#13 - Aortic stenosis, Aortic valve insufficiency/ Mitral Valve insufficiency (Brown)

Question 1

classic triad of symptoms for aortic valve stenosis

Answer 1

Exertional angina
exertional syncope
exertional dyspnea
NO FATIGUE

Question 2

T/F At the time of presentation, patients with aortic valve stenosis can be monitored before intervening.

Answer 2

False. They deteriorate rapidly after presentation with symptoms, so you need to fix it with surgery ASAP.

Question 3

Which valvulur disease would cause angina, dyspnea, and syncope with no fatigue?

Answer 3

aortic valve stenosis.

Question 4

Case:

• low diastolic pressure
• wide pulse pressure
• long blowing murmur.

Diagnosis?

Answer 4

severe chronic mitral regurgitation / insufficiency

Question 5

Case:

• long systolic murmur
• hyperkinetic apical impulse heard near left anterior axillary line

Diagnosis?

Answer 5

chronic mitral regurgitation

(aortic valve regurg has a hyperkinetic impulse, but the location isn’t changed - it would not be heard over the axillary line.

Question 6

You see a patient. He has elevated JVP, which drops when he breathes in. What is the most likely diagnosis?

Answer 6

Pericardial effusion w/ tamponade

Question 7

Case

• ascites
• leg edema
• increased JVP
• positive Kussmaul sign (JVP rises with inspiration)

Diagnosis?

Answer 7

Constrictive pericarditis.

Question 8

Case.

• long systolic murmur
• normal diastolic pressure
• narrow pulse pressure

Answer 8

aortic stenosis

diastolic pressure stays normal, since filling isn’t affected.
Since the LV can’t push its fluid out normally (reduced either in volume or time), this will impact the systolic pressure, reducing the pulse pressure.

Question 9

What kind of murmur is heard with aortic stenosis?

Answer 9

systolic murmur.

crescendo-decrescendo in nature

Question 10

Physical exam findings for aortic stenosis.

Answer 10

• BP can be normal
• Pulse pressure often decreased (due to low systolic pressure.)
• weak carotid pulse with sustained upstroke (carotid massages your finger instead of tapping it) - due to increased time it takes to get fluid through the small hole.
• hyperkinetic apical thrust - enlarged and sustained but NOT displaced.

Question 11

T/F - in aortic stenosis, the pressure gradient across the valve correlates with severity of symptoms.

Answer 11

True.

Question 12

What happens to the Left ventricle in aortic stenosis?

Answer 12

It becomes hypertrophic but NOT dilated (since stenosis requires increased force but not increased storke volume. )
-it also becomes quite stiff

Question 13

What labs do you do for aortic stenosis?

Answer 13

EKG,
CXR
Echocardiogram

Question 14

What does EKG show with aortic stenosis?

Answer 14

LV hypertrophy.

Question 15

CXR findings for aortic stenosis.

Answer 15

normal heart size.

• post-stenotic dilatation of the aorta may be seen.
• calcification of the aortic valve may be seen.

Question 16

Echocardiogram findings for aortic stenosis.

Answer 16

• high pressure gradient across valve

- hypertrophy.

Question 17

What are the similarities and differences between aortic stenosis and aortic regurgitation?

Answer 17

• both present with dyspnea and angina.
• both have increased apical impulse.
• both have left ventricle hypertrophy, look similar on EKG.

Aortic stenosis

• syncope common
• fatigue not present.
• narrow pulse pressure
• apical impulse strong, not displaced.
• systolic murmur (crescendo/decrescendo)
• carotid artery pulse slow, soft (massage)
• LV hypertrophy, but NO dilation

Aortic regurgitation

• syncope uncommon
• exertional fatigue common
• wide pulse pressure.
• apical impulse strong, displaced (due to dilation)
• diastolic murmur (decrescendo)
• carotid pulse is brisk, strong, visably pulsatile.
• femoral pistol shots maybe present.
• LV hypertrophy WITH dilation.

Question 18

What are the 3 primary symptoms (along with 2 lesser ones) for aortic regurgitation?

