Valvular Heart Disease Flashcards
Aortic stenosis vs aortic regurgiation clinical profile
Aortic stenosis vs aortic regurgiation physical exam findings
Compensated vs Decompensated aortic regurgitation
Murmurs result from the following mechanisms:
- 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
Murmur timing
systolic, diastolic, or continuous
Systolic murmur grading
Diastolic murmur grading
High-frequency murmurs are caused by ___ and best appreciated with ___.
High-frequency murmurs are caused by high-pressure gradient flow and best appreciated with the diaphragm.
Low-frequency murmurs are caused by ___ and best appreciated with ___.
Low-frequency murmurs are caused by low pressure gradient flow and best appreciated with the bell.
Crescendo–decrescendo murmur
Rises and then falls in intensity
‘Diamond shaped’ on echocardiogram
Typical murmur description format
“A grade III/VI high-pitched, crescendo–decrescendo systolic murmur, heard best at the upper-right sternal border, with radiation toward the neck.”
Classification of systolic murmurs
Why do some murmurs crescendo-decrescendo?
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.
Aortic stenosis pressure/sound diagram
How can one tell how severe aortic stenosis is from cardiac exam?
Paradoxically, it does not correlate to the intensity of the murmur.
Rather, the more severe the stenosis, the later the peak moves in systole
Classification of diastolic murmurs
Murmur of a ventricular septal defect
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
How does one evaluate the severity of a ventricular septal defect?
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.
If a diastolic murmur occurs early in diastole, it is probably ___. If it occurs mid-diastole, it is probably ___.
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.
Non-pathologic mid-to-late diastolic murmurs
May occur simply due to increased flow across a normal mitral or tricuspid valve.
Peri-pathologic mid-to-late diastolic murmurs
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
Classification of continuous murmurs
Most common valvular heart disease
Aortic valve stenosis
Most common causes of aortic valve stenosis
- Congenital bicuspid aortic valve
- Aortic valve degeneration (calcification)
- Rheumatic fever (type III hypersensitivity post-Streptococcus pyogenes infection)
Evaluating for aortic stenosis on physical exam
- 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)
Valsalva maneuver
Treating aortic stenosis
- 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
Aortic regurgitation on PV curve
Evaluating for aortic regurgitation on physical exam
- Early diastolic murmur, high-pitched
- S3 (due to compensation)
- Laterally displaced, hyperdynamic PMI
- Brisk and priminent upstroke to carotid
Treating aortic regurgitation
- Decrease preload (nitrates, diuretics)
- Antiarrhythmics (maintain sinus rhythm)
- Definitive cure is surgical valve replacement
Cardiac remodeling overview
Treating coarctation
- Surgical remodeling of aorta to remove narrowed segment
- Balloon dilaton within narrowed segment - risky in very young, more helpful with young adult patients
Types of aneurysm
___ aortic aneurysms have a much higher risk for rupture than ___ aortic aneurysms.
Thoracic aortic aneurysms have a much higher risk for rupture than abdominal aortic aneurysms.
Abdominal aneurysms are usually due to ___.
Abdominal aneurysms are usually due to atherosclerotic disease
DeBakey classification of aortic dissection
Endovascular aortic repair
Place a flow-tube within the lumen of an aorta with tear and aneurysm to guide flow and prevent growth of aneurysm.
Definition of aortic dissection
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.
Proximal aortic involvement tends to be more devastating because of the potential for ___
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
