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Cardiology and Respiratory SA Med > Atrioventricular valve disease > Flashcards

Atrioventricular valve disease Flashcards

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1
Q

What are the two common forms of adult onset AV valve disease?

A
  1. ENdocardiosis (degeneration)

2. Endocarditis (infection)

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2
Q

What is the most common form of AV valve disease in dogs?

A
  • Endocardiosis
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3
Q

What is the most common heart disease in the dog?

A
  • Endocardiosis
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4
Q

What are four reasons that AV valves can be insufficient?

A
  1. Endocardiosis
  2. Endocarditis
  3. Dilation
  4. Dysplasia (congenital)
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5
Q

What do both endocardiosis and endocarditis ultimately result in?

A
  • Insufficiency or incompetence of the AV valves
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6
Q

Does valvular insufficiency always equal valvular disease?

A
  • NOPE

- Common secondary complications of ventricular enlargement as well

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7
Q

What can help you dfiferentiate the underlying cause of AV valve insufficiency?

A
  • Signalment is super helpful
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8
Q

Pathophysiology of AV valvular insufficiency

A
  • Blood leaks backwards into the atrium as soon as the ventricular pressure exceeds the atrial pressure (AKA in systole)
  • Increased atrial size
  • Decreased forward stroke volume
  • Systolic plateau or flat murmur
  • Left ventricular dilation
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9
Q

Pathophysiology of CHF secondary to left AV valvular insufficiency

A
  1. Left atrial dilation/pressure
  2. Pulmonary venous pressure
  3. Pulmonary edema

AND

  1. cardiac output is limited
  2. Neurohormonal increase in RAAS
  3. Fluid retention (CHF)
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10
Q

Do animals always show progressive disease before getting CHF?

A
  • Nope
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11
Q

Tricuspid valvular pathophysiology

A
  • same on right side
  • Cranial and caudal vena cava pressures increase resulting in pleural effusion and/or hepatic venous congestion and ascites
  • Elevations of systemic venous pressures are also related to fluid retention from low cardiac output
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12
Q

Definition of AV valve endocardiosis

A
  • Age related degenerative disease of the cardiac valves of dogs
  • Myxomatous degeneration
  • Valve accumulates glycosaminoglycans and become very nodular and globular looking
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13
Q

AV Valve degeneration in horses

A
  • Horses develop it as well, but it is not referred to as endocardiosis
  • Valve cups ocntract and become grossly distorted
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14
Q

Which valve gets distorted most frequently in horses?

A
  • Aortic valve
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15
Q

Endocardiosis in cats and cattle

A
  • Does not happen
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16
Q

Who gets endocardiosis?

A
  • Older small/toy breed dogs

- Cavalier King Charles!!

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17
Q

Which valve is most often affected in endocardiosis?

A
  • Mitral valve, most often
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18
Q

Incidence of endocardiosis in small dogs

A
  • 30-40%
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19
Q

Endocardiosis in CKCS

A
  • Often develops at a young age
  • Familial nature apparent in many breeds
  • Often progress to CHF or progress more quickly
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20
Q

What are key aspects of diagnosis for endocardiosis?

A
  • Signalment and physical exam
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21
Q

Quality of the murmur for endocardiosis

A
  • Systolic click, early stages
  • Initially soft
  • Progressively louder and holosystolic
  • Flat or plateau character
  • PMI is apical (mitral or tricuspid area)
  • Murmur may radiate
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22
Q

Grade of murmur and severity of disease in valvular endocardiosis?

A
  • DOES NOT CORRELATE TO SEVERITY OF DISEASE
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23
Q

What is the most important diagnostic test for AV endocardiosis?

A
  • Thoracic radiographs
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24
Q

What can you evaluate with thoracic radiographs for AV endocardiosis?

