Valvular Heart diseases Flashcards
S1: Lubb
Simultaneous closing of mitral and tricuspid valves
Start of systole, end of diastole
S2: Dubb
Simultaneous closing of aortic and pulmonic valves
End of systole, beginning of diastole
Thrill
Vibratory sensation felt on the skin
Indicates turbulent flow
Grading cardiac murmurs
Systolic Murmurs
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
Diastolic Murmurs
All END in the VENTRICLE: Murmur occurs as the blood is coming to the ventricle
Aortic Regurgitation*
Mitral Stenosis*
Pulmonic Regurgitation
Tricuspid Stenosis
Right sided murmurs louder
during inspiration
Abrupt standing
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.
Squatting
Most murmurs become louder with squatting due to increased afterload
Leg raise
Most murmurs become louder with a leg raise due to increased afterload
Valsalva Maneuver
Most murmurs decrease in intensity during a Valsalva maneuver
Except for mitral valve prolapse
Sustained Hand Grip
Can help differentiate between AS and MR
AS – Murmur decreases
MR – Murmur increases
what will echo tell me?
- 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
Aortic Stenosis
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)
aortic stenosis
Aortic Stenosis
general
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
Unicuspid or Bicuspid Aortic valve
Usually, a fusion of right and left coronary cusps
1-2% of the population
Male predominated
Aortic stenosis
S/Sx
Asymptomatic
SAD
Syncope
Angina
Dyspnea
Heart failure as a result of left ventricular systolic or diastolic dysfunction
Fatigue
Decreased exercise tolerance
Sudden death
aortic stenosis
Physical Examination Findings
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
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
Aortic stenosis
Aotic stenosis
Dx
Transthoracic Echocardiogram
Treatment for Asymptomatic Patients
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
aortic stenosis
Surgical Treatment
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
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
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
Transcatheter Aortic Valve Replacement
- > 70 y
- CKD
- EF <40%
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
for super end stage
Procedure to improve symptoms
Pulmonary Valve Stenosis
general
Rare
Usually, congenital
Pulm sten
S/Sx
Mild-Mod: Asymptomatic
DOE
Chest pain
Eventual right heart failure
Exertional syncope
pulm sten
PE
Palpable?
Palpable parasternal lift due to right ventricular hypertrophy
Hepatic congestion, hepatosplenomegaly
Peripheral edema
Pulm sten
The Murmur
Crescendo-decrescendo systolic murmur
+/- thrill at the supraclavicular notch and LUSB
Pulm sten
Diagnostics
Echocardiogram
Thickened leaflets, right ventricular hypertrophy
EKG
+/- Right atrial dilation, right ventricular hypertrophy
pulm sten
Tx
Percutaneous Balloon Valvuloplasty
Pulmonary Valve Replacement
Mitral Regurgitation
causes
can be due to ant. MI (LAD)
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
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
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
MR
PE
High-pitched blowing Holosystolic murmur
Heard best at apex, may radiate to the axilla
Possible S3
MR
Diagnostics
BNP
Early identifier of left ventricular dysfunction
Chest Xray
Acute vs chronic MR
ECHO
MR
Tx
Meds
Afterload reduction
Vasodilators: Hydralazine, Ace-inhibitors
Diuretics
Anticoagulation if there is A. fib
MR
Surgery
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
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
mitral valve prolapse
Treatment
Meds
Medication
Afterload reduction, beta-blockers for palpitations with PACs/PVCs
Surgery
Mitral valve repair
Mitral valve replacement
Tricuspid Regurgitation
general
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
Tricuspid Regurgitation
The Murmur
Does it increase?
Tru Regurg
Tx
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.
A regurg
etiology
A regurg
Sx
Asymptomatic
Exertional dyspnea
Fatigue
Atypical chest pain
Eventual LV dilation and failure
Orthopnea/PND
AR
Physical Exam Findings: Murmur
blowing decrescendo diastole
AI: aortic insufficiency
AR
PE
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
Corrigan Pulse
Similar to water hammer but referring to the carotid artery
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
Muller’s Sign
Visible systolic pulsations of the uvula
De Musset’s Sign
Head-bobbing with each heartbeat
Becker’s Sign
Visible pulsations of the retinal arteries and pupils
Rosenbach’s Sign
Systolic pulsations of the liver
Gerhard’s Sign
Systolic pulsations of the spleen
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
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
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
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
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
PR
Signs and Symptoms
Most asymptomatic
Right heart failure symptoms
Dyspnea on exertion
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
PR
Dx
Echocardiogram
RV size and function is an indication of the severity
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
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
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
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
MS
S/Sx
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
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)
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
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
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
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
TS
Etiology
Rare by itself, more commonly associated with a multivalve process
Carcinoid syndrome
Infective endocarditis
TS
Signs and Symptoms
Fatigue
Right heart failure symptoms
Giant RA “a wave” transmitting to the jugular veins -> fluttering discomfort in the neck
TS
The Murmur
Low-pitched diastolic murmur, LLSB in 3rd – 4th ICS
Increases with inspiration
TS
Dx
Echocardiogram
Reduction in the tricuspid valve orifice and thickening/diastolic doming of the tricuspid leaflets
EKG
Right atrial enlargement
TS
Tx
Medical
Intensive sodium restriction and diuretics
Surgical
Tricuspid valvuloplasty or replacement
Usually, bioprosthetic valve
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
Systolic Murmurs
Aortic Stenosis
Mitral Regurgitation
Ventricular Septal defect
Atrial Septal defect
Mitral Valve prolapse
HOCM
Pulmonary Stenosis
“MR PAA/ MVP”
Diastolic Murmurs
Mitral Stenosis
Aortic Regurgitation
Pulmonic Insuccificiency
“MS PAID”
Radiation
Mitral regurgitation- axilla
Aortic stenosis- carotids
