Valvular Heart Disease

Question 1

S1

Answer 1

closure of AV valves at start of ventricular systole

Question 2

S2

Answer 2

closure of semilunar valves at start of ventricular diastole

Question 3

S3

Answer 3

sound of rapid filling of ventricles during early diastole

Question 4

S4

Answer 4

sound of late filling from atrial kick in late diastole

Question 5

Cause of Aortic Stenosis (AS)

Answer 5

Senile calcific, bicuspid, rheumatic, congenital, Paget’s, ESRD

Question 6

Medical history of pt with AS

Answer 6

*Angina, *Syncope (fixed obstruction and cannot augment CO under conditions of low SVR; ie: meds, vasovagal), *CHF

SAD- syncope, angina, dyspnea (CHF)

Question 7

Cardiac exam with AS

Answer 7

• Harsh crescendo-decrescendo, late-peaking SEM (systolic ejection murmur) radiating to the neck (carotid arteries)*
• palpable systolic thrill, sustained LV impulse, pulsus parvus et tardus (pulses are weak with delayed peak)
• S2 single (A2 is absent), paradoxical split S2, S4 gallop (S4 heard during diastolic dysfunction)

Question 8

EKF with AS shows

Answer 8

• LVH (left vent hypertrophy)

- LBBB

Question 9

CXR with AS shows

Answer 9

AV calcification, LV prominent without dilation

Question 10

Valsava maneuver is a provocative maneuver for hypertrophic cardiomyopathy and works by

Answer 10

makes L vent smaller, makes murmur LOUDER, less blood in L ventricle,decreasing venous return to R and L heart

Question 11

Squatting is a provocative maneuver for hypertrophic cardiomyopathy and works by

Answer 11

SOFTER WITH SQUATING, more blood is being pushing into heart, more venous return, L vent gets bigger, more turbulence, SOFTER murmur

Question 12

Pulse pressure gets ______ with HCOM (hypertrophic cardiomyopathy); AS pulse pressure is _________

Answer 12

smaller/lower

the same or HIGHER peak (brown heart phenomenon)

Question 13

What indicates a berry aneurysm?

Answer 13

Coarctation of the aorta, headaches, bicuspid valve stenosis

Question 14

50% mortality for angina, syncope and CHF?

Answer 14

angina (5 yrs)
syncope (3 yrs)
CHF (2 yrs)

Question 15

Surgery for AS

Answer 15

TAVR (transaortic valve replacement)

• Put in a new valve (bioprosthetic or mechanical)
• Elderly need valve for 10-15 yrs, use bioprosthetic
• 50 year old or younger pt- use mechanical (only need 1 operation vs multiple replacements with bioprosthetic), need to take coumadin with this

Question 16

When EF falls below ____, need surgery, even with NO symptoms

Answer 16

50

Question 17

In valvular aortic stenosis there is an obstruction between ________, causing excessive muscle growth from septum with turbulent blood

Answer 17

LV and blood leaving aorta

Question 18

Supravalvular aortic stenosis is caused by a syndrome called

Answer 18

Williams Syndrome

• congenital
• Murmur may radiate to subclavian artery (instead of carotid)

Question 19

Shone’s syndrome

Answer 19

• Subvalvular membrane
• congenital flap of tissue (membrane from atrium), causes Subvalvular aortic stenosis- needs surgery, obstructs flow, congenital abnormality, associated with coarctation

Question 20

With severe aortic stenosis, may need to use Bernouli formula to calculate

Answer 20

can convert velocity into pressure and can calculate the valve area- USE ECHO!

Question 21

Aortic Regurgitation (Chronic)

Answer 21

Aortic root dilation from HTN, CMN, bicuspid, ankylosing spondylitis, RA

Question 22

Pt with Aortic Regurgitation will have history of

Answer 22

Dyspnea, Angina, Fatigue, CHF

Question 23

Cardiac exam with Aortic Regurgitation will show

Answer 23

• High pitched blowing, early diastolic decrescendo murmur (on LSB if valvular on RSB if aortic)
• Wide pulse pressure, low diastolic pressure, bounding pulses (quick rising), laterally displaced PMI
• S3 gallop

Question 24

Another murmur that may be heard with aortic regurg

Answer 24

Austin-flint murmur at apex (diastolic MR; MV struck by regurgitant jet, you will not hear loud S1 or OS which is common w/ mitral stenosis)

Question 25

Other cardiac signs with aortic regurg

Answer 25

- Quinckes pulse: capillary pulsation - DeMusset’s sign (head bobbing) - Corrigan's sign: water hammer pulse - Durosier's sign: femoral retrograde bruits - Bisferiens pulse - Mueller's sign: systolic pulsation of uvula - Traube's sign: pistol shot femorals - Hill's sign- BP lower ext > BP upper ext

Question 26

CXR with aortic regurg shows

Answer 26

*Cardiomegaly, boot-shaped heart, LV enlargement (dilated LV)

