Valvular Heart Disease: Aortic and Mitral Flashcards
As stenosis develops:
Resistance to flow ____
Pressure must ____ to maintain flow
If pressure cannot be ____, then flow will ____
increase
increase
increased; decrease
Compensatory Mechanisms for Valve Stenosis include?
Hypertrophic remodeling
Increased contractility
As regurgitation develops:
Flow of blood will occur towards the area of?
Hemodynamic consequences depend on?
least resistance
chamber compliance
Valve Regurgitation Compensatory mechanisms include?
Chamber dilation to increase compliance and decrease pressure
Increase total stroke volume in order to maintain forward stroke volume
Consequences of Valve Dysfunction
Chamber remodeling results in?
enlargement and hypertrophy
Consequences of Valve Dysfunction
Pressure Overload occurs from which valve dysfunction?
Causes what type of hypertrophy?
Pulmonic Stenosis and Aortic Stenosis
Concentric ventricular hypertrophy
Consequences of Valve Dysfunction
Volume overload occurs from which valve dysfunction?
Causes what type of hypertrophy?
Tricuspid Regurgitation and Mitral Regurgitation
Eccentric Ventricular Hypertrophy
Consequences of Valve Dysfunction
Cardiac ____
Pulmonary ____
Clinical symptoms of?
fibrosis
hypertension
heart failure
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
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
Aortic Stenosis Symptoms
Angina
Increased LVEDP & Decreased coronary perfusion pressure in setting of LVH leads to subendocardial ischemia,
Concomitant CAD
Aortic Stenosis Symptoms
Occurs due to decreased blood flow to brain?
Syncope
Aortic Stenosis PE
Asymmetric BP in young patients could suggest?
Pulsus tardus et parvus means?
Coarctation w/ a bicuspid valve
Delayed/weak carotid upstroke
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
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
Aortic Stenosis - Diagnostic Testing
EKG shows?
LVH
LAE
may develop Afib
Aortic Stenosis - Diagnostic Testing
Lab work to collect?
BNP
Aortic Stenosis - Diagnostic Testing
Cardiac Cath shows?
evaluate CAD & hemodynamics
Aortic Stenosis Treatment
Indications for surgery
Severe AS w/ Symptoms
Severe AS w/ EF < 50%
Severe AS undergoing another cardiac surgery
Aortic Stenosis Treatment
Medical Therapy
No medical therapy specifically for AS
Treat concomitant HTN, CAD, Afib
Less invasive option for AVR is?
TAVR - Transcatheter Aortic Valve Replacement
Acute AR - Presentation
Hx includes
Dissection
Endocarditis
Severe dyspnea
Respiratory distress
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
Chronic AR - Presentation
Hx includes
Symptoms will depend on LV function
DOE, fatigue, HF
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