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CMT-uno > Valvular Heart diseases > Flashcards

Valvular Heart diseases Flashcards

1
Q

S1: Lubb

A

Simultaneous closing of mitral and tricuspid valves
Start of systole, end of diastole

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2
Q

S2: Dubb

A

Simultaneous closing of aortic and pulmonic valves
End of systole, beginning of diastole

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3
Q
A
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4
Q

Thrill

A

Vibratory sensation felt on the skin
Indicates turbulent flow

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5
Q

Grading cardiac murmurs

A
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6
Q

Systolic Murmurs

A

All BEGINS in the VENTRICLE: The murmur occurs as the blood leaves the ventricle

Aortic stenosis* - radiates to carotid
Mitral regurgitation* 5th intercostal radiates toward axilla
Pulmonic stenosis
Tricuspid regurgitation

Ventricular septal defect
Hypertrophic cardiomyopathy

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7
Q

Diastolic Murmurs

A

All END in the VENTRICLE: Murmur occurs as the blood is coming to the ventricle
Aortic Regurgitation*
Mitral Stenosis*
Pulmonic Regurgitation
Tricuspid Stenosis

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8
Q

Right sided murmurs louder

A

during inspiration

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9
Q

Abrupt standing

A

Most heart murmurs diminish in intensity with standing due to reduced venous return to the heart and subsequently reduced right and left ventricular diastolic volumes.

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10
Q

Squatting

A

Most murmurs become louder with squatting due to increased afterload

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11
Q

Leg raise

A

Most murmurs become louder with a leg raise due to increased afterload

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12
Q

Valsalva Maneuver

A

Most murmurs decrease in intensity during a Valsalva maneuver
Except for mitral valve prolapse

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13
Q

Sustained Hand Grip

A

Can help differentiate between AS and MR
AS – Murmur decreases
MR – Murmur increases

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14
Q

what will echo tell me?

A
  • ejection fraction ( sx risk stratification)
    -chamber sizes
    -Possibly aortic root enlargement
    -Estimate right ventricular systolic pressure ( estimates pressure in lungs, pulmonary hypertension)

Valve:
-Pressure across valve (gradient), mean and peak
-Calculation of valve size

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15
Q

Aortic Stenosis

A

pressure coming OUT of valve is higher
causing stretching in aorta (can cause aneurism)
LV will also start enlarging and dilating (can lead to secondary mitral regurg bc valve spread apart from enlargement)

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16
Q

aortic stenosis

A
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17
Q

Aortic Stenosis

general

A

Narrowing of the aortic valve
Normal aortic valve is 3 – 4 cm with little to no pressure difference across the valve
Progressive narrowing of the left ventricle outflow tract
-Now the left ventricle must generate higher systolic pressure which increases left ventricular wall stress
-In response to the pressure overload, the left ventricle undergoes compensatory concentric hypertrophy

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18
Q

Unicuspid or Bicuspid Aortic valve

A

Usually, a fusion of right and left coronary cusps
1-2% of the population
Male predominated

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19
Q

Aortic stenosis

S/Sx

A

Asymptomatic

SAD
Syncope
Angina
Dyspnea

Heart failure as a result of left ventricular systolic or diastolic dysfunction
Fatigue
Decreased exercise tolerance
Sudden death

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20
Q

aortic stenosis

Physical Examination Findings

A

Harsh crescendo-decrescendo systolic murmur heard best at the right upper sternal border

S1 is usually unaffected, as AS progresses S2 diminishes and can eventually disappear

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21
Q

Cardiac auscultation reveals a systolic ejection murmur over the right second intercostal space that radiates to the neck. What is the most likely diagnosis?
Aortic stenosis
Mitral regurgitation
Pulmonic stenosis
Tricuspid regurgitation

A

Aortic stenosis

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22
Q

Aotic stenosis

Dx

A

Transthoracic Echocardiogram

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23
Q

Treatment for Asymptomatic Patients

A

Directed towards prevention of coronary artery disease
Blood pressure control
Blood glucose control
Cholesterol control
Exercise
Stop smoking
Maintenance of sinus rhythm

If heart failure symptoms develop, manage the symptoms with diuretics
With caution

