Valve disorders

Question 1

When you hear harsh/rumbling sounds, think

Answer 1

stenosis (pressure overload)

Question 2

When you hear a blowing sound, think

Answer 2

regurgitation

Question 3

What’s unique about the MVP murmur?

Answer 3

click - delayed (which also decreasing venous return increases this murmur)

Question 4

AR MS PT: diastolic murmurs

Answer 4

aortic regurg and mitral stenosis, tricuspid stenosis, pulmonic regurg

Question 5

Where does mitral regurg radiate to?

Answer 5

axilla

Question 6

Where do aortic and pulmonic stenosis radiate to?

Answer 6

carotid

Question 7

What are some general symptoms someone with aortic stenosis may present with?

Answer 7

exertional dyspnea, fatigue, angina, syncopal episodes

Question 8

What puts someone at risk for aortic stenosis?

Answer 8

metabolic syndrome, obesity, HTN, smoking, renal failure, hyperlipidemia, males, oxidate stress, age

Question 9

What is a severe aortic valve area indicating aortic stenosis?

Answer 9

<1 (this is a trend)

Question 10

At what age does degenerative/calcific aortic stenosis occur?

Answer 10

60s-70s, RARE in <50

nodular calcification of all 3 flaps

Question 11

At what age does congenital aortic stenosis present?

Answer 11

around 50, with bicuspid or unicuspid aortic valve

Question 12

How do you know an aortic stenosis is from rheumatic fever?

Answer 12

History, 3 cusp valve, mild calcification, + fissured commissures

Question 13

What does calcium do to the aortic valve and how does this present on an EKG?

Answer 13

obstructs ventricular flow –> increased afterload –> LVH!

this can ultimately lower CO and cause hypoperfusion :(

Question 14

What does this murmur indicate:
systolic ejection murmur with a crescendo-decrescendo late peaking, low pitched, HARSH, heard over right sternal border and radiates to the carotid arteries?

Answer 14

aortic stenosis

Question 15

How can you increase an aortic stenosis murmur?

Answer 15

sit forward, increase venous return, expiration

Question 16

Are there extra heart sounds with aortic stenosis?

Answer 16

yes

Question 17

What’s the gold standard for aortic stenosis Dx (actually for all valve disorders)?

Answer 17

TTE

Question 18

What would you see on a CXR of aortic stenosis?

Answer 18

cardiomegaly, calcification, root dilation

Question 19

What is another indicator of aortic stenosis (think phys)?

Answer 19

ejection fraction

Question 20

What’s the only effective treatment for aortic stenosis?

Answer 20

aortic valve replacement

Question 21

What’s your recommendation for type of prosthesis for <60 years for aortic stenosis?

Answer 21

mechanical prosthesis MUST BE PUT ON ANTICOAGULANTS

Question 22

What’s your recommendation for type of prosthesis for >60 years for aortic stenosis?

Answer 22

porcine or bovine, last 10-15 years and avoid need for anticoagulation!

Question 23

What are some symptoms that could indicate aortic insufficiency/regurg?

Answer 23

acute - sudden, severe SOB, fast HF, CP, aortic dissection

chronic - asymptomatic until exertional fatigue, paroxysmal nocturnal dyspnea and pulmonary edema, and sudden death

Question 24

Is acute aortic insufficiency an emergency?

Answer 24

yes

Question 25

What could acute aortic regurg be caused by?

Answer 25

aortic dissection or endocarditis maybe trauma

Question 26

In who is aortic regurg more prevalent?

Answer 26

african americans, men, and older

Question 27

What else can cause aortic regurg?

Answer 27

congenital BICUSPID aortic valve, rheumatic fever, dilation of aortic root

Question 28

What does this murmur indicate: diastolic decrescendo murmur, high pitched blowing sound (loudest at left sternal border/Erb's point)?

Answer 28

aortic regurgitation

Question 29

how can you make aortic regurgitation louder?

Answer 29

leaning forward, expiration, increased venous return

Question 30

What other murmur may you hear in aortic regurg?

Answer 30

austin-flint murmur

Question 31

What else on aortic regurg PE could indicate the dx?

Answer 31

- bounding pulses - WIDE pulse pressure - Becker - visible pulsations of retinal arterioles - Corrigan - "water-hammer" pulse - Hill - popliteal s>40 brachial s - Quincke - visible pulsations on fingernail bed w/ light compression

Question 32

How do you treat aortic regurgitation?

