Valvular Disease

Question 1

What is the most common valvular disease?

Answer 1

calcific aortic stenosis

Question 2

What are the mechanisms of aortic stenosis?

Answer 2

• aortic valve sclerosis
• bicuspid aortic valve
• rheumatic fever -> aquired bicuspid aortic valve

Question 3

What is aortic valve scleoris?

Answer 3

calcification and fibrosis of the aortic valve preventing full opening of the valve

mechanisms similar to those of athersclerosis and with similar risk factors:

• age
• HTN
• hyperlipidemia
• inflammation

Question 4

When is aortic valve sclerosis seen?

Answer 4

age 60-80

Question 5

What is a bicuspid aortic valve?

Answer 5

congenital fusion of 2 of the 3 arotic valve leaflets

-predisposes to valve calcification (seen earlier)

can be aquired as a result of rheumatic heart disease

Question 6

What changes occur in the heart due to aortic stenosis?

Answer 6

increased resistance of the aortic opening -> increased pressure -> LVH

Question 7

What is the clinical presentation of aortic stenosis?

Answer 7

initially asymptomatic

progression may lead to symptoms with exertion and eventually at rest

Presentation:

• systolic ejection murmur (crescendo-decrescendo)
• > angina -> syncope -> CHF

Question 8

What is the prognosis and treatment for aortic stenosis?

Answer 8

prognosis worsens with progression of symptoms

-angina -> syncope -> CHF = approx. 5, 3, and 2 years respectively until death

threatment is surgical aortic valve replacement/repair:

-in symptomatic or functionally deficient pts

Question 9

What is mitral annular calcification?

Answer 9

calcification of the mitral annulus at the base of the mitral leaftlets

Question 10

What is the epidemiology of mitral annular calcification?

Answer 10

• females
• >60

Question 11

How does mitral annular calcification present?

Complications?

Answer 11

normally remains asymptomatic

Complications:

• mitral regurgitaiton
• mitral stenosis
• arrhythmia
• thrombus formation
• infective endocarditis

Question 12

What is mitral valve prolapse?

(causes)

Answer 12

mitral valve leaflets prolapse into LA during LV contraction

Causes:

• mostly idiopathic
• connective tissue diseases (Marfan and Ehlers-Danlos)
• ischemia; chordae tendinae damage
• rheumatic heart disease

Question 13

What structural findings are associated with mitral valve prolapse?

Answer 13

• thick and rubbery leaflets; deposition of GAGs -> myxomatous degeneration
• “hooding” of leaflets

Question 14

What is the epidemiology of mitral valve prolapse?

Answer 14

• relatively common 2-3% of adults
• 7:1 female predominance

Question 15

How does mitral valve prolapse present?

Complications?

Answer 15

asymptomatic with mid-systolic click; murmur if reguritaiton is present

Complicaitons:

-mitral regurgitation; most common cause in developed countries

Rare:

• infective endocarditis
• mitral insufficiency (possible chordal rupture)
• arrhythmia (typically atrial, rarely ventricular)
• thromboembolism

Question 16

What is the prognosis and treatment for mitral valve prolapse?

Answer 16

very good prognosis; serious complications are rare

generally does not require treatment itself beyond treatment of complications

Question 17

What is rheumatic fever?

Answer 17

autoimmune condition triggered by molecular mimicry of M streptococcal Ag of group A streptococcus

Ab and cell-mediated reaction to heart, joints, soft tissue, skin, and nervous system

Question 18

What is the clinical presentation of rheumatic fever?

Answer 18

occurs 2-4 weeks after group A strep infection

Presentation:

• fever >101 + J♥(O)NES criteria
• Joints: migratory polyarthritis (mostly large joints)
• ♥: pancarditis (endo, myo, and pericarditis)
• Nodules: subcutaneous nodules
• Erythema marginatum (ring-shaped macular rash)
• Sydenham chorea (ballismus occasionally w/ behavorial changes)

Question 19

What tests are used to diagnose rheumatic fever?

Answer 19

• antistreptolysin O (ASO)
• antistreptococcal DNAse B (ADB)

cannot culture for strep as inciting infeciton has likely resolved

Question 20

What are complications of rheumatic fever?

Answer 20

collectively refered to as rheumatic heart disease

Acute (inflammation):

• pancarditis
• verrcurae, valvular vegetations
• MacCallum plaque (thickened posterior LA wall)

Chronic (valvular changes):

• valvular lesions -> regurgitaiton/stenosis
• affects mitral > aortic > tricuspid (rarely pulmonary); MAT

-LAE -> A-fib

-infective endocarditis

Question 21

What pathologic findings are associated with the heart in rheumatic fever?

Answer 21

Aschoff bodies:

-lesions in the heart consisting of T-cells, plasma cells, and Anitschkow cells

Anitschkow cells:

• **pathognomonic** for rheumatic fever
• macrophage
• caterpilar-like chromatin
• owl-eye apperance

Question 22

What is infective endocarditits?

(risk factors)

Answer 22

infection of damaged cardiac valves or structural anomalies in the heart

Risk factors:

• male
• age >60
• IVDU
• body peircings
• poor dentition; dental procedures

Question 23

What organisms are responsible for infective endocarditits?

Answer 23

native, structurally abnormal valves -> Streptococcus viridians

poor dentition -> HACEK (Heomphilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

prosthetic valves -> Staphylococcus epidermidis

IVD -> Staphylococcus aureus

Question 24

What valves does infective endocarditis normally effect?

Answer 24

mitral > aortic > tricuspid > pulmonary (same order as rheumatic heart disease)

IVD particularlly affects the right sided valves -> tricuspid/pulmonary

Question 25

What is the clinical presentation of infective endocarditis?

Answer 25

_Acute endocarditits_: - **rapid** onset of **high fever + extracardiac manifestations** - typically *_S. aureus_* _Subacute endocarditis_: -**slow** onset of **low fever + extracardiac manifestations** _Extracardiac manifestations_: - **splinter hemorraghes** - **Osler nodes** (painful nodules on pads of fingers/toes) - **Roth spots** (retinal hemorrhages with pale center) - **Janeway lesions** (non-tender, macules on palms and soles)

Question 26

What is nonbacterial thrombotic endocarditis? (cause)

Answer 26

**sterile** valvular **thrombi** caused by _procoagulative states_: - **sepsis** - **cancer** - **antiphospholipid syndrome** - **SLE** -\> Libman-Sacks

Question 27

What is carcinoid heart disease? | (pathophysiology)

Answer 27

caused by **mediators** released by **carcinoid tumors**; most commonly **serotonin** **liver clears excess serotonin** from carcinoid tumors, **progression of tumor** growth can produce **too much serotonin** for the liver to clear **or metastasis to the liver** can occur allowing serotonin to **enter hepatic vein and reach heart** serotonin stimulates **fibrosis of the cardiac valves**

Question 28

What valves are typically affected in carcinoid heart disease?

Answer 28

**right sided valves**, tricuspid \> pulmonary **pulmonary tissue** also **clears serotonin**, protecting left valves

Question 29

How does carcinoid syndrome/carcinoid heart disease present?

Answer 29

_Systemic/carcinoid syndrome_: - **flushing** - **dermatitis** - **bronchoconstriction** - **diarrhea** _Heart_: -**tricuspid insufficiency** -\> right sided heart failure