VALVULAR HEART DISEASE Flashcards
Valvular heart disease
■ MITRAL STENOSIS ■ AORTIC STENOSIS ■ MITRAL REGURGITATION ■ AORTIC REGURGITATION ■ TRICUSPID REGURGITATION ■ TRICUSPID STENOSIS ■ PULMONARY STENOSIS ■ PULMONARY REGURGITATION ■ MIXED LESION
MITRAL STENOSIS
Definition:
The mitral valve’s incapacity to open completely in diastole, due to
- comisural fusion
- cusps thickenning
- remodeling of the subvalvular structures
MITRAL STENOSIS
Etiology
Rheumatic fever - most of the patients, Other etiologies are very rare: –Congenital, MS+atrial septal defect= Lutembacher syndrome. –Mitral valve annular calcification - elderly. –Other causes of LV inflow obstruction: ■atrial myxoma ■LA ball thrombus ■cor triatriatum.
MITRAL STENOSIS-Pathology
Fusion of the comissures, cusps or chords.
Contracture and thickening of the cusps.
Shortening and fusion of the chordae tendinae.
Funnel –shaped orifice.
SLIDE 5
Mitral Stenosis
Pathophysiology
■ Obstruction between LA and LV. ■ Pressure gradient. ■ Elevated LA pressure. ■ LA pressure increases at elevated HR. ■ Pulmonary vascular resistance elevated. ■ Pulmonary hypertension ■ Right ventricular hypertrophy, enlargement. ■ Systemic venous congestion
Mitral stenosis-Classification
■ Large: more than 2 sqcm.
■ Medium: 1,5-2sqcm.
■ Severe:<1sqcm.
Mitral stenosis-Symptoms.
■ Exertional dyspnea. ■ Fatigue. ■ Presyncope, syncope. ■ Cough, wheezing. ■ Paroxysmal nocturnal dyspnea. ■ Orthopnea. ■ Hemoptysis. ■ Hoarsenes(Ortner syndrome
Mitral stenosis
Physical findings
■ Mitral facies. ■ Tachypnea. ■ Turgid jugulars. ■ Jugular pulse. ■ Pulmonary rales, pleural fluid. ■ Diastolic thrill. ■ Sustained RV lift
Mitral stenosis
-Auscultaion
slide 10 ,11 ,12
Mitral stenosis- Complications
■ Atrial fibrillation/flutter. ■ Embolism: Systemic:cerebral, coronary, preipheral; pulmonary. ■ Acute pulmonary edema. ■ RV heart failure. ■ Infective endocarditis. ■ Chest pain/angin
Mitral regurgitation
Definition: Clinical syndrome determined by the
incomplete closure of the mitral valve during systole.
MR - Causes
SLIDE 15 , 16
MR-pathophysiology
■ A volume of blood is regurgitated from the LV to the LA
LV overload.
■ End diastolic pressure increases
LA preassure is increased,
LA is dilated,
Pulm HTN can develop.
■ LV is dilated
Syst LV dysfunction appears (may be irreversible)
■ Pulmonary arterial hypertension can appear
+
RV failure during evolution.
MR-pathophysiology
SLIDE 18
MR-physical examination
■ Carotid upstroke is brisk.
■ Laterally displaced apical impulse with enlarged LV.
■ Apical thrill-severe MR.
■ Left sternal border lift –RV dilation.
■ S1 is included in the murmur, usually normal, may be increased in rheumatic heart disease.
■ S3 gallop-large volume of regu
MR-physical examination (II)
■ The hallmark of MR is the systolic murmur-most often holosystolic, is of blowing type, but may be harsh in mitral valve prolapse
MR in mitral valve prolapse.
■ MR limited to telesystole.
■ Frequent -5%pop. especially in young women.
■ Habitus is sometimes characteristic: longiline- asthenic woman with mild chest
deformities:pectus excavatum, pectus carinatum.
■ Palpation- bifid apical impulse.
■ Meso or telesystolic click, followed by –in a minority of cases – by telesystolic murmur
Mitral Valve Repair
SLIDE 22
Aortic stenosis
Definition: obstruction to blood outflow from the LV to the aorta. Causes: 1. Congenital. 2. Acquired: - Degenerative - Rheumatic
Rare causes:
- Infective endocarditis
- Paget bone disease
- SLE
- Rheumatoid involvement
- Irradiation
Aortic stenosis - PATHOLOGY
SLIDE 24
Aortic stenosis - Pathophysiology
■ Obstruction in LV outflow. ■ Gradient LV-Ao. ■ LV pressure rises,. ■ LV wall stress increases. ■ LV dysfunction develops ■ LV hypertophy develops. ■ LV filling pressure increaqses. ■ LV systolic failure develop
Aortic stenosis-classification
SLIDE 26
Aortic stenosis-symptoms
■ Angina pectoris. ■ Exertional presyncope ■ Syncope. ■ Heart Failure ■ Pulmonary edema
AS- CLINICAL FINDINGS
■ Peripheral pulse: parvus et tardus- taking longer time to reach the peak pressure, peak is reduced.
