What is aortic stenosis? What are the main causes?
Inability of the aortic valve to open properly
Thickening/calcification, rheumatic heart disease, or congenital (bicuspid)
What is a Wigger's diagram?
Shows you pressures, volume, EKG, and heart souds
What happens to aortic pressure relative to LV pressure in aortic stenosis-- in Wigger's diagram?
Higher P in LV due to inability of valve to open AND delays upstroke of aortic pressure bc it can't open
What compensation and decompensation happens in aortic stenosis?
(1) Compensation: wall thickness increases to allow LV pressure to increase
(2) Decompensation: hypertrophic heart --> decreased LV compliance
What are the symptoms of aortic stenosis?
Angina: increased muscle mass --> increased O2 demand
Syncope: failure to augment CO during exercise
Dyspnea: hypertrophy --> decreased LV compliance --> increased LVDP --> increased PCWP
What's the physical diagnosis of aortic stenosis?
Carotid upstroke delayed & reduced in amplitude
Harsh systolic ejection murmur R 2nd intercostal space
Paradoxical splitting of S2
What's the prognosis of aortic stenosis?
Long latent period (benign)
Once you get symptoms, you decline much more rapidly
What's the treatment for aortic stenosis?
Surgical aortic valve replacement
Transcatheter valve replacemtn
What is aortic regurgitation? Causes?
Leaking of aortic valve due to
(1) Primary abnormality of aortic valve leaflet
(2) Dilitation of aortic root
Many causes-- congenital (bicuspid), endocarditis, rheumatic, aortic dissection, Marfan's, hypertension
What are metrics for the size of regurgitation?
Effective regurgitant orifice
What's the difference between acute and chronic aortic regurgitation?
Acute: normal LV size/compliance so increase LV diastolic V and P --> increase in PCWP & pulm congestion = shock, resp failure= emergency!
Chronic: compensation allows it to be better tolerated -- heart can accept a larger volume w/less increase in diastolic pressure
- widened pulse pressure bc increase in SV leads to increase in aortic systolic BP & large regurg volume leads to decrease in diastolic pressure
-Normal CO is maintained
- Dyspnea, fatigue, decreased exercise tolerance, angina (rare)
What are the physical findings of chronic aortic regurgitation?
Decrescendo diastolic murmur (diminishes) at LLSB
Similar metrics of severity of aortic stenosis
How do you treat aortic regurg?
Surgical aortic valve replacement
What is aortic dissection?
Blood can escape through a tear in aorta --> enters aortic wall & goes through media of the aorta
Caused by htn, connective tissue disorders (Marfan)
What is mitral stenosis? Causes?
Mostly rheumatic also calcif, congential, endocarditis
Valve can't open properly --> abnormal diastolic gradient across stenotic mitral valve (normall, P's are =)
What's the pathophysiology/symptoms of mitral stenosis?
LA P/V overlad --> backup in PA --> pulmonary alveolar edema & RV pressure overload
Can lead to atrial dilitation due to P/V overload --> predisposed to A-Fib, tachycardia, and stangnant flow (risk of LA clot formation)
Dyspnea, Pulm alveolar edema
What do you find on the physical exam of aortic stenosis?
Loud S1 due to mitral valve closure
Opening snap in diastole
**Earlier snap/longer rumble =more severe disease
What's the progression of MS? Treatment?
Long latent period, 10 year survival after symptom onset 50% wherease asymptomatic patient >80% live 10 years
Treat with valvuloplasty, surgical mitral valve replacemetn
+ diuretics, rate/rhythm control, aticoag's for AFib
What's mitral regurgitation? Causes?
During systole, portion of LV stroke volume ejected back into low pressure LA
Mitral valve leaks --> back flow into LA during systole --> increased LA, V+P, decreased CO, volume stress on LV due to return of regurg volume to LV in addition to normal pulmonary venous return
Rheumatic, degenerative, endocarditis, rupture chords/ pap muscles
What's the difference between acute and chronic MR?
Acute: noncompliant LA --> increase LAP/PCWP --> acute pulm edema --> RV failure
Also CO decreases
Chronic: LA enlargement --> accomodation of regurg volume
**shift of LV diastolic P-V relationship, normal CO maintained, eccentric hypertroph due to volume overload
- fatigue, weakness on exertion, dyspnea, Afib
What do you see on physical exam of MR?
Holosystolic murmur at apex radiating to axilla; worsens with fist clench bc increased afterload
Apex can be displaced/diffuse
Treat: diuretics, afterload reduction, if functional MR, treat underlying dysfunction, mitral repair/replacement
AS, AR, MS, MR: PV loops