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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
Q

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

A

B) stress test

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26
Q

Bioprosthetic “Tissue” Valves

A

Last an average of 10-15 years
Surgical or transcatheter: Bovine or Porcine
Long-term anticoagulation not required

Endocarditis prophylaxis is indicated

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27
Q

Mechanical valve

A

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

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28
Q

Transcatheter Aortic Valve Replacement

A
  1. > 70 y
  2. CKD
  3. EF <40%
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29
Q

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

A

B) 76- year- old with chronic kidney disease, EF 35%, and elevated frailty index

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30
Q
A

for super end stage
Procedure to improve symptoms

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31
Q

Pulmonary Valve Stenosis

general

A

Rare
Usually, congenital

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32
Q

Pulm sten

S/Sx

A

Mild-Mod: Asymptomatic
DOE
Chest pain
Eventual right heart failure
Exertional syncope

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33
Q

pulm sten

PE
Palpable?

A

Palpable parasternal lift due to right ventricular hypertrophy

Hepatic congestion, hepatosplenomegaly
Peripheral edema

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34
Q

Pulm sten

The Murmur

A

Crescendo-decrescendo systolic murmur
+/- thrill at the supraclavicular notch and LUSB

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35
Q

Pulm sten

Diagnostics

A

Echocardiogram
Thickened leaflets, right ventricular hypertrophy
EKG
+/- Right atrial dilation, right ventricular hypertrophy

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36
Q

pulm sten

Tx

A

Percutaneous Balloon Valvuloplasty
Pulmonary Valve Replacement

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37
Q

Mitral Regurgitation
causes

A

can be due to ant. MI (LAD)

38
Q

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

A

Rheumatic fever

39
Q

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

A

Mitral regurgitation

40
Q

Mitral Regurg

S/Sx

A

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
Q

MR

PE

A

High-pitched blowing Holosystolic murmur
Heard best at apex, may radiate to the axilla
Possible S3

42
Q

MR

Diagnostics

A

BNP
Early identifier of left ventricular dysfunction
Chest Xray
Acute vs chronic MR

ECHO

43
Q

MR

Tx
Meds

A

Afterload reduction
Vasodilators: Hydralazine, Ace-inhibitors
Diuretics
Anticoagulation if there is A. fib

44
Q

MR

Surgery

A
45
Q

Mitral Valve Prolapse

general

A

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
Q

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

A

Mitral Valve Prolapse
Mid systolic click and palpitations

47
Q

mitral valve prolapse

Treatment
Meds

A

Medication
Afterload reduction, beta-blockers for palpitations with PACs/PVCs

Surgery
Mitral valve repair
Mitral valve replacement

48
Q

Tricuspid Regurgitation

general

A
49
Q

Tricuspid Regurgitation

Signs and Symptoms

A

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
Q

Tricuspid Regurgitation

The Murmur
Does it increase?

A
51
Q

Tru Regurg

Tx

A
52
Q

Aortic Regurgitation (Insufficiency)

general

A

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
Q

A regurg

etiology

A
54
Q

A regurg

Sx

A

Asymptomatic
Exertional dyspnea
Fatigue
Atypical chest pain
Eventual LV dilation and failure
Orthopnea/PND

55
Q

AR

Physical Exam Findings: Murmur

A

blowing decrescendo diastole
AI: aortic insufficiency

56
Q

AR

PE

A
57
Q

Water Hammer Pulse

A

“Collapsing pulse”
Rapid swelling and falling arterial pulse
Best appreciated by palpation of the radial or brachial arteries or the carotid pulse

58
Q

Corrigan Pulse

A

Similar to water hammer but referring to the carotid artery

59
Q

Hill’s Sign

A

Popliteal cuff systolic pressure exceeding brachial pressure by more than 60 mmHg with patient in the recumbent position
Most sensitive for AI

60
Q

Muller’s Sign

A

Visible systolic pulsations of the uvula

61
Q

De Musset’s Sign

A

Head-bobbing with each heartbeat

62
Q

Becker’s Sign

A

Visible pulsations of the retinal arteries and pupils

63
Q

Rosenbach’s Sign

A

Systolic pulsations of the liver

64
Q

Gerhard’s Sign

A

Systolic pulsations of the spleen

65
Q

AR???

Dx

A

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
Q

aortic regurgitation

Treatment

A

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
Q

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

a. aortic regurgitation

68
Q

Tricuspid Regurgitation

primary and secondary

A

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
Q

Pulm reg

etiology

A

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
Q

PR

Signs and Symptoms

A

Most asymptomatic
Right heart failure symptoms
Dyspnea on exertion

71
Q

PR

Physical Examination (murmur)

A

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
Q

PR

Dx

A

Echocardiogram
RV size and function is an indication of the severity

73
Q

PR

Treatment

A

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
Q

Mitral stenosis

general

A

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
Q

MS

etiology

A

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
Q

MS

Pathophysiology

A

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
Q

MS

S/Sx

A
78
Q

MS

The Murmur

A

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
Q

MS

PE

A

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
Q

MS

Dx Echo

A

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
Q

Mitral Stenosis Treatment (not meds)

A

Nonsurgical
Percutaneous mitral balloon commissurotomy (PMBC)
Surgical
Surgical (open) tissue vs. mechanical valve replacement
+/- Maze procedure
+/- Left atrial appendage ligation/Watchmen

82
Q

MS

Medical Treatment

A

Diuretics:
Usually, Loop diuretic
Pulmonary vascular congestion
Beta-blockers
Heart rate control
If A. fib
Warfarin
INR goal: 2.0-3.0

83
Q

Tri sten

Pathophysiology

A

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
Q

TS

Etiology

A

Rare by itself, more commonly associated with a multivalve process
Carcinoid syndrome
Infective endocarditis

85
Q

TS

Signs and Symptoms

A

Fatigue
Right heart failure symptoms
Giant RA “a wave” transmitting to the jugular veins -> fluttering discomfort in the neck

86
Q

TS

The Murmur

A

Low-pitched diastolic murmur, LLSB in 3rd – 4th ICS
Increases with inspiration

87
Q

TS

Dx

A

Echocardiogram
Reduction in the tricuspid valve orifice and thickening/diastolic doming of the tricuspid leaflets
EKG
Right atrial enlargement

88
Q

TS

Tx

A

Medical
Intensive sodium restriction and diuretics
Surgical
Tricuspid valvuloplasty or replacement
Usually, bioprosthetic valve

89
Q

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

A
90
Q

Systolic Murmurs

A

Aortic Stenosis
Mitral Regurgitation
Ventricular Septal defect
Atrial Septal defect
Mitral Valve prolapse
HOCM
Pulmonary Stenosis
“MR PAA/ MVP”

91
Q

Diastolic Murmurs

A

Mitral Stenosis
Aortic Regurgitation
Pulmonic Insuccificiency
“MS PAID”

92
Q

Radiation

A

Mitral regurgitation- axilla
Aortic stenosis- carotids

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