Valvular Heart Disease Flashcards by Joel Glotfelty

Heard during rapid ventricular filling

Normal in younger patients
In adults may indicate dilated ventricle with tending of chordae tendinae

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Atrial systole causes ejection of blood into a stiffened ventricle

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Caused by opening of stenosis aortic or pulmonic valve

Ejection Click

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Usually seen in mitral stenosis

Opening Snap (OS)

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Sound generated by turbulent blood flow as a result of structural or hemodynamics changes

Murmurs

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Generated when there is flow between chambers that have widely different pressures throughout systole

Holosystolic/pansystolic murmers

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Crescendo-decrescendo murmers that occur when blood is ejected across aortic or pulmonic outflow tracts

Midsystolic/systolic ejection

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Starts shortly after S1 when ventricular pressure rises enough to open valve

Midsystolic/systolic ejection

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Begin with S1 and end in mid systole

-Occurs In patients with acute MR

Early systolic murmers

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High-pitched murmers at the left ventricular apex

-Start after S1 and end before or at S2

Mid to late systolic murmurs

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Often due to tethering and malcoaptation of the mitral leaflets

Mid to late systolic murmurs

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Begin with S2, when ventricular pressure drops below that in the aorta or pulmonary artery

-Usually high pitched and decrescendo

Diastolic murmurs

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Usually originate from the mitral ad tricuspid valves

-Occur early during ventricular filling

Mid-diastolic murmurs

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A classic example of a mid-diastolic murmur is

Mitral Stenosis

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Due to a relative disproportion between valve orifice size and diastolic blood flow volume

Mid-diastolic murmur

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Begin during the period of ventricular filling that follows atrial contraction

Occur only in sinus rhythm
Usually due to mitral or tricuspid stenosis

Presystolic murmurs/Late diastolic murmurs

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Begin in systole, peak near S2, and continue into all or part of diastole

Continuous murmurs

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Can be caused by venous hum, PDA, and AV fistulas

Continuous murmurs

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Most commonly caused by rheumatic fever

Mitral stenosis

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Characterized by acute and recurrent inflammation w/ leaflet thickening and calcification

Mitral stenosis

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In mitral stenosis, narrowing of the valve causes decreased

Emptying into LV

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Can cause dysphasia/hoarseness from compression of esophagus or left recurrent laryngeal nerve

LA enlargement from mitral stenosis

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Causes typically higher heart rates as well as a loss of atrial kick

Atrial Fibrillation

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CO becomes subnormal at rest and fails to increase during exercise in

Late/severe MS

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Characterized by loud S1 early and soft S1 late - Opening snap follows S2 - Mid-diastolic rumble

Mitral stenosis

One exam sign of severe mitral stenosis is a short

S2-OS interval

We want to treat with medications that slow the heart rate and thus increase diastolic filling time

Mitral Stenosis

One way to treat mitral stenosis is

Percutaneous Balloon Mitral Valvuloplasty

Due to structural abnormality related to the valve apparatus, leaflets, chordae tendinae, or papillary muscles

Primary Mitral Regurgitation (MR) -also known as degenerative MR

Due to abnormal computation (closure) of the interval leaflets due to a dilated left ventricle causing dilation of the mitral annulus or pulling apart the chordae and leaflets

Secondary Mitral Regurgitation -Also known as functional MR

A portion of LV stroke volume is ejected back into the LA resulting in increased LA volume and pressure and decreased forward CO

Mitral Regurgitation

Caused by an acute change such as papillary muscle rupture or torn chordae tendinae

Acute Severe MR

Compensated MR where SV is increased because LA and LV dilate

Chronic MR

Volume overload causes sufficient dilation to push the LV onto the downward portion of the Frank-Starling curve

Decompensated chronic MR

Results in deterioration of systolic function and symptoms of heart failure

Decompensated MR

Characterized by fatigue and dyspnea w/ increased abdominal girth and peripheral edema

Chronic MR

On exam, we will hear an apical holosystolic murmur that radiates to the axilla with

Chronic MR

With chronic MR, the murmur intensifies with maneuvers that increase

SVR

Due to volume overload of LV seen in chronic MR, we hear an

S3 murmur

Presents w/ acute shortness of breath and severe respiratory difficulty

Acute MR

On physical exam, will have a murmur w/ decrescendo quality due to rapid equilibrium between LV and LA pressures

