Valvular heart disease/murmurs

Question 1

Know the characteristics of mitral stenosis
- Location
- Timing
- Shape
- Maneuvers
- Causes
- Long-term Complications

Answer 1

DIASTOLIC MURMUR

Location: Best heard at the apex with the bell of the stethescope

Timing: LOUD S1 (2/2 rapid closing of the thickened mitral valve), Followed by Opening Snap and decrescendo diastolic rumble (flow across valve)

Shape: Will also hear an early diastolic opening snap (due to valve leaflets ‘snaping’ into the LV) → followed by a low-pitches decrescendo-crescendo rumbling diastolic murmur

Maneuvers: The diatolic mumur will become louder:
- after Valsalva maneuver (when blood pours into the LA)
- after excercise
- during maneuvers that increase afterload (equtting, hand grip)

Causes:
- Rheumatic heart disease (thickening of the mitral valve)

Complications:
- Pulmonary HTN
- A-fib

Question 2

1 cause of mitral stenosis

Answer 2

Rheumatic fever

Question 3

What are the Jones criteria

Answer 3

JONES Criteria = Major criteria for rheumatic fever

Carditis - inflammation of all three heart layers

Migratory Arthritis - mainly large joints

Sydenham Chorea - involuntary movements

Erythema Marginatum - skin rash with advancing edge and clearing center Subcutaneous Nodules

Minor criteria that are important: fever, arthralgia, increased CRP or ESR, prolonged PR interval

2 major criteria OR 1 major + 2 minor

Question 4

In rheumatic fever, histopathologic examination reveals ….

Answer 4

In rheumatic fever, histopathologic examination reveals ….

Question 5

What is the most affected valve in rheumatic fever?

Answer 5

Mitral valve

40% of ARF leads to mitral valve disease and an additional 25% will also get aortic valve disease

Question 6

What is the typical presentation of mitral stenosis

Answer 6

Individual born in philiipines/other 3rd world country who had rheumatic fever as a child, now are in 40s and are diagnosed during pregnancy with mitral stenosis (long time later after rheumatic fever that they get stenosis)

Question 7

Causes of mitral stenosis other than rheumatic fever

Answer 7

Acute and recurrent inflammation that produces a fibrous thickening and calcification of valve leaflets, thickening/shortening of chordae tendinae.
- Carcinoid (neuroendocrine tumor that secretes serotonin, forms scar tissue on heart valves)
- Congenital
- Endocarditis with large vegetations

Question 8

Left atrial enlargement leads to what

Answer 8

A fib very commonly– one of most common causes of a fib is left atria enlargement
A fib can lead to stroke (sometimes pts will present to ER with stroke and then find out they have a fib resulting from mitral stenosis).

Question 9

What is this

Answer 9

Left atrial enlargement–> biphasic p wave, lead 2 has biphasic p wave with 2 peaks

Question 10

ECHO findings for mitral stenosis

Answer 10

-Thickened mitral leaflets
- Abnormal fusion of commissures of leaflets
- Left atrial enlargement
-Very high pulmonary pressure

Question 11

Medical therapy goals and treatments

Answer 11

Goals: Keep in normal sinus rythym and keep the HR slow. Want to make sure the left atrium can get enough blood into the left ventrical, increase diastolic filling time.
Therapy: Diuretics, salt restriction to lower pressure
-Beta blockers
- Avoid vasodilators
-In A fib, lose atrial kick and have higher heart rates,

Question 12

Treatment for mitral stenosis

Answer 12

1) Replacement or repair of mitral valve (MAZE procedure for a fib). Consider CABG if underlying CAD.
2) Balloon valvuloplasty (place balloon catheter into L atrium and across mitral valve)
3) Open mitral valve commissurotomy, Mitral valve replacement

Question 13

MAZE procedure

Answer 13

Surgical procedure for a fib–> severs some of the electrical signals coming from a variety of different areas

Question 14

What are the primary and secondary causes of mitral regurgitation

Answer 14

PRIMARY: disruption of the mitral valve apparatus

A) Leaflets: myxomatous degeneration (MVP), IE, rheumatic fever
B) Mitral Annulus: calcification
C) Chordae Tendineae: rupture from damage
D) Papillary Muscles: ischemia

SECONDARY: LV enlargement and prevention of the leaflets from coaptation

• LV cavity dilatation seen in Systolic HF. Dialates, pulls leaflets apart, get secondary regurgitation.