Question 27

Chronic Aortic insufficiency

Answer 27

Start with ace inhibitor or calcium channel blocker -Chronic AI, LV has lots of time to adapt to increased flow volume (hypertrophies eccentrically, keeps forward output okay), eventually lose compensatory, eventually flow forward flow decreases and this mechanism fails

Question 28

Aortic Regurgitation (acute) can be from

Answer 28

Endocarditis, Aortic dissection, ruptured sinus of Valsalva aneurysm

Question 29

Aortic Regurgitation (acute), patient usually has history of

Answer 29

Acute pulmonary edema

Question 30

Cardiac exam with acute aortic regurg

Answer 30

- Short diastolic murmur | - Faint S1

Question 31

CXR

Answer 31

Normal heart size, pulmonary congestion

Question 32

*Acute* AI, surgery or no?

Answer 32

Surgical emergency!!

Question 33

For chronic AI pt, don't use

Answer 33

Don’t use beta blocker, more regurgitation (prolongs diastole)

Question 34

Mitral Regurgitation (Chronic), causes are

Answer 34

- MVP (valve prolapse) - **Rheumatic fever (more likely MS) - secondary (ischemic, cardiomyopathy) - usually seen post MI - LV dilatation

Question 35

Mitral Regurgitation (Chronic) shows history of

Answer 35

Late-onset of CHF, later R-heart failure

Question 36

Cardiac exam of chronic MR shows

Answer 36

- holosystolic, high pitched "blowing murmur" murmur - loudest at apex, radiates to axilla - S3 gallop and wide-split S2

Question 37

CXR of chronic MR shows

Answer 37

Cardiomegaly, LV/LA enlargement

Question 38

Mitral Regurgitation ACUTE causes

Answer 38

Endocarditis, papillary muscle rupture in setting of MI

Question 39

Mitral Regurgitation ACUTE, patient shows hx of

Answer 39

Acute pulmonary edema

Question 40

Mitral Regurgitation ACUTE cardiac exam shows

Answer 40

-Decrescendo systolic murmur radiates to neck if posterior leaflet and back if anterior leaflet, loud P2, widely split S2

Question 41

CXR for Mitral Regurgitation ACUTE shows

Answer 41

Pulmonary edema, normal heart size

Question 42

Echo for Mitral Regurgitation ACUTE shows

Answer 42

``` flail leaflet (if papillary muscle was ruptured) **WILL SEE LARGE V WAVES** (test) ```

Question 43

Mitral Regurgitation ACUTE, surgery or no?

Answer 43

URGENT, can temporize with vasodilators

Question 44

MVP (Mitral Valve Prolapse) Squatting vs standing? KNOW THIS!

Answer 44

Squatting- more filling- more blood- longer time before you heart the click- its closer to S2 Standing- less blood on left side- less filling- shorter on the click- heart it closer to S1

Question 45

Mitral stenosis causes

Answer 45

- *Rheumatic fever | - calcifications

Question 46

Mitral stenosis, patient hx

Answer 46

Late-onset of CHF, later R-heart failure

Question 47

Mitral stenosis cardiac exam

Answer 47

- follows opening snap - deceased interval between S2 and opening snap means its more severe (no snap if end state, too much stenosis) - Diastolic rumble at apex -short S2-OS interval, loud P2, RV heave - Anything that increases the gradient will increase the murmur intensity - LA pressure > LV pressure during diastole

Question 48

EKG for MS will show

Answer 48

left atrial enlargement and a fib -GIANT P WAVES *NOTHING HAPPENS TO L VENT

Question 49

CXR for MS will show

Answer 49

Pulmonary vein congestion, massive L atrial enlargement

Question 50

Mitral stenosis, patient will present with

Answer 50

-will have hoarseness (pressing on recurrent laryngeal nerve)

Question 51

Tricuspid Regurgitation causes

Answer 51

Rheumatic, carcinoid, functional from RV failure, Ebstein’s anomaly (congenital displacement of anterior tricuspid valve leaflet, severe TR) -(commonly caused by RV dilation)

Question 52

TR pt history

Answer 52

R-sided CHF predominates

Question 53

Tricuspid regurgitation cardiac exam

Answer 53

- Holosystolic murmur at LLSB - *louder with inspiration (Carvallo’s sign) - **prominent CV waves*** and rapid y descent - Loudest at tricuspid area, radiates to RIGHT sternal border

Question 54

Secondary (Functional) | Tri Regurg

Answer 54

Left-sided CHF, MS, MR, primary pulmonary disease, L to R shunt, pulmonic valve stenosis, PA stentosis

Question 55

PRIMARY Tri Regurg

Answer 55

Carcinoid, due to pacemaker, endocarditis, rheumatic fever, marantic, drug-induced, Ebsteins

Question 56

Other rare stenosis

Answer 56

slide 43

Question 57

Drug-induced valve disease

Answer 57

- Ergot alkaloids - For migraines - Fen-fen - Pergolide (L sided valve disease) - MDMA (ecstasy) - IVDA-->endocarditis