Valvular Heart Disease Flashcards
S1
closure of AV valves at start of ventricular systole
S2
closure of semilunar valves at start of ventricular diastole
S3
sound of rapid filling of ventricles during early diastole
S4
sound of late filling from atrial kick in late diastole
Cause of Aortic Stenosis (AS)
Senile calcific, bicuspid, rheumatic, congenital, Paget’s, ESRD
Medical history of pt with AS
*Angina, *Syncope (fixed obstruction and cannot augment CO under conditions of low SVR; ie: meds, vasovagal), *CHF
SAD- syncope, angina, dyspnea (CHF)
Cardiac exam with AS
- 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)
EKF with AS shows
- LVH (left vent hypertrophy)
- LBBB
CXR with AS shows
AV calcification, LV prominent without dilation
Valsava maneuver is a provocative maneuver for hypertrophic cardiomyopathy and works by
makes L vent smaller, makes murmur LOUDER, less blood in L ventricle,decreasing venous return to R and L heart
Squatting is a provocative maneuver for hypertrophic cardiomyopathy and works by
SOFTER WITH SQUATING, more blood is being pushing into heart, more venous return, L vent gets bigger, more turbulence, SOFTER murmur
Pulse pressure gets ______ with HCOM (hypertrophic cardiomyopathy); AS pulse pressure is _________
smaller/lower
the same or HIGHER peak (brown heart phenomenon)
What indicates a berry aneurysm?
Coarctation of the aorta, headaches, bicuspid valve stenosis
50% mortality for angina, syncope and CHF?
angina (5 yrs)
syncope (3 yrs)
CHF (2 yrs)
Surgery for AS
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
When EF falls below ____, need surgery, even with NO symptoms
50
In valvular aortic stenosis there is an obstruction between ________, causing excessive muscle growth from septum with turbulent blood
LV and blood leaving aorta
Supravalvular aortic stenosis is caused by a syndrome called
Williams Syndrome
- congenital
- Murmur may radiate to subclavian artery (instead of carotid)
Shone’s syndrome
- Subvalvular membrane
- congenital flap of tissue (membrane from atrium), causes Subvalvular aortic stenosis- needs surgery, obstructs flow, congenital abnormality, associated with coarctation
With severe aortic stenosis, may need to use Bernouli formula to calculate
can convert velocity into pressure and can calculate the valve area- USE ECHO!
Aortic Regurgitation (Chronic)
Aortic root dilation from HTN, CMN, bicuspid, ankylosing spondylitis, RA
Pt with Aortic Regurgitation will have history of
Dyspnea, Angina, Fatigue, CHF
Cardiac exam with Aortic Regurgitation will show
- 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
Another murmur that may be heard with aortic regurg
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)
Other cardiac signs with aortic regurg
- 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
CXR with aortic regurg shows
*Cardiomegaly, boot-shaped heart, LV enlargement (dilated LV)
Chronic Aortic insufficiency
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
Aortic Regurgitation (acute) can be from
Endocarditis, Aortic dissection, ruptured sinus of Valsalva aneurysm
Aortic Regurgitation (acute), patient usually has history of
Acute pulmonary edema
Cardiac exam with acute aortic regurg
- Short diastolic murmur
- Faint S1
CXR
Normal heart size, pulmonary congestion
Acute AI, surgery or no?
Surgical emergency!!
For chronic AI pt, don’t use
Don’t use beta blocker, more regurgitation (prolongs diastole)
Mitral Regurgitation (Chronic), causes are
- MVP (valve prolapse)
- **Rheumatic fever (more likely MS)
- secondary (ischemic, cardiomyopathy)
- usually seen post MI
- LV dilatation
Mitral Regurgitation (Chronic) shows history of
Late-onset of CHF, later R-heart failure
Cardiac exam of chronic MR shows
- holosystolic, high pitched “blowing murmur” murmur
- loudest at apex, radiates to axilla
- S3 gallop and wide-split S2
CXR of chronic MR shows
Cardiomegaly, LV/LA enlargement
Mitral Regurgitation ACUTE causes
Endocarditis, papillary muscle rupture in setting of MI
Mitral Regurgitation ACUTE, patient shows hx of
Acute pulmonary edema
Mitral Regurgitation ACUTE cardiac exam shows
-Decrescendo systolic murmur radiates to neck if posterior leaflet and back if anterior leaflet, loud P2, widely split S2
CXR for Mitral Regurgitation ACUTE shows
Pulmonary edema, normal heart size
Echo for Mitral Regurgitation ACUTE shows
flail leaflet (if papillary muscle was ruptured) **WILL SEE LARGE V WAVES** (test)
Mitral Regurgitation ACUTE, surgery or no?
URGENT, can temporize with vasodilators
MVP (Mitral Valve Prolapse) Squatting vs standing?
KNOW THIS!
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
Mitral stenosis causes
- *Rheumatic fever
- calcifications
Mitral stenosis, patient hx
Late-onset of CHF, later R-heart failure
Mitral stenosis cardiac exam
- 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
EKG for MS will show
left atrial enlargement and
a fib
-GIANT P WAVES
*NOTHING HAPPENS TO L VENT
CXR for MS will show
Pulmonary vein congestion, massive L atrial enlargement
Mitral stenosis, patient will present with
-will have hoarseness (pressing on recurrent laryngeal nerve)
Tricuspid Regurgitation causes
Rheumatic, carcinoid, functional from RV failure, Ebstein’s anomaly (congenital displacement of anterior tricuspid valve leaflet, severe TR)
-(commonly caused by RV dilation)
TR pt history
R-sided CHF predominates
Tricuspid regurgitation cardiac exam
- 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
Secondary (Functional)
Tri Regurg
Left-sided CHF, MS, MR, primary pulmonary disease, L to R shunt, pulmonic valve stenosis, PA stentosis
PRIMARY Tri Regurg
Carcinoid, due to pacemaker, endocarditis, rheumatic fever, marantic, drug-induced, Ebsteins
Other rare stenosis
slide 43
Drug-induced valve disease
- Ergot alkaloids
- For migraines
- Fen-fen
- Pergolide (L sided valve disease)
- MDMA (ecstasy)
- IVDA–>endocarditis