Answer 18

• angina
• dyspnea
• fatigue (stroke volume is affected)
• palpitations (dilated, hyperdynamic L. ventricle
• inappropriate sweating

Question 19

Why is fatigue present in regurgitation and not in stenosis?

Answer 19

in regurgitation, stroke volume is affected. lack of flow leads to fatigue. In stenosis, the heart usually can compensate enough to maintain normal stroke volume.

Question 20

Physical exam findings of aortic regurgitation.

Answer 20

• hyperkinetic pulse
• widened pulse pressure
• carotids brisk, visibly pulsatile
• femoral pistol shots
• apical impulse strong, displaced down and out.
• diastolic decrescendo murmur.

Question 21

What labs should you order for aortic regurgitation?

Answer 21

EKG, CXR, Echocardiogram.

Question 22

EKG finding for aortic regurgitation

Answer 22

LV hypertrophy.

Question 23

CXR finding for aortic regurgitation

Answer 23

-enlarged left ventricle, with apex displaced down and out.

Question 24

Echocardiogram finding for aortic regurgitation

Answer 24

-tells you severity of regurgitation, and LV size/function.

Question 25

How does flow across the aortic valve change the pressure gradient in aortic stenosis?

Answer 25

minor increases in flow create huge differences in valve gradient. Square root/ exponential relationship. 3x increase in flow = 9x increase in gradient

Question 26

How does valve area change the pressure gradient in aortic stenosis?

Answer 26

Minor decreases in valve area can produce huge differences in valve gradient Square root / exponential relationship. Halving the valve size would produce 4 fold increase in pressure gradient.

Question 27

Why isn't dilation seen in aortic valve stenosis?

Answer 27

stroke volume doesn't go up.

Question 28

T/F aortic valve stenosis can cause sudden cardiac death without atheroscleerosis present.

Answer 28

True

Question 29

What is a normal pulse pressure, and what is a low pulse pressure

Answer 29

Anything less than 25% of the systolic pressure. So for a systolic of 120, narrow PP would any diastolic above 90. He says, in general, 30mm is a low pulse pressure.

Question 30

What 2 categories of etiologies for aortic valve regurgitation

Answer 30

diseases of the aortic valve, or | diseases of the aorta (the diseased aorta can "stretch out" the leaflets so they can't close --> regurgitation.)

Question 31

What valve disease does Marfan commonly cause?

Answer 31

Aortic regurgitation.

Question 32

What is the key feature on physical exam for chronic aortic regurgitation.

Answer 32

hyperkinetic pulse, and widened pulse pressure. This is the opposite of aortic stenosis.

Question 33

Explain the hyperkinetic pulse and widened pulse pressure seen in aortic regurgitation.

Answer 33

The heart ejects twice the normal volume faster than normal, to combat the reverse flow raising the systolic pressure. Diastolic is lower than normal because fluid is falling back through the valve during diastole (creating negative pressure.)

Question 34

What are the categories of etiologies for mitral valve insufficiency?

Answer 34

``` Etiologies are divided by components of the mitral valve. 1-leaflets 2-annulus (ring) 3-chordae tendinae 4-papillary muscle ```

Question 35

Which diseases affect the mitral valve leaflets, causing regurgitation?

Answer 35

rheumatic heart disease, endocarditis. Prolapse

Question 36

Which diseases can affect the mitral valve annulus, causing regurgitation?

Answer 36

Marfan's syndrome, also happens in elderly

Question 37

Which diseases can rupture the mitral valve chordae tendinae, causing regurgitation?

Answer 37

endocarditis, otherwise idiopathic

Question 38

What is mitral valve prolapse?

Answer 38

it is myxomatous degeneration of the leaflets (myxomatous -= weakening of the connective tissue)

Question 39

What is the cause of mitral valve prolapse?

Answer 39

it is idiopathic, but probably an autosomal dominant trait | -can be part of a genetic trait like Marfan's

Question 40

What is the prevalence of Mitral vvalve prolapse?

Answer 40

2.5% of the population has it.

Question 41

Relationship between Marfan's and Mitral Valve Prolapse.

Answer 41

most with Marfan's have it. But most of the people who have MV prolapse don't have Marfan's

Question 42

What are the auscultatory findings in mitral valve prolapse?

Answer 42

"click and