Answer 32

aortic valve replacement, same as aortic stenosis afterload management

Question 33

What are common findings in mitral stenosis?

Answer 33

exertional dyspnea, hemoptysis, palpitations, thromboembolism, pulmonary HTN --> RHF with ascites, edema, hepatomegaly

Question 34

When is the onset of mitral stenosis?

Answer 34

30s and 40s

Question 35

What is the MCC of mitral stenosis?

Answer 35

rheumatic fever 20 years post episode

Question 36

In who is mitral stenosis most common?

Answer 36

females

Question 37

What else can mitral stenosis be caused by?

Answer 37

congenital issues, infective endocardidits, many other diseases...

Question 38

What does this murmur describe: low pitched mid-diastolic rumbling murmur after prominent/loud opening snap, at apex?

Answer 38

mitral stenosis

Question 39

How do you make mitral stenosis louder?

Answer 39

left lateral decubitus, expiration, increased venous return

Question 40

What on an EKG could indicate mitral stenosis?

Answer 40

atrial fibrillation, LAE, pulmonary HTN (RVH, RAD)

Question 41

What valve area means severe mitral stenosis?

Answer 41

<1. Yup

Question 42

What prophylaxis must be given in mitral stenosis for high risk patients?

Answer 42

endocarditis

Question 43

What prophylaxis is essential for all patients to prevent mitral stenosis?

Answer 43

benzathine penicillin

Question 44

If rhythm is normal sinus in mitral stenosis, tx =

Answer 44

diuretics, BBs, CCbs

Question 45

If rhythm is afib in mitral stenosis, tx =

Answer 45

ventricular rate control w/ BBs, CCBs, digitalis + anticoagulations

Question 46

If a patient has mitral stenosis and is unstable, tx =

Answer 46

direct current cardioversion

Question 47

If there's a fib, chances are you need

Answer 47

anticoagulation

Question 48

What's your INR target (MS)

Answer 48

2-3

Question 49

IF there are signs of pulmonary HTN, intervention is needed! Treatments for mitral stenosis =

Answer 49

1) percutaneous mitral balloon valvuloplasty 2) valve replacement surgery if 1st isn't good or high PA pressure

Question 50

In who is mitral regurg most seen?

Answer 50

women 15-30 years with familial history

Question 51

What are some symptoms of mitral regurg?

Answer 51

acute - pulmonary edema, dyspnea, CP chronic - fatigue, orthopnea, SOB, DOE

Question 52

What are two ways to get mitral regurg?

Answer 52

primary like from MVP affecting valve, or secondary such as disease like CAD acute - no LA/LV enlargement chronic - enlargement

Question 53

What's the most common form of valvular disease and isolated MR in north america?

Answer 53

MVP

Question 54

What murmur is this: mid or late systolic "click" with high pitched mid-late systolic crescendo-decrescendo "whooping" or "honking" at apex?

Answer 54

MVP

Question 55

How do you increase MVP murmur?

Answer 55

decrease venous return like standing up

Question 56

Whats this murmur: high pitched blowing apical pansystolic murmur at apex that radiates to axilla?

Answer 56

mitral regurg

Question 57

How do you increase mitral regurg murmur?

Answer 57

LLD, increased venous return

Question 58

With advanced mitral regurg, what could you see on PE?

Answer 58

RV failure with ascites, hepatomegaly, DOE

Question 59

What could you see on a mitral regurg EKG?

Answer 59

LAE, LVH, a fib (Chronic) mitral stenosis was RVH!

Question 60

If atrial fibrillation with mitral regurg, tx =

Answer 60

anticoag therapy w/ INR goal 2-3

Question 61

How do you treat mitral regurg first line?

Answer 61

treat HF, HTN, and reduce afterload with diuretics, BBs, ACE-Is, digitalis

Question 62

IF a patient has acute ischemic mitral regurg AND endocarditis, tx =

Answer 62

surgery

Question 63

If a patient has chronic nonischemic severe MR, surgery is recommended if =

Answer 63

symptomatic from CHF new onset AF pulmonary HTN EF<60% replace valve! mitral clip! TAVI

Question 64

What valve disorder is often masked by mitral stenosis symptoms such as like pulmonary congestion and fatigue with severe displaying hepatomegaly, ascites, edema, and potentially cirrhosis?

Answer 64

tricuspid stenosis

Question 65

What murmur is only seen with mitral stenosis and is rarely seen alone if at all that is from carcinoids or prosthetic failure in developed or rheumatic fever in developing countries?

