CHAPTER 54 VALVULAR EMERGENCIES

Question 1

T/F: Any diastolic murmur or new systolic murmur with symptoms at rest is pathologic and warrants emergent echocardiography

Answer 1

TRUE

Question 2

GRADING for murmur

Answer 2

fa1nt
2uiet, but heard immediately with steth on chest wall
3oderately loud
L4WD (Loud)
5ff the steth partly
6ff the steth entirely

Question 3

Mid-diastolic rumble, crescendos into S2

Loud OPENING SNAP S1 , small apical impulse, tapping due to underfilled ventricle

Answer 3

MITRAL STENOSIS

Question 4

Harsh apical systolic murmur starts with S 1 and may end before S2

Answer 4

ACUTE MITRAL REGURGITATION

Question 5

High-pitched apical holosystolic murmur radiating into S2

Answer 5

CHRONIC MITRAL REGURGITATION

Question 6

Mid-systolic CLICK may be followed by a late systolic murmur that crescendos into S2

Answer 6

MITRAL VALVE PROLAPSE

Question 7

Harsh systolic ejection murmur

Answer 7

AORTIC STENOSIS

Question 8

High-pitched blowing diastolic murmur immediately after S2
Wide pulse pressure

Answer 8

AORTIC REGURGITATION

Question 9

You have discovered a NEW systolic cardiac murmur, mid-systolic, grade 2, asymptomatic (no signs of cardiovascular disease, normal ECG and CXR, murmur does not increase in intensity with Valsalva or standing).

What is your next step?

Answer 9

No further workup!

Question 10

You have discovered a NEW systolic cardiac murmur, mid-systolic, grade 3 (or Early or late systolic diastolic murmur, holosystolic) symptomatic (with signs of cardiovascular disease, abnormal ECG and CXR, murmur increases in intensity with Valsalva or standing).

What is your next step?

Answer 10

Echocardiography

Question 11

MCC of Mitral Stenosis

Answer 11

Rheumatic heart disease

Question 12

Typical early radiographic finding of MS

Answer 12

straightening of the left heart border = left atrial enlargement

Question 13

Indication of anticoagulation for MS

Answer 13

left atrial diameter is >55 mm
atrial fibrillation,
left atrial thrombus,
history of systemic emboli

Question 14

Primary treatment for symptomatic MS

Answer 14

percutaneous mitral commissurotomy,

Question 15

MCC of Mitral regurgitation

Answer 15

Fibroelastic deficiency syndrome
MVP (younger pxs)

Question 16

Typical cause of Acute Mitral Regurgitation

Answer 16

papillary muscle or chordae tendineae rupture from myocardial infarction or valve leaflet perforation from infective endocarditis

Question 17

Seen in any patient with new-onset and marked PULMONARY EDEMA, especially in patients with near-normal heart size on chest radiograph or in those who do not respond to conventional therapy

Answer 17

Acute mitral regurgitation

Question 18

Systolic billowing of one or both leaflets into the left atrium occurring with or without mitral regurgitation.

Answer 18

MVP

Question 19

Maneuvers that decrease preload in MVP

Answer 19

Valsalva or standing
–> cause the click to occur earlier in diastole

Question 20

Maneuvers that increase preload in MVP

Answer 20

squatting

Question 21

Maneuvers that increase afterload in MVP

Answer 21

hand grips

Question 22

Classic triad of aortic stenosis

Answer 22

dyspnea
chest pain
syncope

Question 23

Severe stenosis: aortic valve area

Answer 23

<1.0 cm2

-asymptomatic

Question 24

Classic physical examination findings for AS

Answer 24

1. late peaking systolic murmur at the right second intercostal space radiating to the carotid
2. single or paradoxically split S2, an S4
   gallop
3. diminished carotid pulse with a delayed upstroke = pulsus parvus et tardus

Question 25

In the left lateral decubitus position, listen for a mid-diastolic rumble using the bell of the stethoscope at the cardiac apex

Answer 25

Austin Flint murmur

Question 26

“water hammer pulse”

Answer 26

Peripheral pulse with a quick rise in upstroke due to increased stroke volume followed by collapse from a rapid fall in diastolic pressure

Question 27

“to-and-fro” femoral murmur

Answer 27

Duroziez sign

Question 28

pulsatile head bobbing

Answer 28

de Musset sign

Question 29

capillary pulsations visible at the proximal nail bed while pressure is applied at the tip

Answer 29

Quincke sign

Question 30

What is avoided in acute aortic regurgitation because they block the compensatory tachycardia that is critical in maintaining cardiac output?

Answer 30

Beta-blockers

Question 31

The least likely valve to be affected by acquired disease

Answer 31

PULMONIC valve

Question 32

Rare and is generally accompanied by regurgitation

Answer 32

Tricuspid stenosis

Question 33

Murmur of tricuspid valve regurgitation

Answer 33

soft, blowing, and holosystolic

best heard along the lower left sternal border and increases with inspiration

Question 34

Associated with a rumbling crescendo decrescendo diastolic murmur occurring just before S1

best heard along the lower left sternal border, increases with inspiration, and is often preceded by an opening snap

Answer 34

Tricuspid valve stenosis

Question 36

Harsh systolic murmur, best heard in the left second intercostal space, which increases with inspiration.

Answer 36

Pulmonic stenosis

Question 37

Most sensitive modality for right-sided valvular heart disease

Answer 37

transesophageal echocardiography

Question 38

More durable with lower failure rates, but have a higher risk for thromboembolic complications –> Lifelong anticoagulation is necessary to reduce the thromboembolic risk

Answer 38

Mechanical valves

• require an INR of 2.5 to 3.5
• bileaflet mechanical valves in the aortic position require an INR of 2.0 to 3.0

Question 39

T/F: Emboli are more common from mitral rather than from aortic valves

Answer 39

T

Question 40

Less thrombogenic but are more likely to fail and require repeat surgery. Antiplatelet therapy is recommended for all patients with prosthetic valves

Answer 40

Bioprosthetic valves (porcine, bovine, or human sources)

Question 41

T/F: Acute onset of respiratory distress, pulmonary edema, and cardiogenic shock may be associated with mechanical valve failure, tearing of a bioprosthesis, or a large clot obstructing the valve or preventing closure

Answer 41

T

Question 42

T/F: Patients with severe bleeding complications are best treated with fresh frozen plasma or prothrombin complex concentrate. 3 Avoid parenteral, high-dose vitamin K due to risk of overcorrection

Answer 42

T