Valvular Heart Disease: Aortic and Mitral Flashcards by Andrew Kreutzer

As stenosis develops:
Resistance to flow ____
Pressure must ____ to maintain flow
If pressure cannot be ____, then flow will ____

increase
increase
increased; decrease

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Compensatory Mechanisms for Valve Stenosis include?

Hypertrophic remodeling
Increased contractility

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As regurgitation develops:
Flow of blood will occur towards the area of?
Hemodynamic consequences depend on?

least resistance
chamber compliance

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Valve Regurgitation Compensatory mechanisms include?

Chamber dilation to increase compliance and decrease pressure
Increase total stroke volume in order to maintain forward stroke volume

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Consequences of Valve Dysfunction
Chamber remodeling results in?

enlargement and hypertrophy

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Consequences of Valve Dysfunction
Pressure Overload occurs from which valve dysfunction?
Causes what type of hypertrophy?

Pulmonic Stenosis and Aortic Stenosis
Concentric ventricular hypertrophy

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Consequences of Valve Dysfunction
Volume overload occurs from which valve dysfunction?
Causes what type of hypertrophy?

Tricuspid Regurgitation and Mitral Regurgitation
Eccentric Ventricular Hypertrophy

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Consequences of Valve Dysfunction
Cardiac ____
Pulmonary ____
Clinical symptoms of?

fibrosis
hypertension
heart failure

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Bicuspid Aortic Valve occurs in what % of the population?
These patients are more prone to?
This condition is associated w/?

1-2%
endocarditis
aortopathy and coarctation

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Aortic Stenosis Symptoms
Heart failure

SOB/DOE
D/t diastolic dysfunction from hypertrophied LV there is increased pulmonary venous pressure; eventually leading to systolic dysfunction

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Aortic Stenosis Symptoms
Angina

Increased LVEDP & Decreased coronary perfusion pressure in setting of LVH leads to subendocardial ischemia,
Concomitant CAD

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Aortic Stenosis Symptoms
Occurs due to decreased blood flow to brain?

Syncope

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Aortic Stenosis PE
Asymmetric BP in young patients could suggest?
Pulsus tardus et parvus means?

Coarctation w/ a bicuspid valve
Delayed/weak carotid upstroke

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Aotric Stenosis PE
Auscultation:
Systolic murmur where?
Murmur intensity correlates w/?
Gallavardin phenomenon is when?
Soft or absent S2 sounds occurs when?

at base radiating to neck
severity
dissociation of the harsh and musical components of murmur
severe

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Aortic Stenosis - Diagnostic Testing
Echocardiogram:
Transthoracic shows?
Transesophageal shows?

AVA, Pressure gradients, leflet number, LV function, LVH, Pulmonary HTN
Clarify leaflet number, measure aortic dimension

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Aortic Stenosis - Diagnostic Testing
EKG shows?

LVH
LAE
may develop Afib

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Aortic Stenosis - Diagnostic Testing
Lab work to collect?

BNP

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Aortic Stenosis - Diagnostic Testing
Cardiac Cath shows?

evaluate CAD & hemodynamics

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Aortic Stenosis Treatment
Indications for surgery

Severe AS w/ Symptoms
Severe AS w/ EF < 50%
Severe AS undergoing another cardiac surgery

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Aortic Stenosis Treatment
Medical Therapy

No medical therapy specifically for AS
Treat concomitant HTN, CAD, Afib

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Less invasive option for AVR is?

TAVR - Transcatheter Aortic Valve Replacement

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Acute AR - Presentation
Hx includes

Dissection
Endocarditis
Severe dyspnea
Respiratory distress

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Acute AR - Presentation
PE includes

Pulmonary Edema
LV heave w/ hyperdynamic precordium
Soft diastolic murmur at left lower sternal border; may not be audible
Physical signs of endocarditis or dissection

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Chronic AR - Presentation
Hx includes

Symptoms will depend on LV function
DOE, fatigue, HF

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Chronic AR - Presentation PE includes

Wide pulse pressure Diastolic decrescendo murmur heard best at left lower sternal border at end-expiration (severity is inversely proportional to duration) Systolic murmur due to increased flow

AR diagnostic testing Echocardiogram Transthoracic shows? Transesophageal shows?

Severity of AR, leaflet number, LV function, LV chamber dimensions Clarify leaflet number, measure aortic dimension, dissection, endocarditis

AR diagnostic testing EKG shows?

LVH, LAE

AR diagnostic testing CXR shows

cardiomegaly widened mediastinum pulmonary edema

AR diagnostic testing Lab work to collect

BNP blood cultures

AR diagnostic testing CT or MRI shows

assess AR severity, aorta size

AR diagnostic testing Caridac Cath

evaluate CAD aortogram

AR treatment Acute Severe AR requires

Emergency Surgery Attempt medical stabilization w/ afterload reduction

AR treatment Chronic Severe AR requires

Surgery for symptoms, LV dilation, LV dysfunction (EF <50%) Medical Therapy is limited Treat HTN Consider vasodilators if inoperable

MS - Pulmonary HTN Increased LA pressure is transmitted where?

