Valvular Heart Disease

Question 1

Aortic stenosis vs aortic regurgiation clinical profile

Answer 1

Question 2

Aortic stenosis vs aortic regurgiation physical exam findings

Answer 2

Question 3

Compensated vs Decompensated aortic regurgitation

Answer 3

Question 4

Murmurs result from the following mechanisms:

Answer 4

• Flow across a partial obstruction
• Increased flow through normal structures
• Ejection into a dilated chamber
• Regurgitant flow across an incompetent valve
• Abnormal shunting of blood from one vascular chamber to a lower-pressure chamber

Question 5

Murmur timing

Answer 5

systolic, diastolic, or continuous

Question 6

Systolic murmur grading

Answer 6

Question 7

Diastolic murmur grading

Answer 7

Question 8

High-frequency murmurs are caused by ___ and best appreciated with ___.

Answer 8

High-frequency murmurs are caused by high-pressure gradient flow and best appreciated with the diaphragm.

Question 9

Low-frequency murmurs are caused by ___ and best appreciated with ___.

Answer 9

Low-frequency murmurs are caused by low pressure gradient flow and best appreciated with the bell.

Question 10

Crescendo–decrescendo murmur

Answer 10

Rises and then falls in intensity

‘Diamond shaped’ on echocardiogram

Question 11

Typical murmur description format

Answer 11

“A grade III/VI high-pitched, crescendo–decrescendo systolic murmur, heard best at the upper-right sternal border, with radiation toward the neck.”

Question 12

Classification of systolic murmurs

Answer 12

Question 13

Why do some murmurs crescendo-decrescendo?

Answer 13

The sound follows the flow:

The increase in flow due to increase in pressure from contraction causes the crescendo. At the apex, the pressure is maximal. Then, as pressure decreases (due to the increased felt effect of aterload), the flow decreases.

Question 14

Aortic stenosis pressure/sound diagram

Answer 14

Question 15

How can one tell how severe aortic stenosis is from cardiac exam?

Answer 15

Paradoxically, it does not correlate to the intensity of the murmur.

Rather, the more severe the stenosis, the later the peak moves in systole

Question 16

Classification of diastolic murmurs

Answer 16

Question 17

Murmur of a ventricular septal defect

Answer 17

A form of pansystolic murmur which may be distinguished from AV regurgitation murmurs by:

• It’s location (4th to 6th left intercostal space)
• It’s lack of radiation
• It’s lack of increase in intensity with inspiration

Question 18

How does one evaluate the severity of a ventricular septal defect?

Answer 18

Paradoxically, the murmur gets less intense the greater the flow is! This is because these defects are less turbulent.

The loudest, most turbulent VSDs are actually the safest and least worrisome. It is if a patient has a history of known VSD and it suddenly seems to soften or disappear on cardiac exam that you should be worried.

Question 19

If a diastolic murmur occurs early in diastole, it is probably ___. If it occurs mid-diastole, it is probably ___.

Answer 19

If a diastolic murmur occurs early in diastole, it is probably aortic or pulmonic regurgitation. If it occurs mid-diastole, it is probably mitral or tricuspid stenosis.

Question 20

Non-pathologic mid-to-late diastolic murmurs

Answer 20

May occur simply due to increased flow across a normal mitral or tricuspid valve.

Question 21

Peri-pathologic mid-to-late diastolic murmurs

Answer 21

Hyperdynamic states may also produce a benign disatolic murmur (the murmur itself is benign, the condition may or may not be):

• Fever
• Anemia
• Hyperthyroidism
• Exercise stress

Question 22

Classification of continuous murmurs

Answer 22

Question 23

Most common valvular heart disease

Answer 23

Aortic valve stenosis

Question 24

Most common causes of aortic valve stenosis

Answer 24

1. Congenital bicuspid aortic valve
2. Aortic valve degeneration (calcification)
3. Rheumatic fever (type III hypersensitivity post-Streptococcus pyogenes infection)

Question 25

Evaluating for aortic stenosis on physical exam

Answer 25

• Systolic crescendo-decrescendo murmur with radiation to carotids
• Increases in intensity with passive leg raise
• Decreases in intensity with Valsalva maneuver
• Radiation to carotid arteries
• Soft S2
• S4
• parvus et tardus upstroke to carotid artery (weakened and late)

Question 26

Valsalva maneuver

Answer 26

Question 27

Treating aortic stenosis

Answer 27

• Surgical valve replacement
• Percutaneous valve insertion (high risk)
• Balloon dilation (temporary, used in emergencies to bridge to surgery)
• Medications are really of no use here, this needs surgery

Question 28

Aortic regurgitation on PV curve

Answer 28

Question 29

Evaluating for aortic regurgitation on physical exam

Answer 29

• Early diastolic murmur, high-pitched
• S3 (due to compensation)
• Laterally displaced, hyperdynamic PMI
• Brisk and priminent upstroke to carotid

Question 30

Treating aortic regurgitation

Answer 30

• Decrease preload (nitrates, diuretics)
• Antiarrhythmics (maintain sinus rhythm)
• Definitive cure is surgical valve replacement

Question 31

Cardiac remodeling overview

Answer 31

Question 32

Treating coarctation

Answer 32

• Surgical remodeling of aorta to remove narrowed segment
• Balloon dilaton within narrowed segment - risky in very young, more helpful with young adult patients

Question 33

Types of aneurysm

Answer 33

Question 34

___ aortic aneurysms have a much higher risk for rupture than ___ aortic aneurysms.

Answer 34

Thoracic aortic aneurysms have a much higher risk for rupture than abdominal aortic aneurysms.

Question 35

Abdominal aneurysms are usually due to ___.

Answer 35

Abdominal aneurysms are usually due to atherosclerotic disease

Question 36

DeBakey classification of aortic dissection

Answer 36

Question 37

Endovascular aortic repair

Answer 37

Place a flow-tube within the lumen of an aorta with tear and aneurysm to guide flow and prevent growth of aneurysm.

Question 38

Definition of aortic dissection

Answer 38

Aortic dissection is a life-threatening condition in which blood from the vessel lumen passes through a tear in the intima into the medial layer and spreads along the artery.

Question 39

Proximal aortic involvement tends to be more devastating because of the potential for ___

Answer 39

Proximal aortic involvement tends to be more devastating because of the potential for extension into the coronary and arch vessels, the support structures of the aortic valve, or the pericardial space