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Flashcards in CVD - Valvular pathology Deck (44)

(3) Etiology of aortic stenosis

- Congenital (bicuspid, unicuspid valve)
- calcification (wear and tear)
- rheumatic disease


Definition of aortic stenosis for:
- normal
- mild
- moderate
- severe
- critical

Normal aortic valve area = 3-4 cm2
Mild AS 1.5-3 cm2
Moderate AS 1.0 to 1.5 cm2
Severe AS less than 1.0 cm2
Critical AS less than 0.5 cm2


Pathophysiology of aortic stenosis

Outflow obstruction -> increased EDP -> concentric LVH -> LV failure -> CHF,
subendocardial ischemia


Symptoms of aortic stenosis


- syncope
- angina on exertion
- dyspnoea on exertion

PND, orthopnea, peripheral edema


O/E of aortic stenosis

- Narrow pulse pressure,
- brachial-radial delay,
- pulsus parvus et tardus,
- sustained PMI

Auscultation: crescendo-decrescendo SEM radiating to R clavicle and carotid, musical
quality at apex (Gallavardin phenomenon)

S4, soft S2 with paradoxical splitting, S3 (late)


Ix of aortic stenosis

ECG: LVH and strain, LBBB, LAE, AFib

CXR: post-stenotic aortic root dilatation, calcified valve, LVH, LAE, CHF

Echo: reduced valve area, pressure gradient, LVH, reduced LV function


Mx of aortic stenosis

- Asymptomatic: serial echos, avoid exertion
- Symptomatic: avoid nitrates/arterial dilators and ACEI in severe AS
- Surgery if: symptomatic or LV dysfunction.

Valve replacement for aortic rheumatic valve disease & trileaflet valve.

Percutaneous (transfemoral etc) valve replacement an option for those who are not good candidates for surgery


Etiology of aortic regurgitation
- supravalvular
- valular
- acute onset

- Supravalvular: aortic root disease (Marfan’s, atherosclerosis and dissecting aneurysm, connective tissue disease)

- Valvular: congenital (bicuspid aortic valve, large VSD), IE

- Acute Onset: IE, aortic dissection, trauma, failed prosthetic valve


Pathophysiology of aortic regurgitation

Volume overload -> LV dilatation -> increased SV, high sBP and low dBP -> increased
wall tension -> pressure overload -> LVH (low dBP -> decreased coronary perfusion)


Symptoms of aortic regurgitation

Usually only becomes symptomatic late in disease when LV failure develops

Dyspnea, orthopnea, PND, syncope, angina


O/E of aortic regurgitation
- pulse characterisation
- apex beat
- on auscultation
- heart sounds

Waterhammer pulse, bisferiens pulse, femoral-brachial sBP >20 (Hill’s test wide pulse
pressure), hyperdynamic apex, displaced PMI, heaving apex

Auscultation: early decrescendo diastolic murmur at LLSB (cusp pathology) or RLSB
(aortic root pathology), best heard sitting, leaning forward, on full expiration

soft S1, absent S2, S3 (late)


Ix of aortic regurgitation


CXR: LVH, LAE, aortic root dilatation

Echo/TTE: quantify AR, leaflet or aortic root anomalies

Cath: if >40 yr and surgical candidate – to assess for ischemic heart disease

Exercise testing: hypotension with exercise


Mx of aortic regurgitation

- Asymptomatic: serial echos, afterload reduction (e.g. ACEI, nifedipine, hydralazine)

- Symptomatic: avoid exertion, treat CHF

- Surgery if: NYHA class III-IV CHF; LV dilatation and/or LVEF


Etiology of mitral stenosis

Rheumatic disease most common cause

congenital (rare)


Definition of mitral stenosis

Severe MS is mitral valve area (MVA) less than 1.2 cm2


Pathophysiology of mitral stenosis

MS -> fixed CO and LAE -> increased LA pressure -> pulmonary vascular resistance
and CHF; worse with AFib (no atrial kick), tachycardia (decreased atrial emptying time)
and pregnancy (increased preload)


Symptoms of mitral stenosis

SOB on exertion, orthopnea, fatigue, palpitations, peripheral edema, MALAR FLUSH,
pinched and blue facies (severe MS)


O/E of mitral stenosis
- arrhythmia involved
- auscultation
- heart sounds
- any added sound

AFib, no “a” wave on JVP, left parasternal lift, palpable diastolic thrill at apex

Auscultation: mid-diastolic rumble at apex, best heard with bell in left lateral decubitus
position following exertion

Loud S1, OPENING SNAP following loud P2 (heard best during expiration),
long diastolic murmur and short A2-OS (opening snap) interval correlate with worse MS

Note: Mitral stenosis has an opening snap before diastolic murmur. C.f. Mitral valve prolapse has a CLICK before its systolic murmur.


