Valvular Heart Diseases Flashcards
Hemodynamic hallmark of mitral stenosis (MS)
blood can flow from LA to LV only if propelled by an abnormally elevated left atrioventricular pressure gradient (d.t. reduction in mitral orifice area < 2 cm)
The leading cause of mitral stenosis
RHD
narrowed mitral orifice <4cm2 with obstruction blood flow from LA to LV
MITRAL STENOSIS
MC presenting symptoms of MS
dyspnea
fatigue
decreased exercise tolerance
important cause of morbidity and mortality late in the course of MS
recurrent pulmonary emboli
Characteristic murmur of MS
DIASTOLIC RUMBLING MURMUR PRECEDED BY OPENING SNAP (OS) AT THE APEX
Murmur is usually LOUDER during INSPIRATION and diminishes during forced expiration
Carvallo’s sign
High-pitched, diastolic, decrescendo blowing murmur along the left sternal border
Graham Steell murmur
SIGNS OF CHF:
jugular venous distention dullness on chest percussion → pleural effusion fine rales hepatomegaly and ascites pedal or sacral edema
ECG findings in MS
- atrial fibrillation
- LA hypertrophy
- RV hypertrophy
- RA hypertrophy
Chest x-ray in MS
- left atrial enlargement
- prominent PA
- dilation of the upper lobe pulmonary veins
- posterior displacement of the esophagus by an enlarged LA
• Kerley B lines
-result from distention of interlobular septae and lymphatics with edema when resting mean LA pressure exceeds ~20 mmHg
- pleural effusion and alveolar infiltrates
- pulmonary edema
Important for at risk patients with rheumatic MS
Penicillin prophylaxis
Useful in slowing the ventricular rate of patients w/ AF
beta blockers
nonhydropyridine calcium channel blockers
digitalis glycosides
Should be administered indefinitely to patients w/ MS who have AF or a history of thromboembolism
warfarin therapy
targeted to an international normalized ratio (INR) of 2-3
Indicated in symptomatic (New York Heart Association [NYHA] Functional Class II–IV) patients with isolated severe MS, whose effective orifice (valve area) is < ~1 cm2/m2 body surface area, or <1.5 cm2 in normal sized adults
mitral valvotomy
May be d.t. ACS w/ papillary muscle rupture, chest trauma, endocarditis
Acute MR
May be d.t. RHD, MVP, cardiomyopathies
Chronic MR
Most prominent symptoms in CHRONIC SEVERE MR
fatigue
exertional dyspnea
orthopnea
Characteristic murmur of MR
apical holosystolic murmur of at least grade III
Chest X-Ray findings in MR
LAE
LVH
ECG findings in MR
LAE
LVH
atrial fibrillation
Frequent finding in heritable CT disease
MVP (Floppy syndrome, Barlow’s syndrome)
more common in women 15-30 y/o
more severe in men and > 50 years old
Characteristic murmur of MVP
apical mid- or late non-ejection systolic murmur preceded by a click
ACCENTUATED BY - standing and strain phase of Valsalva maneuver
DIMINISHED BY - squatting and isometric exercises
narrowing of the aortic valve orifice – causes
obstruction to the flow of blood from LV to aorta
AORTIC STENOSIS
CONGENITAL AORTIC VALVE DISEASE
Bicuspid aortic valve (BAV)
- MC aortic heart defect
- AD
- NOTCH1 gene
- abnormalities in nitric oxide synthase and NKX2.5
CALCIFIC AORTIC VALVE DISEASE
degenerative
MC cause of AS in adults
3 CARDINAL SYMPTOMS of AS
- exertional dyspnea
- angina pectoris
- syncope (exertional)
Characteristic murmur of AS
thrill and harsh CRESCENDO-DECRESCENDO SYSTOLIC murmur at the 2nd R ICS
↓ in valsalva maneuver
pulsus parvus et tardus
- carotid arterial pulse rises slowly to a delayed peak
* weak and late-peaking/delayed pulse
Gallavardin effect (AS)
murmur may transmitted to apex resembling murmur of MR
ECG findings in AS
- LV hypertrophy
* ST segment depression and T wave inversion
Gold standard for AS diagnosis
Cardiac Catheterization
- determine the status of coronary artery disease
- coronary angiography is indicated to detect or
- exclude CAD in patients >45 years old with severe AS who are being considered for operative treatment
percutaneous aortic balloon valvuloplasty (PABV)
preferable to operation in many children and young adults with congenital, noncalcific AS
NOT commonly used as definitive therapy in adults with severe calcific AS because of a very high restenosis rate
transcatheter aortic valve replacement
performed with increasing frequency in prohibitive-, high-, and intermediate surgical-risk adult patients worldwide using one of two available systems, a balloon expandable valve and a self-expanding valve, both of which incorporate a pericardial prosthesis
Can be caused by primary aortic valve disease or primary aortic root disease
AORTIC REGURGITATION
Primary Valve Disease
RHD
congenital bicuspid aortic valve
endocarditis
Primary Aortic Root Disease
aortic annular dilation
Marfan’s syndrome
Characteristic murmur of AR
high pitched blowing DECRESCENDO DIASTOLIC murmur in 3rd ICS left PSB
ECG findings in AR
LVH w/ ST depression and T wave inversion in I, avL, V5-V6 (lateral leads)
Chest x-ray findings in AR
apex displaced DOWNWARD and to the LEFT
Management of AR
diuretics, ACE-I and vasodilators for CHF
Aortic Valve Replacement
valve area is < 4cm2 which causes an ↑ in RA pressures with progressive dilatation
TRICUSPID STENOSIS
Does NOT occur as an isolated lesion and usually associated with MS
almost always accompanied by severe TR
TRICUSPID STENOSIS
MC cause of TS
RHD
Carcinoid Syndrome
production of substance that stimulates collagen production – fibrosis of the tricuspid valve
Symptoms in TS
ascites
edema
Signs in TS
ascites, edema, hepatosplenomegaly - signs or R sided CHF
Characteristic murmur of TS
DIASTOLIC murmur at lower left PSB
AUGMENTED - inspiration
REDUCED - expiration and Valsalva (strain phase)
