disease of cardiac muscle characterized by severe myocardial hypertroph, in the absense of a cause for secondary hypertrophy (HBP, AS)
- familial, inherited in 60% of cases
hypertrophic cardiomyopathy’s murmur compared to AS
- murmur is similar except it is louder if patient stands or valsalvas (opposite of valvular AS)
treatment for hypertrophic cardiomyopathy
- calcium channel blocker
- beta blocker
aortic regurgitation (insufficiency)
- leakage of blood back through aortic valve during diastole
primary etiologies of aortic regurgitation (insufficiency)
- rheumatic valvular disease (29%)
- bicuspid aortic valve (12%)
- dilated aortic root (12%)
- acutely dissecting aortic aneurysm
acute causes of aortic regurgitation (insufficiency)
- aortic dissection
- infective endocarditis
treatment of acute aortic regurgitation (insufficiency)
urgent cardiology consult for medication and consideration of valve replacement
clinical presentation
- LV overload and gradual dilation and hypertrophy
- patients may be asymptomatic for 20+ years, then develop only mild DOE
- eventually develop signs of heart failure
chronic aortic regurgitation
murmur associated with aortic regurgitation (insufficiency). where is it best heard
- high-pitched diastolic decrescendo murmur
- aortic area and left sternal border
austin flint murmur
- soft, low-pitched diastolic murmur at the apex which sounds like a diastolic mitral stenosis murmur
- may be associated with aortic regurgitation (insufficiency)
wide pulse pressure is seen in which condition
aortic regurgitation (insufficiency) due to increased systolic and decreased diastolic pressures -> “water hammer” or “corrigan pulse”
CXR findings of aortic regurgitation (insufficiency)
- normal if acute
- LVH if chronic, possible CHF/pulmonary edema
treatment of chronic aortic regurgitation (insufficiency)
- if asymptomatic, f/u q 6-12 months (ECG, echo, CXR)
- vasodilators reduce regurgitant volume and increase EF
- ACE inhibitors are most helpful
- valve replacement is available if symptomatic
mitral regurgitation
- leakage of blood from LV into left atrium
- may develop due to abnormality of
- valve leaflets
- chordae tendinae
- papillary muscles
- valve annulus
etiologies of mitral regurgitation
- papillary muscle necrosis secondary to ischemic heart disease
- inherited
- mitral valve prolapse
- marfans
- rheumatic heart disease (5-15% cases)
- congenital
causes of acute mitral regurgitation
- papillary muscle necrosis from ischemia
- endocarditis
- ***poorly tolerated and often required emergent surgery
explain what happens in chronic mitral regurgitation
- LV adapts to larger blood volume by enlarging and increasing SV
- heart may compensate for years with normal CO but eventually it is unable to keep up with demands and CHF develops
- A-Fib frequently develops due to left atrial enlargement
- pulmonary HTN and RVH may also develop
what often develops with chronic mitral regurgitation
A-Fib due to left atrial enlargement
murmur associated with mitral regurgitation. where is heard best
- high pitched, pansystolic murmur
- loudest at apex
- later stages, S3 develops (early passive rapid filling of the ventricles with blood from atria)
CXR findings common in mitral regurgitation
- left atrial enlargement
- LVH
treatment of chronic mitral regurgitation
- afterload reduction: ACE inhibitors and vasodilators
- sodium restriction and diuretics (Reduce preload)
- anticoagulation for A-Fib
- surgery:
- repair valve vs valve replacement
mitral valve prolapse
due to ballooning of mitral leaflets into the left atrium during systole
heart sounds associated with mitral valve prolapse
- mid-late systolic clicks
- mitral regurgitation may also occur with late systolic murmur
prevelance of mitral valve prolapse
- 5% of general population
- usually benign
diagnostic study for mitral valve prolapse
echocardiogram
management of mitral valve prolapse associated with palpitations or arrhythmias
- B-blockers may be helpful
- if symptomatic or worsening, follow as with other patients with MR
pathophysiology of mitral stenosis
- narrowing of mitral valve
- obstructs flow from LA to LV
- increases LA pressure
- increase pulmonary vascular pressure
most common cause of mitral stenosis
rheumatic heart disease
rheumatic heart disease
- spectrum including acute rheumatic fever, pericarditis, myocarditis, and valvular lesions
- delayed sequela following group A steptococcus pharyngitis
signs and symptoms expected in mitral stenosis
- usually due to pulmonary congestion
- dyspnea, orthopnea, PND, fatigue
- pulmonary edema with hemoptysis
- pulmonary HTN -> RHF
- A-Fib in 40-50%
- 20% have systemic emboli, usually to brain
40-50% of patients with mitral stenosis have what conditions
AFIB
murmur associated with mitral stenosis. where is it best heard
- Loud S1 with opening snap
- mid diastolic rumbling murmur
- apex with patient in left lateral decubitus position, with bell
CXR findings with mitral stenosis
- Left atrial enlargement
- later, pulmonary congestion and RVH
- kerley B lines
management of mitral stenosis
- mild symptoms: diuretics and sodium restriction
- anticoags for A-Fib
- valve sx for progressive symptoms
who needs antibiotic prophylaxis
- prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- previous infectious endocarditis
