Lec 12 Valvular Heart Disease II Flashcards Preview

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Flashcards in Lec 12 Valvular Heart Disease II Deck (59):

What usually causes aortic stenosis?

usually age related degenerative calcific changes = senile changes due to "wear and tear"


What is area of arotic valve normally? when symptoms of aortic stenosis?

normal: 3-4 cm2
symptoms = when valve area 1/4th normal < 1cm2


What are the 2 types of aortic stenosis and which most common?

- supravalvular
- valvular = most common!!
- subvalvular


What are congenital causes of aortic stenosis? Who gets it?

- congenital aortic stenosis or congenital bicuspid valve

-- if pt < 70 yo more likely to have congenital cause


What are acquired causes of aortic stenosis?

- degenerative calcification = most common "wear and tear"
- rheumatic heart disease [have mitral also]
- rare causes like SLE, postradiation, etc


What is pathophysiology of aortic stenosis?

- blood can't flow from LV to aorta during systole
- high LV pressure = increased afterload
- compensatory LV concentric hypertrophy
- over time LV function declines


What are 3 classical symptoms of severe atrial stenosis? [mnemominc]


- syncope [exertional]
- Angina
- Dyspnea on exertion [sign of CHF]


What are physical exam findings of atrial stenosis? heart sounds?

- systolic ejection murmur = crescendo-decrescendo sound; peaks later with more severe stenosis

- weakened [parvus] and delayed [tardus] upstroke of carotid artery pulsations = slow rising pulse and smaller pulse amplitude

- soft and split 2nd heart sound, S4 gallop due to LVH


How is timing of systolic ejection murmur peak associated with severity of atrial stenosis

later peak = more severe stenosis


What is natural history of aortic stenosis?

may have 20+ years of asymptomatic stage then onset of symptoms with HF/syncope/angina leading to death in severe AS


What tests useful in aortic stenosis?

echo: tells you LV wall thickness, most valuable test

cardiac catheterization: confirm severity AS


What valve area measurements for mild, moderate, severe aortic stenosis in cm2?

mild > 1.5
moderate: 1-1.5
severe < 1


What is treatment for aortic stenosis?

- infective endocarditis prophylaxis in dental procedures
- mechanical problem so limited medical treatment
- vasodilators contraindicated in severe AS
- surgical replacement = definitive treatment


What are indications for surgery in aortic stenosis?

- any symptomatic pt with severe AS
- any pts with decreasing EF
- any pts undergoing CABG with moderate or severe AS


What is aortic regurgitation?

leaking of blood into left ventricle during diastole
- due to ineffective aortic valve


What is the pathophysiology of aoritc regurgitation? compensatory mech?

- blood regurgitates back into LV during diastole = pressure and volume overload in LV
- compensatory mech over time: LV dilation and LVH


What is etiology of acute aortic regurgitation?

- aortic dissection --> aortic root dilation
- endocarditis


What is etiology of chronic aortic regurgitation

abnormalities of valve leaflets
- bicuspid aortic valve
- rheumatic fever
- infective endocarditis


What happens in acute AR?

- LV normal size and noncompliant
- volume load of regurgitation --> high LV diastolic pressure --> transmitted to LA/pulmonary --> pulmonary edema + dyspnea

can be a surgical emergency requiring immediate valve replacement


What happens in chronic AR?

- compensatory adaptations
- LV dilates and to lesser degree increases thickness, eccentric hypertrophy
- less of an increase in diastolic pressure in LV _ high stroke volume = bigger systolic P and smaller diastolic P
- bigger pulse pressure [difference betwen arterial systolic and diastolic Ps]


What is treatment for acute AR?

- can be true surgical emergency
- give positive inotrope [dopamine, dobutamine] or vasodilator [nitroprusside]
- avoid beta blockers


What are progressive symptoms of aortic regurgitation?

- dyspnea: exertional, orthopnea, PND
- nocturnal angina
- palpitation due to increase force of contraction


What are physical findings of aortic regurgitation?

- wide pulse pressure
- on auscultation: diastolic blowing murmur on left sternal border; systolic ejection murmur due to increase flow across aortic valve; austin flint murmur at apex in very severe


What is austin flint murmur?

mid-diastolic rumbling murmur at apex during mid-diastole

reflects turbulence of blood flow through mitral valve during diastole due to downward displacement of mitral anterior leaflet by regurgitant stream of blood from aortic regurgitation


What do you see on CXR/echo/aortography in aortic regurg?

CXR: chronic= enlarged cardiac silhouette, aortic root enlargement

Echo: measure degree of AR and identify cause

Aortography: confirm severity of disease


What is treatment of aortic regurg?

