Lectures 13-15: Valvular Heart Disesae Flashcards Preview

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Flashcards in Lectures 13-15: Valvular Heart Disesae Deck (80):
1

Acute rheumatic fever is a consequence of...When are symptoms? Primary organs?

Immune-mediated consequence of group A beta-hemolytic streptococcal pharyngitis; 2-3 weeks after pharyngitis; heart, skin and connective tissue

2

Where is acute rheumatic fever prevalent?

Highly prevalent in developing countries

3

What is the mechanism of acute rheumatic fever (protein)?

Autoimmune cross-reactivity b/t bacterial antigens and normal tissue (M protein)

4

Signs/symptoms of acute rheumatic fever (3)

Migratory polyarthralgias, Syndenham's chorea, erythema marginatum

5

Acute rheumatic fever: heart (2 main points)

Pancarditis (can effect any layer) and mitral regurgitation from valvulitis

6

Acute rheumatic fever: pathology

Aschoff Body: granulomatous lesions w/ a fibroid center and perimeter of immune cells (acutely, eventually develops into fibrosis)

7

JONES

J = joints, O = heart (myocarditis), N = subcutaneous nodules, E = erythema marginatum, S = Sydenham chorea

8

To get diagnosis of acute rheumatic fever, you must have...

Evidence of strep and later manifestations

9

Treat acute episode with...

Antibiotics (penicillin) + anti-inflammatory therapy (aspirin)

10

Secondary prevention...(tx)

IV penicillin every 4 weeks for at least 5 years

11

What is the LT heart consequence of rheumatic fever?

Mitral stenosis = decades later, permanent deformity/impairment of valves

12

What does a stenotic mitral valve do to the left atrium?

Enlarge due to pressure/volume overload

13

Describe the hemodynamic profile of mitral stenosis

Left atrial pressure elevated and there is a pressure gradient b/t left atrium and left ventricle during diastole

14

Consequences of enlarged L atrium (4)

Pulmonary venous congestion --> heart failure; atrial fibrillation --> palpitations; atrial fibrillation --> cerebrovascular accident; impinged recurrent laryngeal --> Hoarseness (Ortner syndrome)

15

Mitral stenosis: exam findings (2)

Diastolic murmur and opening snap (OS)

16

Internval between S2 and OS relates _______ to severity of MS

Inversely

17

Mitral stenosis: ECG findings (2)

P Mitrale: extended, bihumped P wave in Lead II; Atrial fibrillation

18

Mitral stenosis: medical treatment (2)

1. Anticoagulation (even if absence of a fib); 2. Rate control (beta-blockers or the like to increase time for ventricle filling)

19

Does medical therapy of mitral stenosis slow progression?

No, but helps with symptoms

20

When would a patient qualify for percutaneous balloon mitral valvuloplasty (PMBV)? What is the second option to PMBV?

Symptomatic patients or those with a fib/pulmonary hypertension; mitral valve replacement

21

SO: PMBV for ________ patients

Symptomatic

22

T/F: People with normal valves are at risk for infective endocarditis

False: normal valves are resistant

23

Risk factors for infective endocarditis (3)

1. Turbulent blood flow across abnormal, diseased valve; 2. Lesions provoked by electrodes/catheters; 3. Repeated IV injections of solid particles in IV drug users

24

Pathology of infective endocarditis

Vegetation: platelets, fibrin, microorganisms

25

Most common micro-organism to cause infective endocarditis. Second most common? How do you differentiate?

Staph; strep; staph = catalase positive; staph aureus = coagulase positive

26

Catalase positive, coagulase positive?

Staph aureus

27

Catalase positive, coagulase negative?

Another staph, likely staph epidermidis

28

IV drug use, most common micro-organism

Staph aureus

29

Prosthetic valve endocarditis, most common micro-organism

Staph epidermidis

30

Underlying colon malignancy, most common micro-organism

Strep bovis

31

Subacute bacterial endocarditis following dental work, most common micro-organism

Viridan sreptococci

32

Culture negative, most common micro-organisms (mnemonic = 5 + one)

HACEK (Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella); Coxiella (Q fever)

33

Duke criteria is used to diagnose

Endocarditis

34

Clinical manifestations of endocarditis: 2 sets of phenomenom

Vascular/embolic phenomenon: pieces of vegetation break off and travel; Immunologic phenomenon: deposition of circulating immune complexes

35

Is infective endocarditis associated with heart murmurs?

Yes: you can get a new or worsened heart murmur

36

What is a splinter hemorrhage? What phenomenon is it related to?

Black hemorrhage under nail --> skin finding of infective endocarditis; embolic phenomenon

37

Eye finding of infective endocarditis. What phenomenon is it related to?

Roth Spot; embolic phenomenon

38

Oslar nodes: What phenomenon is it related to?

Immunologic phenomenon

39

Role of ECHO in endocarditis

Diagnostic: to find vegetation

40

Infective endocarditis: treatment

Extended course of antibiotics (4+ weeks), consider methicillin-resistant if staph is suspected (vancomycin)

41

If someone is not getting better, you do ________ for their endocarditis. Why else? (2)

Surgery; immune involvement, very large vegetation

42

Etiology of aortic stenosis (three most common causes in order of prevalence)

1. Calcification of normal valve (7th, 8th decade); 2. Calcification of bicuspid valve (6th decade); 3. Rheumatic disease

43

Pathogenesis of aortic stenosis

Risk factors (bicuspid valve, smoking, dyslipidemia) --> aortic sclerosis (inflammation) --> aortic stenosis (calcification)

44

Bicuspid arotic valve (%, 2 most common sequalaes and 2 associations )

Common --> 1 - 2 % of people; aortic stenosis is most common sequalae followed by aortic regurgitation; associated w/ other abnormalities: coarctation of aorta and thoracic aortic aneurysm

45

What kills patients with BAV?