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24
Q

aortic stenosis

Surgical Treatment

A
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25
You are evaluating a patient for aortic stenosis confirmed on transthoracic echocardiogram. Which of the following tests is NOT needed for her pre surgical evaluation? A) transesophageal echocardiogram B) stress test C) left heart cath D) Right heart cath
B) stress test
26
Bioprosthetic “Tissue” Valves
Last an average of 10-15 years Surgical or transcatheter: Bovine or Porcine **Long-term anticoagulation not required** **Endocarditis prophylaxis is indicated**
27
Mechanical valve
Last 1,000s of years (well maybe) Typically used in younger patients **Lifelong anticoagulation with warfarin required** INR range usually 2.0-3.0 (aortic valve) INR range 2.5-3.5 (mitral valve) **endocarditis prophylaxis is indicated**
28
Transcatheter Aortic Valve Replacement
1. >70 y 2. CKD 3. EF <40%
29
Which patient is likely to be referred for transaortic catheter repair? A) 32-year-old patient with a congenital bicuspid aortic disease no other medical diagnosis B) 76- year- old with chronic kidney disease, EF 35%, and elevated frailty index C) 82-year-old with left main coronary artery disease and high cholesterol D) 29 year old with delayed carotid pulse
B) 76- year- old with chronic kidney disease, EF 35%, and elevated frailty index
30
for super end stage Procedure to improve symptoms
31
# Pulmonary Valve Stenosis general
Rare Usually, congenital
32
# Pulm sten S/Sx
Mild-Mod: Asymptomatic DOE Chest pain Eventual right heart failure Exertional syncope
33
# pulm sten PE Palpable?
Palpable parasternal lift due to right ventricular hypertrophy Hepatic congestion, hepatosplenomegaly Peripheral edema
34
# Pulm sten The Murmur
Crescendo-decrescendo systolic murmur +/- thrill at the supraclavicular notch and LUSB
35
# Pulm sten Diagnostics
Echocardiogram Thickened leaflets, right ventricular hypertrophy EKG +/- Right atrial dilation, right ventricular hypertrophy
36
# pulm sten Tx
Percutaneous Balloon Valvuloplasty Pulmonary Valve Replacement
37
Mitral Regurgitation causes
can be due to ant. MI (LAD)
38
A 40-year-old woman comes to the clinic for exertional dyspnea and palpitations.  She emigrated from Cuba four years ago. Physical examination is significant for an irregularly irregular pulse, a loud S1, and a systolic murmur best heard in the left lateral recumbent position. What is the most likely etiology of her murmur? Amyloidosis Diabetes mellitus Hypertension Rheumatic fever
Rheumatic fever
39
A 56-year-old male presents to emergency room department with flash pulmonary edema and a high pitched pansystolic blowing murmur on physical exam. He had an MI 2 weeks ago. What is most likely? Mitral regurgitation Aortic regurgitation Mitral stenosis Tricuspid regurgitation
Mitral regurgitation
40
# Mitral Regurg S/Sx
Acute MR: sudden onset SOB, orthopnea, LE edema, possible cardiogenic shock -Sxs caused by abrupt rise in PCWP  pulm congestion Chronic MR: asymptomatic for years followed by exertional dyspnea & exercise intolerance fatigue, orthopnea and PND as MR progresses Palpitations: possible atrial fibrillation as a result of LA dilation
41
# MR PE
High-pitched blowing Holosystolic murmur Heard best at apex, may radiate to the axilla Possible S3
42
# MR Diagnostics
BNP Early identifier of left ventricular dysfunction Chest Xray Acute vs chronic MR ECHO
43
# MR Tx Meds
Afterload reduction Vasodilators: Hydralazine, Ace-inhibitors Diuretics Anticoagulation if there is A. fib
44
# MR Surgery
45
# Mitral Valve Prolapse general
Standing, Valsalva, dehydration: conditions that decrease LV size and lead to earlier occurrence of prolapse/click with increased duration of the murmur Squatting, phenylephrine infusion: Conditions that increased LV size move the click and murmur later into systole
46
