Valve Dz 2

Question 1

mc cause of mitral stenosis

Answer 1

rheumatic fever

followed by denegeration of valve apparatus

2/3 of people are female

Question 2

pathophys of mitral stenosis (6)

Answer 2

1. decreased emptying of LA causes increased LA pressure
2. LA pressure causes pulmonary venous congestion
3. vasoconstriction and hypertrophy of pulmonary arteries
4. remodeling and pulmonary HTN
5. increased RV pressure leads to RV hypertrophy
6. RV failure

** LV remains preserved until MS becomes so severe diastolic filling declines

Question 3

symptoms of MS

Answer 3

YOUNG (30-40)

1. dyspnea/orthopnea
2. AFib and other dysrhythmia, atrial thombus/emboli
3. chest pain, palpitations, fatigue, weakness and peripheral edema, blood tinged sputum (pulmonary edema)

Question 4

signs of mitral stenosis (murmur)

Answer 4

Opening snap

low, rumbling diastolic murmur @ LV apex (5-6th ICS)

Question 5

evaluation of MS

Answer 5

echo (okay for right side, might find it)

cardiac (L heart cath, femoral artery and thru LV to LA)

Question 6

elements of MS treatment (6)

Answer 6

1. diuretics
2. dietary sodium reduction and nitrates
3. rate control (esp. in AF w/CCB or BB)
4. consider anticoagulation
5. Statins (anti inflammatory, slows progression)
6. avoid after load reduction

Question 7

surgical MS treatment (3)

Answer 7

given to patients with severe symptoms and moderate to severe stenosis

percutaneous valvuloplasty

open mitral valve commissurotomy

open mitral valve replacement

Question 8

critical MS value

Answer 8

< 1.5

Question 9

percutaneous balloon valuloplasty

Answer 9

abrupt inflation of balloon across mitral valve

results in separation of fused cusps

PREFERRED if test is available

Question 10

open mitral valve comissurotomy or replacement

Answer 10

2 dif surgeries
commissurotomy - debridement and separation of fused cusps

replacement - mechanical or tissue valve entirely replaced

Question 11

blood ejects into aorta as well as left atrium during systole

Answer 11

mitral regurgitation

Question 12

functional etiologies of mitral regurg

Answer 12

valve apparatus degeneration or deformation

i.e. CAD, dilated CM, papillary muscle dysfunction

Question 13

organic etiologies of mitral regurge (3)

Answer 13

1. myxedematous degeneration of mitral valve, associated with MVP
2. Infectious endocarditis valve leaflet/chordae destruction
3. Rheumatic disease

Question 14

pathophysiology of MR (6)

Answer 14

1. Atria dilate
2. LV dilation – pre load + regurgitated volume (some hypertrophy)
3. Pulmonary congestion
4. Pulmonary HTN (due to vasoconstriction and hypertrophy of pulmonary arteries)Pulmonary veins engorged
5. RV hypertrophy
6. RV fails—losing systolic function, can’t squeeze

Question 15

symptoms of MR

Answer 15

Asymptomatic gradually develop increasing pulmonary HTN

symptoms start at exercise

HF secondary to reduced CO and pulmonary congestion (DOE, fatigue, AF)

Question 16

MR signs

Answer 16

holosystolic murmur (high pitched, blowing)

could be: wide split, S3, hyper dynamic LV, brisk upstroke

Question 17

MR diagnostics

Answer 17

ECHO

can do cardiac cath

Question 18

MR monitoring

Answer 18

followed annually

surgery done before LV remodeling can occur

Question 19

pharm tx of MR

Answer 19

decreased after load (equalized pressure b/t systemic and LA)

via ACEI, nitrates, anti-HTN and diuretics

Question 20

surgical MR tx

Answer 20

pulmonary HTN and AF indicated earlier surgery

procedure of choice is REPAIR rather than replacement

true replacement indicated if valve is too damaged, papillary muscle dysfunction, or IE

