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Acute Care I > Valvular Heart Disease: Aortic and Mitral > Flashcards

Valvular Heart Disease: Aortic and Mitral Flashcards

1
Q

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

A

increase
increase
increased; decrease

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2
Q

Formula for Flow
Flow = ?

A

Pressure/Resistance

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3
Q

Compensatory Mechanisms for Valve Stenosis include?

A

Hypertrophic remodeling
Increased contractility

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4
Q

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

A

least resistance
chamber compliance

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5
Q

Formula for Delta Pressure
Delta Pressure = ?

A

Delta Volume / Compliance

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6
Q

Valve Regurgitation Compensatory mechanisms include?

A

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

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7
Q

Consequences of Valve Dysfunction
Chamber remodeling results in?

A

enlargement and hypertrophy

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8
Q

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

A

Pulmonic Stenosis and Aortic Stenosis
Concentric ventricular hypertrophy

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9
Q

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

A

Tricuspid Regurgitation and Mitral Regurgitation
Eccentric Ventricular Hypertrophy

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10
Q

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

A

fibrosis
hypertension
heart failure

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11
Q

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

A

1-2%
endocarditis
aortopathy and coarctation

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12
Q

Aortic Stenosis Patho
Valvular obstruction leads to?
Leading to what?

A

Increased Intraventricular pressure to maintain CO
Ventricular walls hypertrophy to reduce wall stress

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13
Q

Aortic Stenosis Patho
Laplace’s Law: Wall Stress = ?

A

Pressure x radius / 2 x thickness

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14
Q

Aortic Stenosis Patho
LVH leads to?

A

Decreased compliance
Impaired passive filling
Increased preload dependence on atrial contraction

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15
Q

Aortic Stenosis Patho
Increased LVEDP leads to?

A

Subendocardial ischemia (decreased myocardial pressure) & pulmonary congestion

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16
Q

Aortic Stenosis Patho
Increased LVEDP and associated problems leads to?

A

Progressive valvular obstruction
Hypertrophy
Fibrosis
Increasing wall stress

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17
Q

Aortic Stenosis Patho
Progressive valvular obstruction, Hypertrophy, Fibrosis, & Increasing wall stress leads to?

A

Ischemia
Arrhythmia
Increased filling pressure
Ventricular dilation
Contractile Dysfunction
Decreased EF

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18
Q

Aortic Stenosis Patho
Ischemia, Arrhythmia, Increased filling pressure, Ventricular dilation, Contractile Dysfunction, & Decreased EF leads to?

A

Angina
Syncope
Dyspnea

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19
Q

Aortic Stenosis Symptoms
Heart failure

A

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

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20
Q

Aortic Stenosis Symptoms
Angina

A

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

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21
Q

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

A

Syncope

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22
Q

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

A

Coarctation w/ a bicuspid valve
Delayed/weak carotid upstroke

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23
Q

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

A

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

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24
Q

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

A

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

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25
Q

Aortic Stenosis - Diagnostic Testing
EKG shows?

A

LVH
LAE
may develop Afib

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26
Q

Aortic Stenosis - Diagnostic Testing
Lab work to collect?

A

BNP

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27
Q

Aortic Stenosis - Diagnostic Testing
Cardiac Cath shows?

A

evaluate CAD & hemodynamics

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28
Q

Aortic Stenosis Treatment
Indications for surgery

A

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

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29
Q

Aortic Stenosis Treatment
Medical Therapy

A

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

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30
Q

Less invasive option for AVR is?

A

TAVR - Transcatheter Aortic Valve Replacement

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31
Q

AR -Etiology
More Common (chronic causes)?

A

Bicuspid aortic valve
Calcific degeneration
Dilated Aorta
Rheumatic HD

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32
Q

AR Etiology
Acute Causes

A

Infective endocarditis
Dissection of the ascending aorta
Trauma

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33
Q

AR Patho
Regurgitation of the arotic valve occurs because of incomplete closure of the valve due to one or both of the following?

A

Valve problem
Dilation of the aorta

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34
Q

AR Patho
Sudden large regurgitant volume imposed on LV of normal (or small) size w/ normal (or decreased) compliance leads to?

A

Rapid increased LVEDP and Increased LAP
LV attempts to maintain CO w/ Increased HR and Increased Contractility

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35
Q

AR Patho
Attempts to maintain forward SV/CO may be inadequate leading to which three problems?

