Valvular Heart Disease Flashcards
pressure overload and volume overload cause ___
hemodynamic burden
long term consequences of hemodynamic burden
muscle dysfunction
myocardial cell hypertrophy
CHF
sudden death
left sided valvular lesions
aortic stenosis
mitral stenosis
non-ischemic mitral regurgitation
aortic insufficiency
aortic stenosis etiology
acquired >65 yrs
- idiopathic disease: degeneration and calcification of trileaflet valve
- active inflammatory process- linked to increased LDL, HTN, Diabetes
congenital: 4th and 5th decade
- bicuspid aortic valve
- also can unicuspid or quadricuspid
most frequent severe valvular disease of the western countries
aortic stenosis
I aortic stenosis, pressure overload of the left ventricle causes ___ and results in muscular dysfunction, high end diastolic pressure.
hypertrophy
3 cardinal symptoms of aortic stenosis
Angina
Syncope
CHF
why is there angina in aortic stenosis?
reduced coronary reverse flow, increased myocardial oxygen demand
why do you have syncope with aortic stenosis?
when a patient with AS tries to exercise, they can not increase their cardiac output so their blood pressure drops and cardiac output drops to dry and maintain blood pressure. if you can not raise your cardiac output then your blood pressure drops and you have a syncope episode
on the physical exam for aortic stenosis, what will you find?
- systolic ejection murmur radiating to neck
- pulses parvus tardus
- S2 may be single or paradoxically split
what is pulses parvus trades?
small, delayed carotid pulse
what is used for Diagnosis of Aortic stenosis
- echo
- cardiac cath
- coronary angiography
aortic stenosis characteristics in females
thicker LV wall which reduces wall stress
increased ejection fraction
requires higher volume to maintain cardiac ouput= more sensitive to diuretics
what is aortic stenosis?
obstruction of left ventricular outflow of blood across the aortic valve
in aortic stenosis, what might you find on an echo
small aortic orifice during systole
LVH
Thickened/calcified aortic valve
in aortic stenosis what might you find on the EKG
LVH
whats the only curative treatment for AS
valve replacement
aortic regurgitation etiology
- leaflet abnormality- endocarditis, RH fever
- aortic root dilation- annuloaortic ectasia associated with aging, HTN, bicuspid valve, marina’s dissection, collagen vascular disease, and syphillis
in chronic aortic regurgitation, there is left ventricular volume overload which results in ___
eccentric hypertrophy, hyper dynamic LVEF
left ventricular volume overload increased stroke volume, systemic HTN increased pulse pressure diastolic blowing murmur Austin flint murmur
chronic aortic regurgitation
when do symptoms in aortic regurgitation typically occur?
when LV dysfunction occurs
aortic regurgitation Peripheral Signs
¥ QUINCKE’S PULSES
¥ CORRIGAN’S PULSE (Bounding full carotid with rapid down stroke)
¥ MUSSET’S SIGN (head bobbing)
¥ HILL’S SIGN (Systolic pressure in leg >30mm Hg higher than in arm)
diagnostic studies used fir aortic regurgitation
ECHO, MRI
when should surgery be done on a patient with aortic regurgitation
- when they are symptomatic
- when they are asymptomatic- rule of 55
- before LVEF is less than 55%
- BEFORE LVESD >55mm
medical therapy for aortic regurgitation
after load reduction with vasodilators (nifedipine)
in aortic regurgitation, there is Incomplete aortic valve closure during diastole –> _______–> LV volume overload–> LV dilation–> CHF
regurgitation of blood to LV
most common cause of mitral stenosis
rheumatic heart disease
first symptoms of mitral stenosis in pregnancy
a-fib
HF in second trimester= think rheumatic heart disease
left heart failure symptoms in mitral stenosis
DOE
Orthopnea
hemoptysis
hoarseness
edema
will their be neck vein distension in someone with mitral stenosis?
yes
what is used to diagnose mitral stenosis
echo
can use EKG and chest x-ray as well
therapy for mitral stenosis in a pt with mild symptoms
diuretics
therapy for pt with mitral stenosis that has a fib
digoxin, BB, diltiazem
anticoagulant therapy
therapy for pt with mitral stenosis that has moderate symptoms, pulmonary hypertension
mechanical relief of obstruction
balloon valvuloplasty
treatment of choice for mitral stenosis
balloon valvuloplasty
patients with mitral stenosis who ate not candidates for balloon valvuloplasty
heavy calcification
subvalvular distortion
more than mild MR
some characteristics of mitral regurgitation
S1 soft
holosystolic murmur
S3
LF lift
Hemodynamic of mitral regurgitation
¥ Volume overload of LV
¥ Hyperdynamic LV systolic function
Normal EF= >60%
medical therapy for mitral regurgitation
vasodilators to stop pressure and decrease resistance
in mitral regurgitation, is surgical repair of the valve or surgical replacement of the valve preferred?