A 38 year- old male with a past medical history of Ehlers-Danlos presents for yearly office visit. He reports new onset of mild palpitations lasting a few seconds with spontaneous onset and resolution. He denies any associated symptoms. On cardiac auscultation you note a new mid systolic click. What is most likely diagnosis? Aortic Stenosis Mitral Valve Prolapse Mitral Regurgitation Tricuspid Regurgitation
Mitral Valve Prolapse **Mid systolic click** and palpitations
47
# mitral valve prolapse Treatment Meds
Medication Afterload reduction, beta-blockers for palpitations with PACs/PVCs Surgery Mitral valve repair Mitral valve replacement
48
# Tricuspid Regurgitation general
49
# Tricuspid Regurgitation Signs and Symptoms
Isolated TR is usually well tolerated With concurrent pulmonary hypertension -> decreased cardiac output -> right heart failure Symptoms of right heart failure Severe: Congestive hepatopathy and bowel edema lead to weight loss, cachexia, jaundice
50
# Tricuspid Regurgitation The Murmur Does it increase?
51
# Tru Regurg Tx
52
# Aortic Regurgitation (Insufficiency) general
Reversal of flow from the aorta into the left ventricle: Diastolic regurgitation of left ventricle stroke volume -> LV volume overload Caused by abnormalities of the aortic root, ascending aorta, or valve leaflets.
53
# A regurg etiology
54
# A regurg Sx
Asymptomatic Exertional dyspnea Fatigue Atypical chest pain Eventual LV dilation and failure Orthopnea/PND
55
# AR Physical Exam Findings: Murmur
**blowing decrescendo diastole** AI: aortic insufficiency
56
# AR PE
57
Water Hammer Pulse
“Collapsing pulse” Rapid swelling and falling arterial pulse Best appreciated by palpation of the radial or brachial arteries or the carotid pulse
58
Corrigan Pulse
Similar to water hammer but referring to the carotid artery
59
Hill’s Sign
Popliteal cuff systolic pressure exceeding brachial pressure by more than 60 mmHg with patient in the recumbent position Most sensitive for AI
60
Muller’s Sign
Visible systolic pulsations of the uvula
61
De Musset’s Sign
Head-bobbing with each heartbeat
62
Becker’s Sign
Visible pulsations of the retinal arteries and pupils
63
Rosenbach’s Sign
Systolic pulsations of the liver
64
Gerhard’s Sign
Systolic pulsations of the spleen
65
# AR??? Dx
Echocardiogram Regurgitant volume LV size and function Annular dilation Dilation of the aorta Premature closure of the mitral valve in severe AI Pericardial effusion
66
# aortic regurgitation Treatment
Mild aortic regurgitation Medical: Vasodilators (hydralazine), diuretics, beta-blockers, CCB, Ace-I Severe aortic regurgitation Surgery: Aortic valve replacement, aortic root replacement Symptomatic patients Asymptomatic patients with certain criteria
67
Which of the following valvular disorders are associated with the de Musset, Muerller, and Duroziez signs? a. aortic regurgitation b. aortic stenosis c. mitral stenosis d. mitral regurgitation
a. aortic regurgitation
68
# Tricuspid Regurgitation primary and secondary
Primary: Any disease process that causes derangements of the tricuspid apparatus Secondary (functional): Anatomically normal valve with right ventricular dilation from a cause: Mitral stenosis Pulmonary hypertension COPD Cardiomyopathy Left heart failure
69
# Pulm reg etiology
Most cases are due to dilation of the valve ring due to pulmonary hypertension or dilation of the pulmonary artery Infective endocarditis – 2nd most common cause Marfan’s syndrome Placement of a pulmonary artery catheter
70
# PR Signs and Symptoms
Most asymptomatic Right heart failure symptoms Dyspnea on exertion
71
# PR Physical Examination (murmur)
Brief low-pitched decrescendo diastolic murmur heard best at the 3rd/4th L ICS Diastolic murmur increases with inspiration 2nd heart sound may be widely split
72
# PR Dx
Echocardiogram RV size and function is an indication of the severity
73
# PR Treatment
Diuretics Vasodilators Treat the underlying disease EX: Pulmonary hypertension – Treat that! Pulmonary valve replacement If the right ventricle is enlarged or dysfunction is present
74
# Mitral stenosis general
Obstruction of blood flow from the LA to the LV due to a narrowed mitral opening Causes blood to back up in the left atria Increases left atrial pressure Causing, pulmonary congestion and pulmonary hypertension ->CHF
