Valvular Heart Disease, Murmurs

Question 1

What is the etiology for mitral stenosis?

Answer 1

a. rheumatic valve disease (99%)
b. calcification
c. congenital abnormalities
d. medications (ergotamines, pergolide)

Question 2

What is the pathophysiology of mitral stenosis?

Answer 2

a. A-Fib in 50%
b. high risk of thromboembolism
c. high LA pressure leads to pulmonary congestion
d. Aschoff Bodies

Question 3

What sounds does mitral stenosis make?

Answer 3

Opening snap and diastolic ruble

Question 4

What is the presentation of MS?

Answer 4

a. fish mouth
b. hocky stick valves
c. dyspnea/pulmonary edema/thromboembolism
d. hemoptysis in extreme cases

Question 5

What is the prognosis and treatment of MS?

Answer 5

a. progressive loss of valve area
b. pulmonary congestion, can lead to R heart dysfunction
c. hypertrophy
d. LEFT ATRIAL APPENDAGE CLOT

Question 6

What is the primary etiology of MR?

Answer 6

a. mitral valve prolapse
b. myxomatous degen. (gel-like valve)
c. infectious endocarditis (staph aureus from IVs or strep viridans if congenital)
d. rheumatic heart disease
e. trauma
f. anoretic drug: fen-phen
g. cleft mitral valve

Question 7

What is the acute pathophysiology of MR?

Answer 7

Acute:

a. decrease in LV afterload
b. increase in LV preload
c. increased SV
d. press. and vol. overload of LA

Question 8

What is the secondary etiology of MR?

Answer 8

a. enlarged LV and mitral valve annulus bc of ischemic heart disease
b. papillary muscle of chordae tendinae rupture/malfunction
c. clacification of mitral annulus (women > 60)

Question 9

What is the chronic pathophysiology of MR?

Answer 9

a. decrease in LV afterload
b. increase in LV preload
c. eccentric LV hypertrophy
d. LA enlargement

Question 10

What is the sound of MR? What makes it better or worse?

Answer 10

Click during systole (prolapse only!) and the holosystolic murmur.

Squatting makes it quieter.

Question 11

What is the presentation of MR?

Answer 11

a. pulmonary edema

b. V wave shows increased pressure in LA during systole

Question 12

What is the prognosis and treatment of MR?

Answer 12

Acute: poorly tolerated
Chronic: prolonged asymptomatic, but CHF, A Fib, and pulmonary hypertension. 5 year survival = 22%

Question 13

What is the etiology of MVP?

Answer 13

billowing of a leaflet past plane of valve annulus.

Question 14

What is the pathophysiology of MVP?

Answer 14

thickened, redundant leaflets, stretched chordae and dilated annulus.

Question 15

What is the sound of MVP?

Answer 15

a click! in systole and a subsequent systolic murmur.

Question 16

What is the presentation of MVP?

Answer 16

can be same as MR (dilated LA, pulmonary congestion, reduced SV, etc. ), and it occurs in 4-5% of adults

Question 17

What is the etiology of aortic stenosis?

Answer 17

a. degenerative: calcification, leaflet thickening, inflammatory pathway
b. congenital bicuspid valve (pts. less than 70): 3:1 males to females, in 1% of population
c. rheumatic: most common in world (but not US), causes commissures to fuse and thickens subvalvular apparati

Question 18

What is the pathophysiology of AS?

Answer 18

a. increased LV afterload
b. LV concentric hypertrophy
c. diastolic LV dysfunction is common
d. valve area of 2cm^2 or smaller

Question 19

What murmur does AS make?

Answer 19

a systolic crescendo/decrescendo (whoosh!)

Question 20

How does AS present?

Answer 20

a. late peaking systolic ejection murmur

b. weakened and delayed upstroke of carotid artery pulsations

Question 21

What is the treatment and prognosis of AS?

Answer 21

angina, syncope, CHF (5, 3, and 2 year survival rate, respectively)

aortic valve replacment

Question 22

What is the etiology of AR?

Answer 22

a. dilated aortic root
b. Marfan’s
c. endocarditis
d. dissection
e. bicuspid valve issues
f. trauma
g. rheumatic fever

Question 23

What is the pathophysiology of AR?

Answer 23

a. increased preload
b. increased afterload
c. LV pressure/volume overload
d. LV dilates
e. LV eccentric hypertrophy

Question 24

What is the murmur associated with AR?

Answer 24

diastolic murmur with absence of S2.

Question 25

What is the presentation of AR?

Answer 25

Acute: LV normal size but non-compliant
Chronic: increased LV SV, widened pulse pressure, decreased coronary artery perfusion

Question 26

What is the treatment and prognosis for AR?

Answer 26

a. can have a prolonged asymptomatic period
b. Ab prophylaxis
c. long-standing volume overload can lead to LV dysfunction

Question 27

What is the etiology of TS?

Answer 27

almost always due to rheumatic heart disease.

Question 28

What is the pathophysiology of TS?

Answer 28

RA enlargement.

Question 29

What is the presentation of TS?

Answer 29

results in elevated RA/SVC/IVC pressures; leg edema, hepatomegaly

Question 30

What is the treatment and prognosis of TS?

Answer 30

It is very RARE!

Question 31

What is the etiology of TR?

Answer 31

a. function TR 90% of the time
b. endocarditis
c. trauma
d. rheumatic HD
e. carcinoid syndrome (tumor with serotonin)
f. myxomatous degeneration
g. ebstein’s anomaly
h. anoretic drugs

Question 32

What is the pathophysiology of TR?

Answer 32

RV volume overload

Question 33

What is the presentation of TR?

Answer 33

elevated RA/SVC/IVC pressures, ascites, leg edema, hepatomegaly

Question 34

What is the treatment and prognosis of TR?

Answer 34

often tolerated and asymptomatic.

Question 35

What is the etiology of pulmonic stenosis?

Answer 35

a. common congenital abnormality (Tetralogy of Fallot)
b. congenital rubella syndrome
c. noonan syndrome

Question 36

What is the pathophysiology of PS?

Answer 36

RV hypertrophy

Question 37

What is the etiology of PR?

Answer 37

usually secondary to pulmonary hypertension and/or dilated pulmonary artery

Question 38

What is the presentation of PR?

Answer 38

rarely clinically significant.