A

Pulmonary Edema (Increased LVEDP and Increased LAP)
Cardiogenic Shock (Decreased forward SV/CO)
Myocardial Ischemia (decreased CPP, Increased myocardial O2 demand)

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36
Q

AR Patho
Regurgitant Volume leads to what compensatory mechanism?

A

1) Increased LV dilation leading to Increased LVED volume & Increased Chamber compliance
2) Increased LV hypertrophy (eccentric & concentric) stimulated by Increased LV afterload

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37
Q

AR patho
The compensatory mechanisms maintain what?

A

a relatively low LVEDP, adequate forward SV/CO, and sufficient coronary perfusion pressure

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38
Q

AR Patho
Compensation leads to Decompensation which results in?

A

Steadily increasing regurgitant volume load
Further ventricular dilation leading to wall stress
Inability to continue further hypertrophy to decrease afterload
Contractile dysfunction leading to Decreased EF/SV/CO and Increased LVEDP

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39
Q

AR Patho
Decompensation results in what?

A

CHF Symptoms
Angina (decreased CPP and Marked LVH)

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40
Q

Acute AR - Presentation
Hx includes

A

Dissection
Endocarditis
Severe dyspnea
Respiratory distress

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41
Q

Acute AR - Presentation
PE includes

A

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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42
Q

Chronic AR - Presentation
Hx includes

A

Symptoms will depend on LV function
DOE, fatigue, HF

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43
Q

Chronic AR - Presentation
PE includes

A

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

44
Q

AR diagnostic testing
Echocardiogram
Transthoracic shows?
Transesophageal shows?

A

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

45
Q

AR diagnostic testing
EKG shows?

A

LVH, LAE

46
Q

AR diagnostic testing
CXR shows

A

cardiomegaly
widened mediastinum
pulmonary edema

47
Q

AR diagnostic testing
Lab work to collect

A

BNP
blood cultures

48
Q

AR diagnostic testing
CT or MRI shows

A

assess AR severity, aorta size

49
Q

AR diagnostic testing
Caridac Cath

A

evaluate CAD
aortogram

50
Q

AR treatment
Acute Severe AR requires

A

Emergency Surgery
Attempt medical stabilization w/ afterload reduction

51
Q

AR treatment
Chronic Severe AR requires

A

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

52
Q

MS - Patho
There is a Decreased what in Mitral Stenosis?

A

Mitral valve area

53
Q

MS - Patho
Pressure gradient between LA and LV depends on what?

A

Transvalvular flow
Diastolic filling time
valve obstruction

54
Q

MS - Patho
Increased LA pressure leads to?

A

LA enlargement to decrease LA pressure

55
Q

MS - Patho
LAE leads to?

A

Afib and clotting

56
Q

MS - Patho
Increased LA pressure leads to?

A

pulmonary vascular remodeling
pulmonary HTN
RV dysfunction

57
Q

MS - Patho
Conditions that increase the transvalvular flow rate increase the?
These conditions include

A

Pressure gradient and may precipitate symptoms
Fever
Pregnancy
Exercise
Anemia

58
Q

MS - Patho
Conditions that decrease diastolic filling time?

A

Tachycardia
Afib

59
Q

MS - Pulmonary HTN
Increased LA pressure is transmitted where?

A

Pulmonary Vasculature (passive HTN)

60
Q

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

A

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

61
Q

MS - Pulmonary HTN
RV dysfunction occurs due to?

A

pressure overload

62
Q

MS - Pulmonary HTN
Pulmonary Vasculature changes may be?

A

irreversible

63
Q

MS - Symptoms

A

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

64
Q

MS and Afib
Increased LA size and fibrosis leads to?

A

abnormal electrical activity predisposing to Afib

65
Q

MS and Afib
Deleterious sequelae includes?

A

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

66
Q

MS - PE
Soft, low pitched
duration reflects severity?

A

Diastolic rumbler

67
Q

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

A

Opening snap (OS) follows S2

68
Q

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

A

pulmonary HTN
MR
R Heart failure

69
Q

MS Diagnostic Testing
Echocardiogram
Transthoracic shows?
Transesophageal shows?

A

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

70
Q

MS Diagnostic Testing
EKG shows?

A

LAE
Afib
R axis deviation

71
Q

MS Diagnostic Testing
CXR shows

A

LAE
Enlarged pulmonary arteries

72
Q

MS Diagnostic Testing
Cardiac Cath shows

A

invasive hemodynamics
evaluation of CAD

73
Q

MS - Treatment
Medical?