Thoracic aortic aneurysm

46

Pathophysiology of aortic stenosis

Gradient b/t LV and aorta during systole --> murmur

47

Three symptoms of aortic stenosis and impact on median survival

1. Angina (5 years); 2. Syncope (3 years); 3. HF (2 years)

48

Why does HF occur in aortic stenosis?

Contractile dysfunction develops because of insurmountably high afterload

49

What is the murmur in aortic stenosis?

Coarse crescendo-decrescendo (diamond shaped) late-peaking systolic murmur

50

Describe pulses in aortic stenosis

Weakened (parvus) and delayed (tardus) upstroke of the carotid artery

51

A valve area of less than...is what?

1.0 cm2 = severe aortic stenosis

52

Treatment for aortic stenosis..

No proven medical therapy

53

What is the preferred treatment for symptomatic severe aortic stenosis?

Surgical aortic valve replacement

54

Indication for aortic valve replacement

SYMPTOMS

55

Define aortic regurgitation

Incomplete closure of the aortic valve in diastole resulting in retrograde flow from the aorta back into the LV (in diastole)

56

Mechanisms of aortic regurgitation (6, 2 categories)

Abnormalities of valve leaflets: Bicuspid valve, infective endocarditis, rhematic heart disease; Dilation of aortic root: age/hypertension-related, aortic aneurysm (CT disease), aortic dissection

57

Describe problem found in Marfan syndrome

Medial necrosis of aorta --> dilation of proximal ascending aorta --> aortic dissection AND mitral valve prolapse from dilation of mitral valve

58

What gene is defective in Marfan?

Fibrillin

59

Hemodynamic profile of aortic regurgiation

Aortic pressure falls rapidly during diastole with a wide pulse pressure (difference b/t systolic and diastolic blood pressure)

60

Heart sound in aortic regurgitation

Blowing murmur in early diastole: low-frequency, mid-diastolic rumble, decrescendo

61

Findings in chronic aortic regurgitation vs acute aortic regurgitation

Chronic: enlarged LV that has decreased pressure to LA; Acute: sudden shock of elevated pressure to LA --> pulmonary congestion

62

Symptoms (3) and signs (3) of aortic regurgitation

Symptoms: exertional dyspnea, fatigue, uncomfortable sensation of forceful heart beat; Signs: widened pulse pressure, blowing murmur, Austin-Flint murmur

63

Austin-Flint Murmur: describe and what does this cause?

Downward displacement (closure) of the anterior leaflet of the mitral valve during diastole by the regurgitant stream of aortic regurgitation; functional cause of mitral stenosis

64

Physical findings in aortic regurgitation (3, but don't memorize this stuff)

1. Bisferiens pulse (double systolic impulse in carotid or brachial artery); 2. Quincke sign (capillary pulsations visible at proximal nail bed); 3. Bounding carotides

65

Dicrotic notch is normal/abnormal. What is it?

Normal; rebound effect from arterial elasticity after systolic filling

66

Who gets aortic regurgitation treatment? What is the treatment?

Medical therapy does not slow progression, but symptomatic patients may benefit from valve replacement

67

Mitral regurgiation has two large categories. What are these?

Primary cause: structural defect of valve component; Secondary cause: valve is structurally normal but regurgitation results from LV enlargement

68

Mitral regurgitation and acuity

If it's acute, you have dilated high pressure LA --> pulmonary edema; chronically, LA is accommodating and it has dilated

69

Hemodynamic profile of mitral regurgitation

Tall v wave (atrial filling) due to back-flow from ventricle

70

What is the most common cause of mitral regurgiation

Myxomatous degeneration: extra mitral valve tissue

71

What are the typical symptoms of mitral regurgitation? Why?

Dyspnea, orthopnea, PND = pulmonary edema

72

Murmur of mitral regugitation

Apical holosystolic murmur that often radiates to axilla

73

What does holosystolic mean?

All of systole = starts at S1 and extends to S2

74

Define mitral valve prolapse. What is it frequently accompanied by?

Abnormal billowing of a portion of one or both mitral leaflets into the left atrium during ventricular systole; mitral regurgitation

75

Does mitral valve prolapse always affect patients?

Nope: often regurge is minimal and it doesn't cause symptoms

76

Causes of mitral valve prolapse?

Familian, or accompanyting CT diseases (Marfan)

77

What is the classic exam finding of mitral valve prolapse?

Midsystolic click (tensing chordae tendinae as leaflet billows into LA)

78

Mitral regurgitation treatment (acute, chronic primary, chronic secondary)

Acute MR: surgery; Chronic primary MR: surgery for symptomatic patients = mitral valve repair (not replacement); Chronic secondary MR: medical therapy

79

What is the medical therapy for acute MR?

Afterload reduction

80

Two types of valves and key points

Mechanical: requires LT consistent anticoagulation; Bioprosthetic: less durable --> 50% failure in 15 years

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