Valve Lecture

Question 1

Overview concept

Answer 1

valvular lesion –> stress –> compensation –> decompensation (CHF)

Question 2

pressure overload –>

Answer 2

increase contractility and get concentric hypertrophy

Question 3

volume overload –>

Answer 3

increase compliance, get dilated hypertrophy

Question 4

Stress from aortic stenosis

Answer 4

pressure load on LV

Question 5

stress from aortic insufficiency

Answer 5

volume load on LV

Question 6

stress from mitral regurg

Answer 6

volume load on LV

Question 7

stress from mitral stenosis

Answer 7

special case, doesn’t impact the LV, impacts the LA

Question 8

What do P for Ao, LA, and LV look like in cardiac catherization of healthy heart?

Answer 8

Question 9

Etiology of Aortic Stenosis

Answer 9

* degenerative in pt over 70yo

* bicuspid in pt under 70 yo

* rheumatic

Question 10

Name the valvular lesion show

Answer 10

aortic stenosis

Question 11

aortic stenosis symptoms

Answer 11

* angina (supply and demand imbalance, more muscle more demand, Less perfusion pressure = less supply)

* syncope (Inability to augment cardiac output, A fixed stenosis does not allow for augmentation)

* CHF (Increase in left atrial pressure and pulmonary venous pressure)

Question 12

aortic stenosis findings on palpation

Answer 12

• Carotid Pulses - “Parvus et Tardus” (weak and late)
• Percordium - Sustained PMI

Question 13

aortic stenosis findings on auscultation

Answer 13

• S4 from hypertrophy
• crescendo-decrescendo holosystolic murmur

Question 14

therapy for aortic stenosis

Answer 14

a. Pulmonary congestion: diuretics
b. Valve replacement
i. Surgery
ii. Percutaneous approach
iii. Trans-apical approach

Question 15

etiology of aortic insufficiency

Answer 15

• abnormalities of valve leaflets
  
  • congenital
  • endocarditis
  • rheumatic
• dilatation of aortic root
  
  • aortic aneurysm
  • aortic dissection
  • annuloaortic ectasia
  • syphilis
  • HTN

Question 16

Name the valvular lesion

Answer 16

aortic insufficiency

Question 17

Austin Flitt murmur

Answer 17

mitral murmur as a result of aortic regurg gushing back and not allowing MV to open

Question 18

acute aortic regurg sx

Answer 18

• LV = Noncompliant
• LA = Noncompliant
• Pulmonary circulation
= edema

Question 19

aortic insufficiency sx

Answer 19

• Dyspnea on exertion
• Fatigue
• Decreased exercise tolerance
• Forceful contractions

Question 20

aortic insufficiency findings on palpation

Answer 20

• carotids - water hammer pulse
• PMI - diffuse (dilated ventricle)

Question 21

aortic insufficiency auscultation findings

Answer 21

*Murmur
• Diastolic: decrescendo at LLSB
• Mid Diastolic: Austin – Flint at the apex
* Sounds: s3

Question 22

aortic insufficiency treatment

Answer 22

• Medical Management: Diurectics for Pulmonary congestion
• Surgical Management for Symptomatic and severe regitation OR Asymptomatic + Structural changes: Dilatation/Function
  
  • Surgical Techniques
    
    • Valve replacement
    • Aortic root replacement

Question 23

Etiology of mitral valve insufficiency

Answer 23

• Leaflets
  
  • Myxomatous degeneration
  • Rheumatic Disease
  • Endocarditis
• Mitral Annulus
  
  • Annular Calcification
• Papillary Muscles - Dysfunction or Rupture
• Chordae Tendineae: Rupture (w/ MI) or Endocarditis
• Left Ventricle
  
  • Cavity Dilatation
  • Hypertrophic CMP

Question 24

Name the valvular lesion (on the right)

Answer 24

mitral regurg

Question 25

Pathophysio of mitral regurgitation

Answer 25

\* dilated LA a. Increase in volume bc of regurg, increased preload → over time, eccentric hypertrophy and increase in compliance as a result of increased volume i. Accommodate more volume at a lower pressure b. There is no isovolemic contraction here; blood is leaving the LV during systole c. Restoration of FSV, normal LVEDP because of restored SV (but not all going forward, some goes back to LA)

Question 26

pathophysio of acute MR

Answer 26

sudden drop in CO, follows path of least resistance (backward) i. LA, normal size and compliance (hi pressure because of high volume) ii. Pulmonary vasculature: high pressure, congestion and edema

Question 27

Does EF include both forward and backward flow?

Answer 27

Yes

Question 28

(Chronic) Mitral Insufficiency: Symptoms

Answer 28

• Severe MR • CHF – SOB – Abdominal girth – Lower extremity edema • Pulmonary Hypertension • Atrial Fibrillation

Question 29

Mitral insufficiency (MR) auscultation findings

Answer 29

Murmur – Holosystolic at the apex (Not always plateau) – Radiation – Maneuvers 1 Increase afterload (Hand grip) – louder murmur 2 Decrease Preload (standing,valsalva) – Softer murmur

Question 30

Mitral Insufficiency Palpation

Answer 30

PMI – Diffuse (large ventricle)

Question 31

Mitral Insufficiency: Treatment

Answer 31

Medical Management • Pulmonary Congestion Surgical Management • Symptomatic and severe insufficiency • No Symptoms – Structural changes: Dilatation/Function • Afib/Pulm HTN Approaches • Mitral Valve repair • Mitral Valve Replacement

Question 32

What is mitral valve prolapse?

Answer 32

Billowing of the mitral valve leaflets into the left atrium during ventricular systole (could be related to enlarged MV leaflets or myxomatous tissue)

Question 33

MVP sx

Answer 33

* asx * palpitations

Question 34

MVP on auscultation

Answer 34

Mid systolic click | (w/ or w/o murmur)

Question 35

How does MVP auscultation finding change with manuevers?

Answer 35

* stand --\> decr preload, shrink ventricle, early click * squat --\> incr preload, expand ventricle, late click

Question 36

Etiology of Mitral Stenosis

Answer 36

* Rheumatic Fever * Congenital Stenosis * Mitral Annular Calcification * Endocarditis Note: MS is not very common

Question 37

Pathophys of mitral stenosis

Answer 37

Left Ventricle spared but Pressure load on left atrium --\> Increased left atrial pressure --\> Left Atrium dilates

Question 38

Mitral Stenosis: Pathophysiology Decompensated

Answer 38

Pressure load on left atrium --\> Increased left atrial pressure --\> Increase pulmonary venous/capillary pressure --\> Increased right sided pressures

Question 39

Mitral Stenosis: Symptoms

Answer 39

• Dyspnea – Exertion progressing to rest – PND – Orthopnea • Right Sided Symptoms – Pulmonary Hypertension – Hepatomegaly, ascites, edema • Complications – Atrial Fibrillation – Stroke – Hemoptysis

Question 40

Mitral Stenosis: Palp and Auscult

Answer 40

• Palpation – Normal PMI – RV heave • Murmur – Diastolic decrescendo – Presystolic accentuation – Apex (left lateral decubitus) • Sounds – High Pitched Opening Snap

Question 41

Mitral Stenosis: Treatment

Answer 41

• Medical Management – Vascular Congestion – Atrial Fibrillation – Thromboembolism • Definitive Management – Balloon valvuloplasty – Surgical: Valve replacement

Question 42

SEE SUMMARY SLIDES 63 & 64

Answer 42

Question 43

summary slides continued

Answer 43