Question 15

Pansystolic murmur

Answer 15

Occurs during systole/during the entire phase of systole

Question 16

Key exam findings on Mitral regurgitation

Answer 16

Pansystolic apical murmur that radiates to axilla on auscultation
S3 that indicates increased volume returning to LV in diastole
In chronic MR, LV dialates and has displaced PMI.
Chest X-ray–> pulmonary edema for acute, left atrial and ventricular enlargement for chronic.

Question 17

Diagnostics for Mitral regurgitation

Answer 17

Echo
- Identifies structural causes of MR
- Grades severity of valve by doppler
- Determines LV and LA size and fx

Catheterization
- Diagnoses an ischemic cause and grades severity of MR. Measures pressure differences across valve.

Question 18

TX for Mitral regurgitation

Answer 18

• Keep “HIGH AND DRY” (keep HR fast so that there isn’t as much pressure that goes back to pulmonary arteries, and DRY= get fluid out of lungs with diuretics).
• Acute: Vasodialators to reduce resistance to forward flow and diuretics to help with congestion
• Chronic: Vasodialators are NOT useful in chronic mitral regurgitation.

Question 19

Mitral regurgitation causes which heart failure?

Answer 19

Systolic (Left ventricle)

Question 20

What is the murmur of Mitral Regurgitation

Answer 20

Pansystolic apical murmur that radiates to axilla
Presence of S3, indicates increased volume returning the LV in diastole

Question 21

What is PERCUTANEOUS MITRAL CLIP?

Answer 21

Treats mitral regurgitation

Used in high-risk surgical patients that cannot have open heart surgery

Question 22

What is the presentation of MVP

Answer 22

PATH:

• Usually female
• sometimes accompanied by mitral regurgitation
• May be genetic or seen as part of a connective tissue disorder such as Marfan Syndrome or Ehlers-Danlos

1) Valve leaflets, particularly the posterior leaflet, are enlarged (> 5 mm)

2) Leaflets and chordae lose tensile strength (fibrin/collagen) and replaced with loose MYXOMATOUS CONNECTIVE TISSUE

Question 23

Sx of mitral valve prolapse

Answer 23

• usually asx
  -ARRHYTHMIAS are more common with MVP and the patient may complain of chest pain or PALPITATIONS

Question 24

PE of mitral valve prolapse

Answer 24

PE:

• Inspection: higher incidence of pectus excavatum
• Auscultation: MIDSYSTOLIC CLICK and late systolic murmur heard best at the apex (results from a sudden tensing of the leaflet as it is forced back into the LA)

-The murmur is related to the regurgitant flow through the incompetent valve.

-Can alter the murmur by maneuvers that increase preload and the volume of the LV (squatting increases venous return -> improves LV filling -> delays prolapse of the valve into the LA -> later click and murmur; if the volume of the blood in the LV is decreased by standing -> prolapse occurs more easily -> earlier auscultation)

Question 25

Dx of mitral valve prolapse

Answer 25

Echo: CONFIRMS diagnosis as it shows posterior displacement of one or both of the mitral valve leaflets into the LA during systole

Question 26

Treatment of Mitral valve prolapse

Answer 26

MVP is typically benign and requires no therapy. Reassurance and monitor for any progression of mitral regurgitation. Patients who experience palpitations should avoid stimulants. Can use beta blockers for premature atrial or ventricular beats or symptoms of palpitations.

Question 27

Mitral valve prolapse exam

Answer 27

Inspection: Pectus excavatum - Auscultation: Midisystolic click, late systolic murmur herd best at apex and left lateral decubitus position - Squatting increases venous return, later click. - Standing causes earlier click on auscultation

Question 28

Know the characteristics of aortic stenosis - Location - Shape - Radiation - Causes

Answer 28

SYSTOLIC EJECTION MURMUR - S2 if often diminished (may even be absent if severe) Location: along the R sternal border in the 2nd intercostal space Shape: crescendo-decrescendo systolic ejection murmur Radiation: to the carotids Causes: - Calcified aortic valves - Bicuspid aortic valves Pulses: "Pulsus parvus et tardus" (Peripheral pulses are often weak and delayed)

Question 29

Causes of aortic stenosis

Answer 29

CAUSES: - Typically an age related degenerative disease associated with a calcified valve. The “wear and tear” of the valve leads to endothelial and fibrous damage causing calcification. - atherosclerosis with endothelial dysfunction, lipid accumulation, inflammation, and infiltration by macrophages - Congenital abnormality (bicuspid aortic valve) → Predisposed to more turbulent flow and damage leading to premature calcification (earlier than age 65) - Rheumatic Aortic Stenosis

Question 30

Physical exam findings in Aortic stenosis

Answer 30

- MURMUR: crescendo-decrescendo systolic murmur at RUSB - S4 due to atrial contraction into a stiff LV - Pulsus parvus (weak) and tardus (late) upstroke of the carotid artery owing to obstructed LVOT

Question 31

Murmur for Aortic stenosis

Answer 31

Crescendo-decrescendo systolic murmur at RUSB

Question 32

What is helpful to slow the progression of aortic stenosis

Answer 32

No medical therapy will help definitively (statins are potentially helpful) Avoid medication that results in hypotension, though.