Acute Mitral Regurgitation

May have hypotension and may have hypoxia from acute pulmonary edema

Acute MR

On ECG, mitral regurgitation is characterized by

LA enlargement and LVH

To treat an acute MR, we want to give

Diuretics and vasodilators

Relieve pulmonary edema in acute MR

Diuretics

Reduce SVR and augment forward cardiac output in acute MR

Vasodilators

Are less useful for treating chronic MR than they are for treating acute MR

Vasodilators

Systolic billowing of 1 or both mitral leaflets into the LA w/ or w/out MR

Mitral Valve Prolapse

May be accompanied by connective tissue disease such as Marfan’s Syndrome or Ehlers-Danlos Syndrome

Mitral Valve prolapse

Mitral Valve prolapse is usually asymptomatic, but we can see palpitations if their are

Arrhythmias

On exam, presents w/ mid systolic click and late systolic murmur at the apex

Mitral Valve Prolapse

With mitral valve prolapse, increased venous return causes more traction on the chordae and a later

Click and Murmur

Most common cause in adults is calcification of a previously normal trileaflet valve

Aortic Stenosis

Progresses from base of the cusps to the leaflets, eventually causing a reduction in leaflet motion and effective valve area

Calcification

Due to narrowing of the valve, and thus increased LV pressure is needed to drive blood into the aorta

Aortic Stenosis

LV undergoes concentric hypertrophy and decreased compliance with

Aortic Stenosis

On physical exam, presents with a coarse, systolic ejection murmur w/ a weakened or delayed carotid pulse

Aortic Stenosis

Aortic stenosis causes a stiff LV, which results in an

S4 murmur

Three symptoms of aortic stenosis are

1. ) Angina 2. ) Syncope 3. ) CHF

Due to imbalance between myocardial oxygen supply and demand

Angina

W/ aortic stenosis, the ventricle can not increase CO due to a fixed stenosis valve orifice. Thus, during exertion we see

Syncope

A classical ECG finding of aortic stenosis is

LVH

Characterized by blood regurgitation from aorta into LV in diastole

Aortic Regurgitation

The LV must pump the normal pulmonary venous return plus the regurgitant volume with

Aortic Regurgitation

Half of the cases of aortic regurgitation are due to

Aortic Root Dilation (annuloaortic ectasia)

15% of cases of aortic regurgitation are due to

Bicuspid aortic valve

LV is normal size and non-compliant. Regurgitation volume causes LV diastolic pressure to rise w/

Acute Aortic Regurgitation

Acute aortic regurgitation is characterized by

Dyspnea and pulmonary edema

Over time, the LV dilates and hypertrophies w/

Chronic Aortic Regurgitation

Increases w/ chronic AR, which allows LV to accommodate larger regurgitant volumes

Compliance

Aortic and systemic diastolic pressures drop, leading to widened pulse pressure and decreased coronary artery perfusion

Chronic AR

Characterized by dyspnea on exertion, decreased exercise tolerance, and sensation of forceful heart beat

Aortic Regurgitation

On exam, gives a blowing murmur early in diastole at left eternal border

Aortic Regurgitation

Has widened pulse pressure leading to bounding pulses -Characteristic Water-Hammer pulse (Corrigan’s Pulse)

Aortic Regurgitation

When capillary pulsations are visible at nail beds or lip -Seen in AR

Quince Sign

Drop in pressure in mid systole due to Venturi effect. So you feel a double pulsation -Feature of AR

Pulses Bisferiens

A low frequency, mid-diastolic rumble due to flow across the mitral valve, heard at the apex -Feature of AR

Austin Flint Murmur

With AR, we can see bobbing of the head w/ each heart beat. This is called

De Mussets Sign

Visible pulsations of the uvula seen in AR

Muller’s Sign

Systolic and diastolic sounds heard over the femoral artery in AR

Traube’s Sign (“Pistol Shots”)

In AR, we can see popliteal BP be higher than Brachial Systolic BP by more than 60 mmHg. This is called

Hill’s Sign

We can treat AR by targeting

Afterload reduction (Ca2+ blockers and ACE inhibitors)

Most commonly rheumatic in origin and has an opening snap and diastolic rumble that increases w/ respiration

Tricuspid Stenosis

We see a large a wave on neck veins with

Tricuspid Stenosis

Usually functional and is from a dilated RV

Tricuspid Regurgitation

Presents w/ symptoms of right heart failure

Tricuspid Regurgitation

On physical exam, presents w/ prominent v waves on JVP and a holosystolic murmur that increases w/ inspiration

Tricuspid Stenosis

We can also see a pulsating liver w/

Tricuspid stenosis

Rare and usually congenital

Pulmonic Stenosis

Usually due to severe pulmonary hypertension

Pulmonic Regurgitation

Characterized by a high-pitched decrescendo murmur along the left eternal border

Pulmonic Regurgitation