Answer 65

tricuspid stenosis

Question 66

What murmur is a mid-diastolic rumble w/ presystolic accentuation best heard along left sternal border + over xiphoid process?

Answer 66

tricuspid stenosis

Question 67

What increases a tricuspid stenosis murmur?

Answer 67

inspiration, increased venous return

Question 68

What do these diagnostics indicate: - RAE - prominence of RA + SVC on CXR w/o enlargement - echo = valve is thickened + domes in diastole, area<1, RA + IVC are enlarged

Answer 68

tricuspid stenosis

Question 69

How do you treat tricuspid stenosis?

Answer 69

diuretics to relieve fluid congestion

Question 70

What could tricuspid regurgitation present as?

Answer 70

fatigue, DOE, cervical pulsations, abdominal fullness, diminished appetite, muscle wasting

Question 71

What could cause tricuspid regurgitation?

Answer 71

secondary to dilation of annulus from RVE due to pulmonary artery HTN - NOT primary == -pacemaker lead placement -late stages of rheumatic fever or CAd -cardiomyopathies -infarction of papillary muscles -TVP -carcinoid heart disease -infective endocarditis -leaflet trauma

Question 72

What does this PE indicate: - right sided HF, distended neck veins, marked hepatomegaly, ascites, pleural effusion, edema?

Answer 72

tricuspid regurgitation

Question 73

What murmur is: blowing high pitched holosystolic murmur along left sternal margin?

Answer 73

tricuspid regurgitation

Question 74

What increases a tricuspid regurg murmur?

Answer 74

inspiration -- Carvallo's sign (which can distinguish from mitral regurg!), increased venous return

Question 75

What do these diagnostics indicate: EKG - atrial fibrillation CXR- RA+RV enlargement, pleural effusion echo - RA dilation, RV volume overload w/ abnormal interventricular wall movement + prolapsed leaflet

Answer 75

tricuspid regurgitation

Question 76

What's the treatment for tricuspid regurgitation?

Answer 76

diuretics for RHF + treatment of pulmonary HTN

Question 77

What are the indications for treatment for tricuspid regurgitation?

Answer 77

-triscupid regurg 1) clinical decision (improvement) 2) moderate to severe TR or any structural TR 3) RV volume overload 4) RHF 5) repair vs replacement endocarditis 1) severe TR 2) persistent sepsis 3) recurrent PE 4) excision vs replacement vs repair

Question 78

In who is pulmonary stenosis most common?

Answer 78

pediatric patients, with female>male

Question 79

How does pulmonary stenosis present?

Answer 79

>1 year = murmur only 2nd, 3rd, 4th decade of life = CRHF, DOE

Question 80

How do you cause pulmonary stenosis?

Answer 80

congenital the majority of the time OR acquired from endocarditis or rheumatic fever, secondary to previous procedures "teratology of Fallot"

Question 81

What is this murmur: loud, harsh systolic murmur w/ ejection click radiating towards left shoulder?

Answer 81

pulmonary stenosis

Question 82

Does pulmonary stenosis decrease or increase with inspiration?

Answer 82

Rinspiration

Question 83

What diagnostics do these indicate - EKG - RVH, RAE, RAD?

Answer 83

pulmonary stenosis

Question 84

How do you treat pulmonary stenosis?

Answer 84

must always monitor!! diuretics for symptoms + signs of CHF percutaneous balloon valvuloplasty = initial intervention w/ congenital valvar PS

Question 85

What dominates pulmonic regurgitation and its symptoms?

Answer 85

pulmonary artery HTN -- right heart volume overload + RHF symptoms -- hepatic congestion (fullness + bloating), ascites, JVD, edema

Question 86

What causes pulmonic regurgitation?

Answer 86

secondary due to pulmonary HTN and issues from left heart or congenital

Question 87

What is this murmur: high pitched, decrescendo diastolic blowing murmur along left sternal border "Graham steel"

Answer 87

pulmonic regurgitation

Question 88

What increases the pulmonic regurg murmur?

Answer 88

inspiration, increased venous return

Question 89

How do you treat pulmonic regurg?

Answer 89

focus on underlying cause -- reduce PA vascular resistance + pulmonary HTN

Question 90

SAD is for

Answer 90

aortic stenosis syncope angina dyspnea

Question 91

Low CO, perfusion “Pulsus tardus”

Answer 91

aortic stenosis

Question 92

Low CO -> low BP Increased backflow = increased preload → increased SV → high BP and WIDE pulse pressure

Answer 92

aortic regurg