- infective endocarditis prophylaxis in dental procedures
- medica: vaosdilators [ACEIs] improve stroke volume and decrease regurg if pt symptomatic or has HTN
- surgical = definitive treatment if any symptoms or EF below 50%


What is classic clinical scenario of degenerative [rather than congenital] atrial stenosis?

pt presents later on >60/70 and has concurrent coronary artery disease


What happens to LV in aortic stenosis?

pressure overload [try to eject and has both aortic stenosis and system vascular resistance to overcome


What are compensatory mech in aortic stenosis?

- hypertrophy of LV to decrease wall stress


What happens to LV in mitral regurgitation?

volume overload [some blood from LV goes back to LA so then get even more preload in LA that goes to LV in the next contraction]


What happens to LV in mitral stenosis?

volume underload [not as much blood can get from LA to LV]


What happens to LV and aortic pressures in aortic stenosis?

gradient after aortic valve opens = LV has higher pressure than aorta and can't equilibrate

gradient develops when aortic valve opens and increases in early systole to reach peak then goes down


What heart sounds in aortic stenosis?

- 1st hear sound
- then may have ejection sound [ES]
- diamond shaped [crescendo-decrescendo] ejection murmur [systole]
- may have quiet/absent S2 or paradoxical splitting S2
- then may have S4


How do you determine severity of aortic stenosis?

late peaking of systolic murmur = more severe aortic stenosis = LV needs to work harder to force blood through valve

absent S2 tends to occur in late peaking


What is paradoxical splitting?


occurs in aortic stenosis [or left BBB]
- normally S2 = A2 then P2 and splitting increases with inspiration because P2 later

in paradoxical splitting: A2 delayed; P2 before A2 and splitting decreases with inspiration because P2 closer to A2


What is different HCM vs AS sounds?

HCM = murmur starts right at S1 = holosytolic
AS = maay have splitting of first sound = loud ejection sound [ES] then crescendo-decrescendo murmur starts after


When can you hear S4?

when left ventricular hypertrophy --> systemic hypertension, aortic stenosis, hypertrophic cardiomyopathy


Which of these 3 spares isovolumic contraction?

- aortic stenosis
- hypertrophic obstructive cardiomyopathy
- mitral valve regurgitation

aortic stenosis!


What is valve area, mean gradient, and jet velocity in severe aortic stenosis?

valve area: < 1.0 cm2
mean gradient: >40 mmHg
jet velocity: > 4 m/sec


Why should you avoid vasodilator in aortic stenosis?

drop BP may get syncope


What is normal LV pressure?



What is normal LA pressure?



What happens to LV in aortic regurgitation?

volume AND pressure overload


What compensatory mech if volume overload LV? type of hypertrophy?

= eccentric hypertrophy


What compensatory mech if pressure overload LV? type of hypertrophy?

= concentric hypertrophy


Which valvular disease causes biggest left ventricles?

aortic regurgitation!!


What is etiology of acute aortic regurgitation?

aortic dissection


What treatment of acute aortic regurgitation?

true surgical emergency!!
- give positive inotrope = dopamine, dobutamine
- give vasodilator = nitroprusside
- avoid beta blockers


Should you give balloon pump in acute aortic regurg?

NO!!! Don't do it!!


What is etiology of chronic aortic regurgitation?

- bicuspid aortic valve
- rheumatic heart disease
- infective endocarditis


What do you see in carotid pulse of aortic regurgitation?

dancing carotids = low diastolic pressure = aamplification of dicrotic notch at time of aortic vavle closure and second pul


Which murmurs increase with inspiration? expiration?

murmurs of right heart increase with inspiration
murmurs of left hear increase with expiration


What are symptoms of acute regurgitation?

asymptomatic until 40s or 50s
progressive symptoms: dyspnea [+ signs of LH failure], nocturnal angina, palpitations [due to forced contraction]


What are physical findings of aortic regurgitation?

wide pulse pressure
hyperdynamic + displaced apical impulse


What do you hear on auscultation in aortic regurgitation?

- diastolic decrescendo blowing murmur at left sternal border [main murmur]
- austin flint murmur at apex
- systolic ejection murmur = due


What is austin flint murmur?

- sounds like mitral stenosis = blood flowing back = fluttering of mitral valve
- low pitched apical mid-diastolic rumble
- occurs in aortic regurgitation


What is corrigan pulse?

- sign of aortic regurgitation
- high amplitude, abruptly collapsing pulse


What is quincke pulse?

exaggerated reddening and blanching of nail beds
sign of aortic regurgitation


What should you think it pt comes in VDRL positive with heart problems?

they have syphilis = historically classic cause of aortic root dilation/regurgitation

need aortic valve replacement