Valvular Heart Disease Flashcards
What do stenotic lesions lead to
pressure overload on upstream
What do regurgitant lesions lead to
Volume overload and dilation of chambers
What is Diastolic dysfunction
The inability of ventricle to relax/decreased wall compliance limiting filling during early passive diastole. Atria has to contract harder to get blood out
What does diastolic dysfunction lead to
Pressure in atria rises and backs up to the lungs- Pulmonary edema
Also- atrial arrhythmias
What are causes of LV diastolic dysfunction
HTN VH fibrosis Infiltrative CM Pericardial constriction
What are causes of RV diastolic dysfunction
rare
constrictive pericarditis
restrictive cardiomyopathy
What do right murmurs do
increase with inspiration
What are left HF symptoms
dyspnea pulmonary edema crackles PE pallor/cyanosis
What are right HF symptoms
JVD
peripheral edema
Hepatomegaly
ascites
How can you grade a murmur
I: heard in quiet room by expert
VI: thrill with very loud murmur without steth
What murmurs warrant an echo
Systolic > grade II
any diastolic
What is the most common cause of aortic stenosis
calcified valve
What is the compensatory response to aortic stenosis
LVH, more pressure needed to overcome rigid valve.
Reduced EF
LA hypertrophy
What is the classic triad associated with aortic stenosis
Angina
Syncope
Heart failure
What are characteristics of aortic stenosis on exam
Delayed carotid upstroke
Sustained, diffuse apical impulse
Systolic murmur at RUSB, crescendo-decrescendo, radiating to neck
How should you treat a patient with severe AS that is not a surgical candidate
TAVR or medical therapy to control HF
What diagnostic test is contraindicated in AS
exercise stress test
What surgical treatments are available for AS patients
#1: Mechanical or tissue valve replacement -Balloon valvuloplasty for peds, or as a bridge for adults (will restenose in 6 mo.)
What are the types of valves
Bioprosthetic: shorter lifespan (10-15 years)
Mechanical: lifelong anti-coag (warfarin) needed
What are the biggest issues with a TAVR
CVA
Complete heart block
paravalvular leak
What are the causes of aortic regurgitation
abnormalities of leaflets/aortic root
chronically progresses slowly over 10 years until LV dysfunction
What is the #1 cause of acute aortic regurgitation
Aortic Dissection (also endocarditis)
What happens during chronic AR
- Increased LV EDV
- Increased wall stress causes LVH
- CO initially increased but decreases as disease progresses and aorta is less compliant
What will you see on PE for chronic AR
- Water hammer pulse
- Blowing Diastolic Decrescendo Murmur at LUSB
- Signs of left HF
What can you see on chronic AR CXR
Aortic knob, cardiomegaly
Who is a candidate for surgical treatment for chronic AR
Symptomatic
ASx but having heart surgery
LV dysfunction
Aortic root dilation >5 cm (less for marfans)
What should nonsurgical candidates with chronic AR do
Take vasodilators, CCB, ACE
BB for aortic root enlargement
What is the cause of chronic aortic regurgitation
aortic root disease
What is dangerous with acute AR
no time to develop compensatory mechanisms; Hemodynamic emergency
Leads to cardiovascular decompensation
What are symptoms of acute aortic regurg
weakness, AMS, dyspnea, syncope
**CP=Aortic dissection
How are PE findings for acute aortic regurgitation
Hemodynamic compromise
Soft, thready, rapid diastolic murmur
How do you treat acute arctic regurgitation
surgical emergency!