75
# MS etiology
Rare in the US Most commonly the result of rhematic fever Develops in 40% of patients with rheumatic heart disease Occurs 10-20 years after the initial infection 2/3 are female patients Less common causes include congenital MS, SLE, RA, atrial myxoma, bacterial endocarditis, and severe mitral annular calcification
76
# MS Pathophysiology
Stenosis causes an increase in LA pressure (LAP) which raises pulmonary venous and capillary pressures, resulting in exertional dyspnea As the disease progresses, chronic increased LAP leads to pulmonary hypertension, tricuspid and pulmonary incompetence, and eventually right heart failure
77
# MS S/Sx
78
# MS The Murmur
Low pitches, rumbling, mid-diastolic murmur Best heard in the left decubitus position with the bell of the stethoscope Length of the murmur correlates better with the severity, than loudness **Opening snap** Extra diastolic sound that follows S2 Due to a stiff mitral valve
79
# MS PE
Pulmonary edema (rales) Apical diastolic thrill may be felt in the lateral decubitus position (purring cat) +/- irregularly irregular rhythm Left and possible right heart failure symptoms Malar rash: Cutaneous vasoconstriction results in pinkish-purple patches on the cheek (mitral facies)
80
# MS Dx Echo
Echocardiogram Mitral orifice and gradient LA size LVEF (Left ventricular ejection fraction) EKG Atrial fibrillation is common with course fibrillatory waves Left atrial enlargement P-mitrale Broader P wave in lead II that is notched +/- RAD (right atrial dilation) +/- RVH (right ventricular hypertrophy) (with pulmonary HTN) Chest radiograph Left atrial enlargement: straightening, of the left heart border, retrocardiac double density, elevation of the left main bronchus +/- enlarged pulmonary artery (While the aorta and left ventricle are normal or small in size) +/- calcification in the mitral valve area
81
Mitral Stenosis Treatment (not meds)
Nonsurgical Percutaneous mitral balloon commissurotomy (PMBC) Surgical Surgical (open) tissue vs. mechanical valve replacement +/- Maze procedure +/- Left atrial appendage ligation/Watchmen
82
# MS Medical Treatment
Diuretics: Usually, Loop diuretic Pulmonary vascular congestion Beta-blockers Heart rate control If A. fib Warfarin INR goal: 2.0-3.0
83
# Tri sten Pathophysiology
Narrowing of the tricuspid valve Causes blood to back up into the right atrium Causing a diastolic pressure gradient between the right atria and right ventricle The gradient increases during inspiration and exercise Decreases with expiration
84
# TS Etiology
Rare by itself, more commonly associated with a multivalve process Carcinoid syndrome Infective endocarditis
85
# TS Signs and Symptoms
Fatigue Right heart failure symptoms Giant RA “a wave” transmitting to the jugular veins -> fluttering discomfort in the neck
86
# TS The Murmur
Low-pitched diastolic murmur, LLSB in 3rd – 4th ICS Increases with inspiration
87
# TS Dx
Echocardiogram Reduction in the tricuspid valve orifice and thickening/diastolic doming of the tricuspid leaflets EKG Right atrial enlargement
88
# TS Tx
Medical Intensive sodium restriction and diuretics Surgical Tricuspid valvuloplasty or replacement Usually, bioprosthetic valve
89
# Board Tips For Mastering Murmur Questions Know which 4 are systolic and which 4 are diastolic “MR PASS/ MVP”: mitral regurgitation, pulmonic aortic stenosis systolic, mitral valve proloapse “MS PAID”: mitral stenosis, pulmonic aortic insufficiency, diastolic Know where the valves are located Know key terms: Ex: Ejection click
90
Systolic Murmurs
Aortic Stenosis Mitral Regurgitation Ventricular Septal defect Atrial Septal defect Mitral Valve prolapse HOCM Pulmonary Stenosis “MR PAA/ MVP”
91
Diastolic Murmurs
Mitral Stenosis Aortic Regurgitation Pulmonic Insuccificiency “MS PAID”
92
Radiation
Mitral regurgitation- axilla Aortic stenosis- carotids

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