A
  • Degree of volume load/heart size

- Evaluate for possible congestion or CHF

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25
Radiographic abnormalities with AV endocardiosis
- Depend on stage - May be normal even with severe heart murmur, early in disease - +/- left atrial enlargement - +/- left ventricular enlargement - +/- pulmonary venous congestion or pulmonary edema
26
ECG with mitral valve endocardiosis
- May be normal - May have evidence of LA or LV enlargement - If you see a change, it's there, but if you don't see it, doesn't mean it's not - May have arrhythmias due to dilated atria
27
Possible abnormalities with ECG
- P mitrale (wide P) - Atrial fibrillation (indicates severe left atrial enlargement and irritation) - SV (atrial) premature bet - Tall R wave
28
Echocardiography changes for AV endocardiosis
- Thickened, irregular mitral valve or tricuspid valve - Valve may prolapse into the atrium - +/- left atrial enlargement - +/- left ventricular enlargement - +/- right atrial or ventricular enlargement - +/- systolic dysfunction - Mitral or tricuspid regurgitation can be seen on color Doppler - Good systolic function until very severe and chronic volume overload present
29
Early impacts on contracility for mitral valve endocardiosis?
- Good contractility until quite late in disease
30
What type of hypertrophy happens with mitral valve regurgitation?
- Eccentric hypertrophy due to volume overload
31
Stage A endocardiosis definition
- Breeds at risk no murmur | - e.g. chihuahuas, Cavalier King Charles Spaniels
32
Stage A endocardiosis therapy
- None, monitor yearly
33
Stage B1 endocardiosis definition
- Minimal to no atrial enlargement
34
Stage B1 endocardiosis therapy
- Non, monitor q6-12 months with echocardiogram | - If a Cavalier or a breed at risk, probably monitor closer to 6 months
35
Stage B2 endocardiosis definition
- Moderate to severe atrial enlargement
36
Stage B2 endocardiosis therapy
- Pimobendan +/- Enalapril
37
Stage C endocardiosis definition
- Severe cardiomegaly, CHF
38
Stage C endocardiosis treatment
- Pimobendan - Enalapril - Furosemide - diet changes
39
Stage D endocardiosis definition
- Refractory CHF
40
Stage D endocardiosis treatment
- Pimobendan, enalapril, furosemide, additional diuretics
41
Furosemide mechanism
- Diuretic | - Na/K/Cl channel inhibitor (Loop diuretic)
42
Furosemide purpose in CHF
- Diuretic to reduce pulmonary edema
43
Enalapril mechanism
ACE inhibitor - Blocks conversion from Angiotensin I to Angiotensin II
44
Enalapril purpose
- Inhibit RAAS since you are giving Furosemide
45
Pimobendan mechanism
- Inodilator | - Calcium channel sensitizer
46
What should you give if there are atrial tachyarrhythmias or atrial fibrillation?
- Digoxin or diltiazem
47
MOA of Diltiazem
- Calcium channel blocker
48
What drug is contraindicated with CHF?
- Beta blockers | - Do NOT generally use a beta blocker
49
Effects of angiotensin II
- Increased thirst - Increased aldosterone and subsequent increased Na and water - Vasoconstriction - Increased sympathetic tone - Myocardial remodeling
50
MOA of Digoxin
- Blocks the sodium/potassium pump - Will alternatively do a sodium/calcium exchanger - Results in a rise of intracellular calcium
51
Mechanism of Dobutamine
- See the diagram in the notes
52
Prognosis for mitral valve endocardiosis
- usually slowly progressive (over years) - Some dogs will never progress (approximately half) - Some breeds progress faster (CKCS) - Prognosis good with successful treatment of CHF (~1.5-2.5 years)
53
Class C monitoring
- Every 2-6 months for left congestive heart failure (radiographs) - Home respiratory rates - Renal enzymes and blood pressure
54
What are two occasional complications with endocardiosis?
- Ruptured chordae tendonae | - Left atrial tear
55
Ruptured chordae tendonae
- Acute increase in amount of mitral valve regurgitation - Acute, severe left heart failure - Emergency situation
56
Left atrial tear
