Valvular heart disease CIS (Darrow) Flashcards
A 35 y/o female from South Africa presents with a history of rheumatic heart disease. She presents with fever, fatigue and neck throbbing. She complains of abdominal fullness. Examination shows peripheral edema and ascites. There is a 1/6 systolic blowing murmur at the lower left sternal border with a 3/6 diastolic rumble (tricuspid stenosis). Both murmurs are increased with inspiration . A split first heart sound is present.
This patient would also be expected to exhibit which abnormality in the jugular venous tracing?
Prominent A wave Prominent C wave Sharp Y descent Minimal V wave Prominent CV wave
1. What valve gradient is considered significant in this case? 2. What is the most common cause of this in the US? 3. What is the sign related to the increased intensity with inspiration?
Prominent A wave (cannon a wave) with blunted y descent
when right atrium contracts and there is a stenotic tricuspid valve, the a wave will increase.
Blunted y descent- very tiny b/c valve won’t let blood leave efficiently
- What valve gradient is considered
significant in this case?
Valve–> tricuspid stenosis
Valve gradient > 5 mmHg - What is the most common cause
of this in the US?
Carcinoid (rarely rheumatic) - develops on tricuspid leaflets. see picture on slide 3 - What is the sign related to the increased
intensity with inspiration?
Carvallo sign
(blood goes into the right atrium–> right ventricle, so the murmurs get louder with inspiration- Carvallo sign)
what is the treatment of tricuspid stenosis?
Diuretics – especially torsemide –better absorbed from the gut *** Spironolactone for ascites.
-reduce volume coming back to the heart
Balloon valvotomy, open commissurotomy, or bioprosthetic valve (because of low flow velocity and tendency to clot with mechanical valves).
A 55 y/o female with history of a prior right ventricular MI presents with fatigue and abdominal fullness. Examination shows peripheral edema and ascites. There is a 3/6 systolic blowing murmur at the lower left sternal border with an audible S3 (when the AV valves open, and blood rushes in, but there is already old blood in there, and it creates vibratory sound). The murmur is increased with inspiration (Carvallo sign)
This patient would also be expected to exhibit?
Q wave in V6 Small RV diameter Kerley B lines Pulmonary valve regurgitation Prominent “cV wave”
This is most likely a tricuspid regurgitation
Prominent “cV wave”***
large amount of regurgitated blood
there is a huge filling wave
Q wave in V6- NO, this is lateral wall MI
what is the treatment of tricuspid regurg?
Treat the primary issue, ie LV failure or pulmonary hypertension.
If a true valvular defect, then use a bioprosthetic*** valve since mechanical valves will clot with the low flow state at the tricuspid valve.
What else causes this valvular defect (tricuspid regurg) to exist?
Any RV dilation as in pulmonary hypertension, pulmonic regurgitation, or LV failure where PA or RV systolic pressure is above 40 mmHG.
Or more rarely an inherent valvular problem as in Ebstein’s anomaly, pacemaker catheter injury, endocarditis, MI, sarcoid, RV dysplasia, or even fenfluramine/phenteramine (“FenPhen”) which causes low pressure TR.
A 55 y/o male with COPD and pulmonary hypertension presents with a split P2 and a diastolic 2/6 murmur at the left 2nd intercostal space (pulmonic valve) that increases with a deep breath.
what does he have ?
he has high pressure pulmonary insufficiency/regurg
What is the difference between low and high pressure Pulmonary Insufficieny?
Pulmonic regurgitation – high pressure PI - Prolonged RV systole with split S2, from pulmonary hypertension as from mitral stenosis, ie Graham-Steell murmur. (due to COPD or mitral stenosis)
Low pressure PI - very little murmur - for example, trauma with a dilated pulmonary annulus, carcinoid plaque, bicuspid valve, repaired tetralogy, etc. (Due to some event that involved the pulmonic valve)
what is the treatment of pulmonic regurgitation
High pressure – treat pulmonary hypertension.
(ex. treat COPD)
Low pressure – watchful expectancy.
A 35 y/o pregnant female from Iran presents with exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Auscultation with the patient in the left lateral decubitus position reveals a loud M1 and an early diastolic sound at the mitral area. EKG, chest xray and ECHO are shown. see slide 16
patient has mitral stenosis
straightening of the left heart border
hockey stick sign
more findings?? see slide
what are the ausculatory findings with mitral stenosis
4 signs!!
Thickened immobile leaflets (RF) versus annular calcium deposits (degenerative). Symptoms with pregnancy or AF.
Loud M1 (unless calcified).
Opening snap (unless calcified)- earlier after S2 with worsening LA pressure.
Rumbling diastolic murmur – bell lightly.
Presystolic accentuation of diastolic rumble (as the atrium contracts)
what are 2 syndromes associated with mitral stenosis and how do they present?
Two syndromes:
A. Mild to moderate (valve surface area of 1.5 cm2) with early pulmonary edema.
B. Severe (< 1 cm2 ) with pulmonary HTN (“2ndary pulmonary vasculature stenosis”) and right sided CHF, AFib and low CO. (vessels are clamping down) this patient doesn’t have pulmonary edema, but rather right sided heart failure, can go into A-fib, etc.
what is graham steell murmur
Graham Steell murmur at left sternal border from relative PI.
mitral stenosis leads to pulmonary regurg/insufficiency (why? listen)
what are the ECG findings in mitral stenosis?
Neg P wave in V1
Right Axis Deviation.
right atrial hypertrophy
mitral stenosis treatment?
Based on ECHO evaluation with a scoring system which grades various mitral parameters to decide time for intervention with mitral valvuloplasty.
Score of 8 or less try valvuloplasty;
> 8-10 needs mechanical (INR 2.5 - 3.0) or bioprosthetic valve (last 10-15 years).
A 55 y/o male with long standing mitral regurgitation presents with new onset palpitations, orthopnea and PND. There is a high pitched pan systolic murmur with an S3* at the apex (VSD can also cause this). The patient is on a beta blocker and an ACE inhibitor. Chest xray, EKG and color doppler ECHO are shown.
* = marker for severe MR
What is the diagnosis and what are the dynamics in regard to preload,
afterload and EF? What eventually happens with LV failure?
MItral regurg–> The mitral valve can be defective at the papillary muscles (dilated cardiomyopathy, MI), chordae (too long, too short or ruptured as in MVP), leaflets (redundant, perforation in endocarditis) or annulus (calcified or cardiomyopathy).
In MR there is a volume load on the heart = increased preload and decreased afterload.
The increased preload = enlarged LV ***= increased EF.
But eventually the LV fails and EF drops with increased end systolic volume.
MR–> CV wave in left atrium *** listen to slide 31 again