A

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

74
Q

MS - Treatment
Nonmedical

A

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

75
Q

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

A

mitral valve
available
rheumatic MS (not calcific)

76
Q

Percutaneous mitral balloon valvuloplasty
Contraindications include?

A

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

77
Q

MVR is generally for those who?

A

are not candidates for balloon valvuloplasty

78
Q

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

A

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

79
Q

MR - Etiology
Acute MR

A

Endocarditis
Ischemia / infarction / papillary muscle rupture
Ruptured chord

80
Q

MR - Etiology
Chronic MR

A

Multiple causes (organic and functional)

81
Q

MR - Etiology
Organic MR is caused primarily by?

A

Lesions to the valve leaflets / chordae
(degenerative / MVP, Rheumatic, Endocarditis)

82
Q

MR - Etiology
Functional MR is caused primarily by?

A

Ventricular dysfunction usually accompanying annular dilation
(non-ischemic cardiomyopathy (NICM), Ischemic cardiomyopathy)

83
Q

Functional MR - Dilated Cardiomyopathy (ischemic and non-ischemic)
Mechanisms of MR due to both:

A

Annular dilation from ventricular enlargement
Papillary muscle displacement due to ventricular enlargement and remodeling prevents adequate coaptation

84
Q

Functional MR - Ischemic Cardiomyopathy
Ischemic MR is usually d/t prior infarction that has caused what? leading to?
which leads to?

A

thinning and dilation of the ventricle
displacement of papillary muscles
prevents adequate coaptation of the leaflets

85
Q

Acute MR - Patho
Sudden large volume load imposed on LA and LV of normal size and compliance leads to?

A

Rapid increased LVEDP and LAP
Increased LV preload (from volume load) facilitates LV attempt to maintain forward SV/CO w/ Increased HR and Increased Contractility via Frank-Starling mechanisms and catecholamines

86
Q

Acute MR - Patho
Attempts to maintain forward SV/CO may be inadequate depsite a supra-normal EF because a large portion is ejected backwards due to the lower resistance of LA causing?

A

Pulmonary edema (increased LAP)
Hypotension (or shock) (decreased forward SV/CO)

87
Q

Chronic MR - Patho
Degenerative MR/MVP
Volume load imposed on LA and LV (usually it gradually increases over time) leads to?

A

Increased LVEDP and LAP

88
Q

Chronic MR - Patho
Degenerative MR/MVP
Increased LVEDP and LAP leads to?

A

Compensatory dilation of the LA and LV to accommodate volume load at lower pressures: this helps relieve pulmonary congestion
Increased LV hypertorphy (eccentric) stimulated by LV dilation (increased wall stress - LaPlace’s Law)

89
Q

Chronic MR - Patho
Degenerative MR/MVP
Compensatory mechanisms lead to?

A

Increased Preload
LV hypertrophy
reduced or normal afterload (low resistance LA provides unloading of LV) leading to Large total SV (supra-normal EF) and normal forward SV

90
Q

Chronic MR - Patho
Degenerative MR/MVP
the large total SV (supra-normal EF) and normal forward SV leads to?

A

“MR begets more MR” (Vicious cycle in which further LV/annular dilation yields increased MR)

91
Q

Chronic MR - Patho
Degenerative MR/MVP
MR begets more MR leads to?

A

Contractile dysfunction leading to:
Decreased EF
Increased End systolic volume which leads to:
Increased LVEDP/volume and LAP

92
Q

Chronic MR - Patho
Degenerative MR/MVP
Increased LVEDP/volume and LAP leads to?

A

Pulmonary congestion and HTN
Reduced forward SV/CO

93
Q

Acute MR
Hx includes

A

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

94
Q

Acute MR PE

A

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

95
Q

Chronic MR
Hx includes

A

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

96
Q

Chronic MR PE

A

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

97
Q

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

A

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

98
Q

MR - Diagnostic Testing
EKG shows

A

LAE, Afib

99
Q

MR - Diagnostic Testing
CXR shows

A

LAE
Enlarged pulmonary arteries

100
Q

MR - Diagnostic Testing
Cardiac Cath shows

A

Vetriculogram
evaluates CAD

101
Q

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

A

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

102
Q

Chronic MR - Treatment
Surgical

A

Valve repair is preferable to replacement

103
Q

Chronic MR - Treatment
Surgical indications

A

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

104
Q

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

A

the ventricle
ACE-I, Beta Blockers, Aldosterone antagonists

105
Q

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

A

appropriate
indicated
improve QOL and/or survival; percutaneous option

Acute Care I (24 decks)

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