Ix of mitral stenosis

ECG: NSR/AFib, LAE (P mitrale), RVH, RAD

CXR: LAE, CHF, mitral valve calcification

Echo/TTE: shows restricted opening of mitral valve

Cath: indicated in concurrent CAD if >40 yr (male) or >50 yr (female)


Mx of mitral stenosis

Avoid exertion, fever (increased LA pressure), treat AFib and CHF, increase diastolic filling time (β-blockers, digitalis)

Surgery if: NYHA class III-IV CHF and failure of medical therapy


(many) Etiology of mitral regurgitation

Mitral valve prolapse, congenital cleft leaflets, LV dilatation/aneurysm (CHF, DCM,
myocarditis), IE abscess, Marfan’s
syndrome, HOCM, acute MI, myxoma, mitral valve annulus
calcification, chordae/papillary muscle trauma/ischemia/rupture (acute), rheumatic


Pathophysiology of mitral regurgitation

Reduced CO -> increased LV and LA pressure -> LV and LA dilatation -> CHF and pulmonary HTN


Symptoms of mitral regurgitation

Dyspnea, PND, orthopnea, palpitations, peripheral edema


O/E of mitral regurgitation
- apex beat
- auscultation

Displaced hyperdynamic apex, left parasternal lift, apical thrill

Auscultation: holosystolic murmur at apex, radiating to axilla ± mid-diastolic rumble,
loud S2 (if pulmonary HTN), S3


Ix of mitral regurgitation

ECG: LAE, left atrial delay (bifid P waves), ± LVH

CXR: LVH, LAE, pulmonary venous HTN

Echo: etiology and severity of MR, LV function, leaflets

Swan-Ganz Catheter: prominent LA “v” wave


Rx of mitral regurgitation

Asymptomatic: serial echos

Symptomatic: decrease preload (diuretics), decrease afterload (ACEI) for severe MR and poor surgical candidates; stabilize acute MR with vasodilators before surgery

Surgery if: acute MR with CHF, papillary muscle rupture, NYHA class III-IV CHF, AF, increasing LV size or worsening LV function, earlier surgery if valve repairable (>90% likelihood) and patient is low-risk for surgery

Most get valve repair (lower rate of IE, no anticoagulation) rather than replacement.


Etiology of tricuspid regurgitation

RV dilatation, IE (particularly due to IV drug use), rheumatic disease, congenital (Ebstein anomaly), carcinoid


Symptomsof tricuspid regurgitation

Peripheral edema, fatigue, palpitations


O/E of tricuspid regurgitation
- [...] sign
- auscultation

“cv” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, holosystolic murmur at LLSB accentuated by inspiration, left parasternal lift


Ix of tricuspid regurgitation

CXR: RAE, RV enlargement
Echo: diagnostic


Mx of tricuspid regurgitation

Preload reduction (diuretics)

Surgery if: only if OTHER surgery required (e.g. mitral valve replacement)


Pathophysiology of tricuspid regurgitation

RV dilatation -> TR -> further RV dilatation -> right heart failure


Etiology of pulmonary stenosis

Usually congenital, rheumatic disease (rare), carcinoid syndrome


Pathophysiology of pulmonary stenosis

Increased RV pressure -> RV hypertrophy -> right heart failure


Symptoms of pulmonary stenosis

Chest pain, syncope, fatigue, peripheral edema


O/E of pulmonary stenosis

Systolic murmur at 2nd left intercostal space accentuated by inspiration, pulmonary
ejection click, right-sided S4


Mx of pulmonary stenosis

Balloon valvuloplasty if severe symptoms


Ix of pulmonary stenosis

CXR: prominent pulmonary arteries enlarged RV
Echo: diagnostic


(many) Etiology of mitral valve prolapse

Myxomatous degeneration of
chordae, thick, bulky leaflets that crowd orifice, associated with Marfan’s syndrome, pectus excavatum, straight back syndrome, other MSK abnormalities; less than 3% of population


Pathophysiology of mitral valve prolapse

Mitral valve displaced into LA during systole; no causal mechanisms found for


Symptoms of mitral valve prolapse

Prolonged, stabbing chest pain, dyspnea, anxiety/panic, palpitations, fatigue, presyncope


O/E of mitral valve prolapse

Ausculation: mid-systolic CLICK (due to billowing of mitral leaflet into LA; tensing of redundant valve tissue); mid to late systolic murmur at apex, accentuated by Valsalva or squat-to-stand maneuvers

Note: midsystolic CLICK in mitral valve prolapse (c.f. opening snap in mitral stenosis before diastolic murmur)


Ix of mitral valve prolapse

ECG: non-specific ST-T wave changes, paroxysmal SVT, ventricular ectopy

Echo: systolic displacement of thickened mitral valve leaflets into LA


Mx of mitral valve prolapse

Asymptomatic: no treatment; reassurance

Symptomatic: β-blockers and avoidance of stimulants (caffeine) for significant palpitations, anticoagulation if AFib

Mitral valve surgery (repair favoured over replacement) if symptomatic and significant

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