■ Heart size increased in heart failure.
■ Palpable G4(S4).
■ Aortic thrill at the base of the heart.
AS-Auscultation
■ Systolic ejection click(bicuspid)
■ Paradoxically split S2.
■ Systolic ejection murmur.
■ In older patients ejection murmur is atypical, heard at the apex as seagull sound – Gallavardin phenomenon.
■ Ejection murmur decreased when LV failure occurs
AORTIC VALVE REPLACEMENT
TAVI= Transcatheter Aortic Valve Implantation SLIDE 30
AORTIC REGURGITATION
Definition:
Incomplete closure of the aortic cusps in diastole and regurgitation of blood from the aorta to the left ventricle.
Aortic regurgitation can be acute or chronic.
AORTIC REGURGITATION-Etiology
SLIDE 32
AORTIC REGURGITATION-Pathology
■ Dilatation of the annulus AR. ■ Valves can show – Thickening – Shortening – Comisural lesions – Calcification, . ■ LV – dilated – hypertrophied. ■ LV dysfunction
AORTIC REGURGITATION-Symptoms
■ Pounding of the head or palpitations. ■ Dyspnea on exertion. ■ Orthopnea, paroxysmal nocturnal dyspnea. ■ Fatigue and weakness. ■ Angina pectoris
AORTIC REGURGITATION-peripheral signs
■ Pulse pressure –elevated.
■ Corrigan pulse- celer et altur.
■ Atrerial hyperpulsatility:
■ Musset sign-bobbing of the head with each heartbeat.
■ Traube sign-pistol-shot heard over the femoral artery.
■ Duroziez sign-systolic murmur fem.a.when compressed proximally, diastolic distally.
■ Quincke pulse-capillary pulsations detected pressing a glass over the patients lips.
■ Arterial dance- carotid pulsations.
■ Waterhammer sign-pulsatons of the forearm when pressed.
■ Landolfi sign – intermittant pupillary hippus – miosis in systole, midriasis in diastole
AORTIC REGURGITATION-physical examination
■ The chest may rock, cardiac impulse may be visible.
■ Diastolic thrill-severe AR.
■ S1 usually soft.
■ Systolic ejection murmur.
■ Early or immediate, blowing descrescendo diastolic murmur, after S2.
■ IN severe AR the murmur is holodiastolic.
■ Austin-Flint murmur of functional mitral stenosis.
■ Signs of left or global heart failure
Tricuspid regurgitation
Definition: incapacity of the tricuspid valve to close completely during systole, resulting in
regurgitation of blood from the right ventricle to the right atrium.
Tricuspid regurgitation -etiology
■ Primary TV disease: – Congenital:Ebstein anomaly – Rheumatic, assoc. with mitral disease. – Infective endocarditis. – Iatrogenic: pacemaker wire trauma. – Degenerative:TV prolapse.
■ Secondary TV disease: – RV dilatation
– Pulmonary hypertension. – Cardiomyopathies – Segmental RVdysf. Due to ischemia, ARVD
Tricuspid regurgitation-symptoms
■ TR is not associated with any complaint until the late phases of the disease when RV dysfunction develops resulting in overt rihgt heart failure syndrome.
■ Symptoms: fatigue, right upper quadrant discomfort, dyspepsia due to gut congestion
Tricuspid regurgitation –
physical examination
■ Edema of the lower limbs. ■ Ascites. ■ Jugular congestion ■ Cachexia due to low cardiac output ■ Right parasternal lift. ■ Systolic pulsa
Tricuspid regurgitation
Auscultation
SLIDE 42
Tricuspid stenosis
■ Rare condition
■ Etiology: rheumatic in most of the cases.
■ Simptoms and general signs similar to those met in TR.
■ Auscultation: low to medium pitched diastolic rumble with inspiratory accentuation,
localized to the lower sternal border.
Pulmonary valve dissease
■ Apart from congenital conditions is very rare.
■ Congenital: PV stenosis, Pulmonary atresia, Bicuspid valve, Infundibular(subvalvular pulmonary stenosis), Idiopathic dilatation of the pulmonary artery.
■ Acquired: reheumatic, Infective endocarditis, carcinoid heart disease, pulmonary hypertension, iatrogenic-Ross operation.
Pulmonary stenosis –physical examination
■ Mild stenosis - systolic ejection click+early systolic murmur.
■ Severity progresses the murmur gets louder and peaks later in systole.
■ S2 is splitted with dealyed pulmonary component, but with further widening in inspiration