Question 21

why do we repair instead of replace valve in MR

Answer 21

1. less need for IE prophylaxis
2. permanent fix
3. decreased need for anti-coagulation

Question 22

Acute MR due to

Answer 22

ischemia or infarction of chordae, papillary muscles, or IE

acutely ill due to less time to compensate and make hemodynamic changes(RV) and decreased preload (LV)

Question 23

Symptoms of acute AR

Answer 23

Acute LV Failure

Acute RV Failure

Rapid pulmonary congestion/Pulmonary edema

HoTN/shock

Question 24

acute AR tx

Answer 24

after load reduction

nitroprusside and urgent valve replacement

Question 25

MVP etiologies

Answer 25

pevelance greater in women 1. genetic (marfan's, connective tissue dz) 2. myxedematous deteriorated leaflets = large floppy leaflet

Question 26

symptoms of MVP

Answer 26

asymptomatic minor amounts have palpitations, anxiety, dizziness, CP may be associated with MR but not always

Question 27

murmur MVP

Answer 27

mid systolic click late systolic murmur

Question 28

diagnostics of MVP

Answer 28

2D echo (determines if there, and if MR as well) serial echo 1-2 yrs to document lack of progression

Question 29

MVP treatment

Answer 29

stimulant avoidance (cocaine, caffeine, tobacco, chocolate) propranolol if palpitations

Question 30

tricuspid stenosis etiologies

Answer 30

rheumatic heart disease typically concomitant mitral or aortic valve disease female predominance

Question 31

Tricuspide stenosis symptoms

Answer 31

signs of RV failure peripheral edema ascites hepatic congestion (pain in RUQ)

Question 32

tricuspid stenosis signs

Answer 32

opening snap at LSB palpable pre-systolic pulsation over liver

Question 33

tricuspid stenosis treatment

Answer 33

medical and surgical treatment to treat other valvular disease may do a valve replacement

Question 34

pathophys Tricuspid regurge

Answer 34

RV dilation secondary to pulmonary HTN and RV failure caused by: COPD, Pulmonary emboli, HF

Question 35

symptoms of TR

Answer 35

initially tolerated pulmonary HTN --> symptomatic systemic back up = peripheral edema, hepatic congestion

Question 36

TR signs

Answer 36

pan systolic, high pitched murmur best heart at sternal border, augmented by increased venous return

Question 37

TR treatment

Answer 37

treating underlying cause of pulmonary HTN or RV failure may need valve replacement

Question 38

pulmonic stenosis

Answer 38

congenital doesn't req. tx until adulthood can treat with balloon valvuloplasty

Question 39

pulmonic regurgitation

Answer 39

occurs when valve annals dilates secondary to pulmonary HTN tx directed at cause of pulmonary HTN or RV failure

Question 40

bioprosthetic valves pros and cons

Answer 40

only need anticoagulation for a few months BUT degeneration sooner (10 yrs)

Question 41

mechanical valves pros and cons

Answer 41

req. anticoagulation for life lasts longer than bioprosthetic (20yrs)

Question 42

when is greatest risk of clot following valve replacement?

Answer 42

first three months ONLY give warfarin

Question 43

aortic valve mechanical replacement no risk factors

Answer 43

anticoagulation with VKA (warfarin) to INR 2.5 + ASA

Question 44

aortic mechanical valve replacement and risk factors

Answer 44

VKA(warfarin) to INR 3 + ASA AF, prior thrombus, LV dysfunction, hyper coagulable conditions

Question 45

mitral valve replacement

Answer 45

VKA (warfarin) target INR of 3 + ASA

Question 46

bioprosthetic valve replacement guidelines

Answer 46

3-6 months, 2.5 INR + ASA

Question 47

TAVR anticoagulation

Answer 47

low bleeding risk = anticoagulate 3+ months for INR 2.5 + ASA MAYBE clopidogril for 6 mo.