- Acute hemo-pericardial effusion - Acute collapse due to decreased dcardiac output - Blood clot may form on tear and allow for temporary improvement - Treatment is careful pericardiocentesis - May have rapid death - Can go into hypotensive shock
57
Valvular endocarditis - how common in dogs?
- Uncommon
58
Usual etiology of valvular endocarditis?
- Usually bacterial | - Rarely fungal or rickettsial organisms
59
Which valve is most commonly impacted by valvular endocarditis in horses and dogs?
- Aortic and mitral
60
Which valve is most commonly impacted by valvular endocarditis in cattle?
- Tricuspid and pulmonic
61
Which valve is most commonly impacted by valvular endocarditis in cats
- VERY RARE | - Don't think of this at first in a cat with a murmur, even if they are sick
62
Factors for infection with endocarditis
1. Hemodynamic 2. Trauma to valve 3. bacteremia source 4. Virulence of bacteria 5. Immunologic competence of host
63
Hemodynamic factor for infection with endocarditis
- turbulence of blood flow | - E.g. Subaortic stenosis, PDA, VSD, endocardiosis
64
Trauma factor for infection with endocarditis
- Trauma to the endocardial surface | - Exposure to collagen fibers allowing platelets and bacteria to adhere
65
Bacteremia factor for infection with endocarditis
- Circulating, even for short periods - Portal may include breaks in the GIT (aka bacterial translocation), or from bone infections or urogenital infections - Iatrogenic can include infected IV lines or surgical procedures
66
Virulence of bacteria factor for infection with endocarditis
- Some bacteria able to adhere better and cause platelet aggregation better than others
67
Immunologic factors for infection with endocarditis
- Immunosuppression, antibody levels, and other issues of host competency are important
68
What are typical scenarios for endocarditis risk factors?
1. Subaortic stenosis*** 2. GI or urinary tract infections 3. Infected surgical implants 4. Oncology patients 5. Migrating foreign body 6. Any cause of sepsis
69
What is usually recommended for at risk patients to reduce the risk for endocarditis?
- Prophylactic antibiotics - 10 days for 2 weeks post - For SAS patients, they will run them on antibiotics prior to the surgical procedures
70
Relationship between dental disease and endocarditis in dogs
- NO proven relationship to dental disease in the dog - Incidence of dental disease >90% - Incidence of mitral valve endocardiosis in dogs is ~40% - Incidence of endocarditis is ~1%
71
PE findings for endocarditis
- Fever (may be intermittent) - New heart murmur or different murmur - +/- tachycardia, bounding pulses (if aortic regurgitation), arrhythmia (myocarditis or systemic inflammation), signs of CHF, Tachypnea (CHF, pneumonia) - Evidence of systemic illness!***
72
CBC findings for endocarditis
- MAY include anemia, inflammatory leukogram
73
Serum biochemistry findings for endocarditis
- Azotemia, elevated serum globulins
74
Blood cultures for endocarditis
- Definitive diagnosis but often negative
75
Serology for endocarditis somewhat common findings
- Bartonella
76
Urinalysis for endocarditis
- Examine for pyuria
77
Urine culture and endocarditis
- Another way to do a blood culture | - Many infections originate or can simultaneously be present in the urinary system
78
Echocardiography and endocarditis
- Early lesions may not be detectable - Valve lesions are thick, irregular hyperechoic masses - Lesions (masses of fibrin, thrombi, and bacteria) may oscillate (vegetations)
79
Treatment for valvular endocarditis
- Antibiotics (ideally based on blood culture results and urine culture) - IV abx for 3-5 days to penetrate fibrin - Oral or injectable antibiotics for 4-6 weeks (in SA or horses)
80
Prognosis for valvular endocarditis
- Overall guarded to poor - Permanent valvular lesions and dysfunction persist - Majority of animals succumb to heart failure or secondary embolic complications - Mitral valve endocarditis better prognosis than aortic endocarditis

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