surgical repair
what might you see on an echo on a pt with mitral regurgitation
hyperdynamic LV
____ is the obstruction of outflow of blood from the right ventricle to the pulmonary artery
Pulmonic stenosis
More than 90% of pulmonic stenoses are ______- can be associated with Carcinoid Syndrome or Tetralogy of Fallot. Valvular pulmonic stenosis is a benign disease, which only rarely progresses
congenital
symptoms in pt with Mild pulmonic stenosis:
Asymptomatic
symptoms in pt with Moderate to severe pulmonic stenosis:
Fatigability, Dyspnea on exertion, Chest pain
symptoms in pt with Severe pulmonic stenosis in the neonate:
Poor feeding, Tachypnea, Cyanosis
Principal finding on examination of pulmonary stenosis
SEM- ejection systolic murmur, loudest at the left upper sternum and radiating towards the left shoulder
Severe _____ is characterised by a loud harsh murmur, an inaudible pulmonary closure sound (P 2 ), an increased right ventricular heave, prominent a waves in the jugular pulse,
pulmonary stenosis
EKG findings on pt with pumonary stenosis
ECG evidence of right ventricular hypertrophy
chest x ray findings on pt with pumonary stenosis
post-stenotic dilatation in the pulmonary artery on the chest X-ray.
in pulmonary stenosis, _______is the definitive investigation.
Doppler echocardiography
Severe pulmonary stenosis (resting gradient > 50 mmHg with a normal cardiac output) is treated by ______ or, if this is not available, by surgical valvotomy
percutaneous pulmonary balloon valvuloplasty
This is rare in isolation and is usually associated with pulmonary artery dilatation due to pulmonary hypertension.
Pulmonary Regurgitation
Pulmonary Regurgitation
may complicate mitral stenosis, producing an early diastolic decrescendo murmur at the left sternal edge that is difficult to distinguish from _____ (Graham Steell murmur).
aortic regurgitation
Tricuspid stenosis is usually ____ in origin and is rare in developed countries.
rheumatic
_____ disease occurs in fewer than 5% of patients with rheumatic heart disease and then nearly always in association with mitral and aortic valve disease.
Tricuspid
Tricuspid stenosis and regurgitation are features of the ____syndrome.
carcinoid
tricuspid stenosis symptoms
Although the symptoms of mitral and aortic valve disease predominate, tricuspid stenosis may cause symptoms of right heart failure, including hepatic discomfort and peripheral edema.
tricuspid stenosis main clinical features
The main clinical feature is a raised JVP. There is also a mid-diastolic murmur, best heard at the lower left or right sternal edge.
tricuspid stenosis treatment
: In patients who require surgery to other valves, either the tricuspid valve is replaced or valvotomy is performed at surgery. Balloon valvuloplasty can be used to treat rare cases of isolated tricuspid stenosis.
Tricuspid regurgitation is common, and is most frequently ‘functional’ as a result of right _____. Refers to an abnormal retrograde flow of blood from the right ventricle to the right atrium
ventricular dilatation
Tricuspid Regurgitation
causes
Primary: Rheumatic heart disease, Endocarditis (particularly in injection drug-users), Ebstein’s congenital anomaly
Secondary : Right ventricular dilatation due to chronic left heart failure (‘functional tricuspid regurgitation’), Right ventricular infarction, Pulmonary hypertension (e.g. cor pulmonale)
Tricuspid Regurgitation symptoms
usually non-specific, with tiredness related to reduced forward flow, and edema and hepatic enlargement due to venous congestion caused by accompanying right-sided heart failure (e.g., jugular venous distention, peripheral edema, parasternal lift, ascites, right-sided S 3 ).
Tricuspid Regurgitation signs
The most prominent sign is a jugular venous pulse. Other features include a pansystolic murmur at the left sternal edge and a pulsatile liver.
echo findings in tricuspid regurgitation
Echocardiography may reveal dilatation of the RV. If the valve has been affected by rheumatic disease, the leaflets will appear thickened and, in endocarditis, vegetations may be seen.
_____ is a congenital abnormality in which the tricuspid valve is displaced towards the right ventricular apex, with consequent enlargement of the RA. It is commonly associated with tricuspid regurgitation.
Ebstein’s anomaly
tricuspid regurgitation treatment
Tricuspid regurgitation due to right ventricular dilatation often improves when the cause of right ventricular overload is corrected, with diuretic and vasodilator treatment of congestive cardiac failure.
