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Most common cause of valvular disease

Aortic stenosis


Causes of aortic stenosis

Bicuspid valve in the young
Rheumatic (often with mitral disease)
Rare (irradiation, collagen disease)


Symptoms of aortic stenosis

"Congestive failure" bc L ventricular obstruction; dyspnea 50%
Angina 30%
Syncope with exercise intolerance
Death rarely presenting symptom except in kids

Most people are asymptomatic, but once they develop, half die in 2-5yrs


Physical exam findings of aortic stenosis

Palpable S4 with heave
Thrill over aortic region
Midsystolic ejection murmur that radiates up neck and along L sternal border


Management of asymptomatic aortic stenosis

Get baseline echo
No competitive athletics
Avoid vasodilators (decrease after load and CO)
F/u with echo every 2 or 5 years depending on severity


Management of symptomatic aortic stenosis

Once symptoms arise, it is lethal so if they are good surgical risk, valve replacement
Substantial hemodynamic and clinical improvement after procedure


Second most common valvular disease

Mitral stenosis


Causes of mitral stenosis

Rheumatic fever--almost all mitral stenosis is a complication after. Usually seen in pts 40-50 y.o.

Rare--congenital or non bacterial thrombotic endocarditis


Symptoms of mitral stenosis

Symptoms tend to be subtle and slow:
Exercise intolerance
Congestive failure-edema, orthopnea, DOE, PND
Hoarseness-recurrent laryngeal nerve
A fib in elderly
Palpitations as progresses


Physical exam findings of mitral stenosis (moderately severe disease)

Sinus rhythm.
Low frequency, mid diastolic rumble heard best at the apex in the L lateral decubitus position
Opening snap after P2
S1 increased and palpable at LSB


Physical exam findings of severe mitral stenosis

A fib
Same murmur, no opening snap
R ventricular heave over apex bc fluid backed up in L atria
Maller flush


Complications of mitral stenosis

Early stage murmurs are often missed, if suspicious have patient do sit up or valsalva maneuver
As progresses, have L atrial enlargement which can lead to thrombi, especially with a fib
HR is critical to evaluating. As HR increases, there is less time for diastolic filling leading to pulmonary HTN


Management of mitral stenosis

Yearly echo
Negative chronotrophs (BB or CCB)
Tx a fib as needed
Low level aerobics to maintain cardio health

Surgical: balloon valvulopasty (early) or replacement (severe)


Timing of intervention of pts with mitral stenosis

Definite: clear sxs of heart failure not related to a fib or severe exercise intolerance
Possibly: moderate-severe pulmonary HTN
Non indicated: no symptoms


Causes of mitral prolapse

Congenital, autosomal dominant inheritance, connective tissue disorders (Marfans, Duchenne MD, Graves)


Symptoms of mitral valve prolapse

Most of the time none

Palpitations most common
Chest pains
exercise intolerance
Cerebral emboli and sudden death very rare


Physical exam findings of mitral valve prolapse

Murmur: usually late systolic, preceded by click, heard best at apex and LLSB
Opening sound of prolapsed valve returning to position during early diastole
Click and murmur highly variable May need to accentuate with squatting or valsalva
Systolic whoop or honk=Pathognomonic


Management of mitral valve prolapse

BB if have sxs consistent with increased sympathetic tone (palpitations), also increases a fib threshold
Exclude any connective tissue disorder
Reassure most are benign
Middle aged males most likely to have mechanical complications


Causes of severe chronic aortic regurgitation

bicuspid valve
Rheumatic Heart Disease (with mitral diseae)
infectious endocarditis


Causes of mild aortic regurgitation

bicuspid valve with severe HTN


Causes of acute aortic regurgitation

Chest trauma


Rare causes of aortic regurgitation

Connective tissue disorder
Collagen vascular disorder


Symptoms of aortic regurgitation

Acute: dyspnea, orthopnea
Chronic: worsening exercise intolerance
"Congestive failure"
Angina in only about 5% of patients--worse at night because HR slows
Bounding peripheral pulses


Physical Exam findings of aortic regurgitation

Pandiastolic murmur that is blowing, high pitch, heard best of LLSB
With severe disease the PMI can be displaced laterally and to the left


Management of aortic regurgitation

Asymptomatic with nl LV systolic function
Need echo a 1-2 years
Vasodilator to maintain EF
High survival rate
If progressive LV dilation or decrease EF, >25% will progress. Sxs with decreased EF and poor functionally capacity-->Need surgery!


Causes of mitral regurgitation

Primary: leaflet, annular, or chordae/papillary muscle abnormalities; or mitral valve prolapse
Secondary: LV dilation or endocardial cushion defect from IHD


Symptoms of mitral regurgitation

Frequently no symptoms
Ischemic heart symptoms
Exercise intolerance
Palpitations long before congestive failure begins
In severe mitral regurgitation, high atrial pressure causes dyspnea.
May lead to atrial hypertrophy and a fib


Physical exam findings in mitral regurgitation

Murmur: systolic, harhs and blowing, high pitched, heard best over apex, and may radiate to left axilla
Thrill may be palpable at the apex
Large and prominent PMI
Brisk pulse
LSB heave due to enlarged L atrium


Signs of severe mitral regurgitation

Intensity of murmur does not correlate to severity
Evidence of pulmonary HTN and volume overload
EKG: LV hypertrophy, a.fib or BBB


Murmur findings that differentiate causes of mitral regurgitation

papillary muscle dysfunction-->crescendo to S2
Mitral valve prolapse-->delayed, preceded by click
posterior ruptured chordae-->mimic aortic stenosis and radiate to 2nd R interspace
anterior ruptured chordae--> radiate to spine and top of head


Management of mitral regurgitation

SURGERY is the tx for ANY LV dysfunction
Regurgitant lesions can cause L ventricular damage before sxs occur
Once EF fall below 60% prognosis worsens
Can use ACEI to decrease afterload
Evaluate yearly with color doppler to quantify severity
CXR of moderate to severe show enlarged L atrium and ventricle, and pulmonary congestion
Prognosis for surgery is poor for pts with IHD


Cardiac conditions that require prophylactic antibiotics

Hx of endocarditis
Congenital defects
Prosthetic valves
Cardiac transplant recipients with cardiac valvular disease