Pulmonary Vasculature (passive HTN)

MS - Pulmonary HTN Chronically Increased pulmonary venous pressures leads to?

remodeling of pulmonary vasculature ( reactive pulmonary HTN, smooth muscle cell proliferation, vasoconstriction)

MS - Pulmonary HTN RV dysfunction occurs due to?

pressure overload

MS - Pulmonary HTN Pulmonary Vasculature changes may be?

irreversible

MS - Symptoms

DOE Chest pain Embolization event Hemoptysis R Heart Failure (edema, hepatomegaly, abdominal fullness) Symptoms may develop d/t factors that increase the transvalvular gradient

MS and Afib Increased LA size and fibrosis leads to?

abnormal electrical activity predisposing to Afib

MS and Afib Deleterious sequelae includes?

Tachycardia increases gradient Decreased LV filling w/ loss of atrial kick Thrombus formation leads to embolization

MS - PE Soft, low pitched duration reflects severity?

Diastolic rumbler

MS - PE Only audible if valve is pliable Marker of severity: decreased timing between S2 and OS as Decreased MVA?

Opening snap (OS) follows S2

MS - PE P2 is loud in the setting of? May have systolic murmur from? May have sings of?

pulmonary HTN MR R Heart failure

MS Diagnostic Testing Echocardiogram Transthoracic shows? Transesophageal shows?

Severity of MS and MR, etiology, LA size, Pulmonary HTN, RV function Clarify etiology, leaflet and subvalvular mobility and calcification, MR severity, LA clot

MS Diagnostic Testing EKG shows?

LAE Afib R axis deviation

MS Diagnostic Testing CXR shows

LAE Enlarged pulmonary arteries

MS Diagnostic Testing Cardiac Cath shows

invasive hemodynamics evaluation of CAD

MS - Treatment Medical?

Antibiotics to prevent recurrent rheumatic fever Afib: anticoagulation and rate control

MS - Treatment Nonmedical

Generally performed for moderate or severe MS w/ concomitant pulmonary HTN and/or symptoms percutaneous surgical

Percutaneous mitral balloon valvuloplasty Balloon dilation of the? Treatment of choice when? Generally only for?

mitral valve available rheumatic MS (not calcific)

Percutaneous mitral balloon valvuloplasty Contraindications include?

Valve anatomy unfavorable (too immobile, tethered, and/or calcified) Moderate or severe MR LA clot

MVR is generally for those who?

are not candidates for balloon valvuloplasty

An abnormality of which components of the mitral valve may cause mitral regurgitation?

Leaflets (anterior and posterior); scallops Annulus Chordae Tendinae Papillary muscles (anterolateral, posteromedial) LV

Acute MR Hx includes

Rapid onset of significant SOB, which may cause respiratory failure Recent infarct (ruptured papillary muscle), ruptured chord, or endocarditis possible precipitants

Acute MR PE

Tachypneic w/ respiratory distress Tachycardic Systolic murmur at the apex (may be absent) Pulmonary edema Apical impulse may be hyperdynamic

Chronic MR Hx includes

Long asymptomatic period as MR progresses As compensatory mechanisms fail the patient experiences DOE SOB w/ less activity, palpitations (afib), CHF sx

Chronic MR PE

Apical holosystolic murmur at axilla In MVP, there may be a midsystolic click heard before the murmur May have irregularly irregular rhythm (afib) Other signs of HF

MR - Diagnostic Testing Echocardiogram Transthoracic shows? Transesophageal shows? Exercise Echo shows?

Severity and mechanism of MR, LV chamber size, LV function, LA size, Pulmonary HTN Clarify severity and mechanism of MR, 3D imaging MR severity and pulm HTN

MR - Diagnostic Testing EKG shows

LAE, Afib

MR - Diagnostic Testing CXR shows

LAE Enlarged pulmonary arteries

MR - Diagnostic Testing Cardiac Cath shows

Vetriculogram evaluates CAD

Acute MR Treatment Surgery is indicated often? While awaiting surgery, aggressive what? Although Tachycardic, avoid what?

urgently or emergently afterload reduction w/ medications or balloon pump can diminis MR and promote Forward flow attempts to slow HR as they are often HR dependent ofr adequate forward CO

Chronic MR - Treatment Surgical

Valve repair is preferable to replacement

Chronic MR - Treatment Surgical indications

Severe MR w/: Symptoms LV dysfunction (EF < 60%) Dilating LV Afib or pulm HTN

Chronic MR - Treatment Treatment is aimed at improving what? Medical treatment for LV dysfunction / CHF includes?

the ventricle ACE-I, Beta Blockers, Aldosterone antagonists

Chronic MR - Treatment Biventricular pacing if? Revascularization if? Surgery to repair or replace the valve may be considered, but unclear if this will? Consider?

appropriate indicated improve QOL and/or survival; percutaneous option