Vasodilator and IV inotropes
Aortic dissection: BB
What causes Chronic mitral regurgitation
MVP
degeneration
rheumatic fever
dilated cardiomyopathy
What happens during chronic mitral regurgitation
LV dilation
Decreased preload, decreased afterload
CO consistent during compensation
LV dilates until HF develops
What are the symptoms of chronic mitral regurgitation
Asymptomatic
Then dyspnea, LHF
Pulmonary HTN and RHF
What will you see on chronic mitral regurgitation PE
Displaced apical impulse
S3
HF Sx
What is the Mitral Regurgitation murmur
Holosystolic, apical blowing murmur radiating to axilla
What medical treatment is available for MR
HF therapy; Diuretics, vasodilators
If with AFib, warfarin
What is the cause of acute MR
papillary infarct
chordae tendinae rupture
What happens during acute mitral regurgitation
acute volume overload into LV (high EDV)
causes acute LHF and cariogenic shock
What are symptoms of acute MR
LHF Sx (pulmonary edema, orthopnea, dyspnea, cariogenic shock)
Whats the acute MR murmur
Holosystolic apical murmur radiating to axilla or back
What is the treatment for acute MR
IV Nitro to reduce after load
IABP as a bridge to repair/replace
What are causes of mitral valve stenosis
mostly rheumatic fever
rarely congenital
What happens with mitral valve stenosis
stenotic valve decreases preload=decreased CO
LA has increased pressure causing pulmonary HTN=right HF
What is the biggest risk in mitral valve stenosis with associated A-Fib
High thromboembolic risk
TIA/CVA
What are the symptoms of mitral valve stenosis
asymptomatic for decades
Dyspnea–>PND, orthopnea
Hemoptysis (bronchial vessel rupture under pressure)
Hoarseness (large LA on recurrent laryngeal)
Endocarditis
What will you see on Mitral stenosis PE
high JVP
Cyanosis (low CO)
apical diastolic thrill
What murmur is heard with mitral valve stenosis
Low rumbling mid-diastolic murmur
Heard with bell in LLD position
What diagnostic studies would you get with Mitral stenosis
Stress echo or L/R cath if symptoms don’t match echo results
TEE to look for thrombi before surgical intervention
What is the treatment for mitral valve stenosis
diuretics and Na restrict for dyspnea. BB to improve exercise capacity
Anti-Coag with WARFARIN to control AFib
What is surgical intervention for Mitral stenosis
Percutaneous balloon valvuloplasty if moderate/wanna become preggers/pulm HTN
Open replacement if severe
What causes tricuspid stenosis
RARELY isolated- usually with TR, aortic/mitral disease Due to rheumatic valve disease carcinoid disease congenital HD endocarditis
What happens during tricuspid stenosis
decreased preload= decreased CO= systemic venous congestion
What are symptoms of tricuspid stenosis
Fatigue (chronic low CO)
RUQ/abd pain (venous congestion)
What will you see on tricuspid stenosis PE
RHF Sx
What is the tricuspid stenosis murmur
Diastolic murmur over LSB (on inspiration)
When would a cardiac cath be needed in tricuspid stenosis
if concerned for other valve abn. or open repair planned
What is surgical intervention for tricuspid stenosis
Only repair if repairing others.
Balloon valvuloplasty w/ no other lesions
Open bioprosthesis replacement
What are the causes of tricuspid regurgitation
Mostly, dilated RV (dilates valve ring)
What happens during Tricuspid regurgitation
Volume overload in RV= increased systemic venous pressure= RHF
What are Tricuspid regurg symptoms
Usually asymptomatic
RHF Sx
What is the tricuspid regard murmur
Pan systolic murmur at 3-4 ICS at LSB, heard on inspiration
How would you treat Tricuspid regurgitation
Medical therapy for RHF if present. If not, nothing (asymptomatic)
When would tricuspid regard require surgery
If severe and organic cause, surgical repair
if repairing another valve and has pull HTN
What are causes of pulmonic stenosis
1- congenital
What happens during pulmonic stenosis
RVH
What are the symptoms of pulmonic stenosis
Cyanosis in newborns
RHF/dyspnea in 40’50’s
What murmur is heard with pulmonic stenosis
Harsh systolic crescendo-decrescendo at 3-4 ICS
What is the treatment for pulmonic stenosis
balloon valvuloplasty if symptomatic or severe
What causes pulmonary regurgitation
Pulmonary HTN dilates valve ring
rarely endocarditis
What is the pathophysiology of pulmonary regurgitation
RV volume overload
What are symptoms of pulmonary regurgitation
RHF
Dyspnea
septic pulmonary emboli and fever (if caused by IE)
What is the Pulmonary Regurg murmur
Low pitch diastolic murmur at 3-4 left ICS
What is therapy for Pulmonary Regurg
treat primary cause
valve replacement or bioprosthetic repair
What is tetralogy of fallot
Ventricular septal defect
Pulmonic stenosis
Overriding aorta
RVH
What are symptoms of tetralogy of fallot
Cyanosis
Tet spells while crying/after feeding
poor growth
clubbing
What relieves Tetralogy of fallot symptoms
Squatting- it increases PVR and decreases RV to LV shunt
What is the murmur associated with tetralogy of fallot
Harsh systolic murmur due to VSD
How do you diagnose Tetralogy
Echo
What is the treatment for Tetralogy
surgical repair w/in 1st year
place shunt if unable to undergo surgery