Question 33

Know the causes, pathophysiology, and murmur/wide pulse pressure of aortic regurgitation

Answer 33

CAUSES: 1) Abnormalities of the aortic valve leaflets - Congenital (bicuspid valve) - Endocarditis - Rheumatic 2) Abnormalities related to a dilated aortic root - Aortic aneurysm (connective tissue disorders like MArfan syndrome) - Aortic dissection - Syphilis - Annuloaortic ectasia PATH: - (Similar to MR) Abnormal regurgitation of blood from the aorta into the LV occurs during diastole. With the next systolic contraction, the LV now has to pump the regurgitant volume AND the normal amount of blood entering the LA. Severity is based on: 1) Size of the regurgitant orifice 2) Pressure gradient across the aortic valve during diastole 3) Duration of diastole SXS: - Acute AR: Look bad, severe dyspnea - Chronic AR: DYSPNEA, fatigue, angina, and decreased exercise tolerance PE: - Bounding pulses - Wide pulse pressure / Hyperdynamic LV impulse (high systolic, low diastolic BP) - MURMUR: Early, DIASTOLIC murmur heard best with the patient leaning forward at the left sternal border - Occasionally will hear a mid-diastolic murmur, (AUSTIN FLINT murmur) at the APEX from heavy the jet of AI impinging on the anterior leaflet of the mitral valve generating turbulence Chest X-ray: - Acute -> pulmonary edema, normal LV size (cardiac silhouette) - Chronic -> enlarged cardiac silhouette, +/- pulmonary edema ECHO: DIAGNOSTIC as can identify and quantify the degree of AR Catheterization: (INVASIZE + risks) - LV function - quantify the degree of AR - assess for co-existing coronary disease

Question 34

Symptoms of Aortic regurgitation

Answer 34

- Acute AR: Look bad, severe dyspnea - Chronic AR: DYSPNEA, fatigue, angina, and decreased exercise tolerance

Question 35

What is a hallmark finding of Chronic Aortic regurgitation

Answer 35

Wide pulse pressure (difference in systolic and diastolic pressure) LV dialates, which causes a larger volume in cavity, decreaseing diastolic pressure and volume in left atrium. This increases stroke volume and systolic pressure

Question 36

When do coronary arteries fill

Answer 36

during DIASTOLE

Question 37

When do you hear an austin flint murmur? Where? In which heart disorder?

Answer 37

You hear it mid-diastole, at the APEX of the heart from the jet of the Aortic valve. Causes mid-late diastolic murmur, acting like mitral stenosis. Sounds like mitral stenosis.

Question 38

Signs of RSHF

Answer 38

Peripheral symptoms - Elevated JVD -Hepatosplenomegaly - Abdominal distention/Ascites - Peripheral edema

Question 39

What is the most common cause of RSHF

Answer 39

LSHF

Question 40

Tricuspid Stenosis cuase

Answer 40

Usually secondary cause (functional rather than structural, related to RV enlargement from elevated pulm pressure or volume overload). Rheumatic fever or carcinoid (neuroendocrine tumor that secretes serotonin, depositing plaques, making immobile). Murmur similar to MS, but heard closer to sternum, intensifies on inspiration.

Question 41

Treatment for tricuspid stenosis

Answer 41

No medical therapy Sx therapy or valvuloplasty

Question 42

Physical exam findings of someone with tricuspid regurgitation

Answer 42

Elevated JVP, prominent V wave Pansystolic murmur at LLSB with S3 Pulsatile liver from extra volume of blood going into systemic hepatic veins

Question 43

Treatment for tricuspid regurgitation

Answer 43

If RV failure occurs, use diuretics and afterload reducing agents Sx therapy is recommended with severe TR with other valve disease or significant pulmonary HTN Tricuspid repair or annuloplasty favored over valve implantation

Question 44

Pulmonary stenosis impacts which patient population

Answer 44

Almost always congenital, or because of carcinoid Usually present in 4-5th decade Echo is diagnostic Therapy with balloon valvuloplasty for severe

Question 45

Pulmonic regurgitation develops when

Answer 45

From dialation of valve ring by enlarged pulmonary artery. Can be congenital or from pulmonary HTN. Exam shows decrescendo diastolic murmur. Echo is diagnostic