Valvular Disorders Flashcards
1
Q
Name the 4 valves of the heart.
A
Tricuspid (Right atria to Right ventricle)
Pulmonary (Right ventricle to pulmonary circulation)
Mitral (Left atria to left ventricle)
Aortic (left ventricle to aorta)
2
Q
What are 2 functions of the valves.
A
Allow blood to flow forward
Prevent backward blood flow
3
Q
T or F: All 4 valves are 3 cusped?
A
False:
all have 3 cusps except the mitral valve
4
Q
Valve ________ is a narrowing of the valve.
A
Stenosis is a narrowing of the valve
5
Q
__________ occurs when the valve has trouble closing. What happens to the blood when this occurs?
A
Regurgitation
Blood will flow backwards when this occurs
6
Q
Which test gives you good information about the valve morphology, LV function, atrial and ventricular chamber size and overall function?
A
Echo
7
Q
What does TEE stand for?
A
Transesophageal echocardiogram
8
Q
According to the ACC/AHA classification guidelines for valvular disease: what stage is a patient in when they become symptomatic?
A
Stage D - Patient is symptomatic.
Stage A - is at risk for valvular heart disease
Stage B - is asymptomatic but has mild to moderate disease
Stage C - is asymptomatic but has severe valvular disease
C1 normal LV function
C2 - abnormal LV function
9
Q
T or false: Aortic stenosis is not very common.
A
False. Aortic Stenosis is very common
10
Q
What is the most common cause of LV outflow obstruction?
A
Aortic Stenosis
11
Q
What are the 3 primary causes of Aortic Stenosis?
A
- Congenital abnormality (bicuspid valve)
- Calcifications (often from aging)
- Rhematic Valve disease (fusion between leaflets causes a small central opening)
12
Q
What is the classic triad of symptoms with aortic stenosis?
A
Dyspnea (usually DOE)
Syncope / exertional dizziness
Angina
13
Q
What is the most common symptom with aortic stenosis?
A
Dyspnea
14
Q
Symptoms of aortic stenosis usually don’t occur until stenosis is severe. What values indicate severe stenosis?
Valve are or = _______mm/hg
A
Valve area < 1.0 cm2 (squared, no idea how to superscript in here!!!!)
Aortic velocity > or = to 4.0 m/s
Mean transvalvular gradient > or = to 40mm/hg
15
Q
According to the ACC/AHA a patient that is asymptomatic but has mild-moderate valvular disease would fall into which classification stage?
A
Stage B - patient is asymptomatic but has mild-moderate valvular disease
16
Q
Which stage of valvular disease is a patient in that has severe valvular disease with Abnormal LV function but is still asymptomatic?
A
Stage C2 - patient is asymptomatic but has severe disease
C2 is abnormal LV function
17
Q
T or F: a patient that has been classified to have Stage C1 will have abnormal LV function and have severe symptoms.
A
False
Stage C1- patient is asymptomatic but has severe valvular disease; normal LV function
18
Q
Aortic Stenosis has a harsh systolic ejection murmur heard best where?
A
Right 2nd intercostal space
19
Q
T or false: Aortic stenosis has Crescendo- decrescendo sound.
A
True
It is a crescendo-decresendo murmur
20
Q
Aortic stenosis manifests as a harsh systolic crescendo-decrescendo ejection murmur that radiates where?
A
Radiates to the carotids
21
Q
What does Parvus et tardus pulse mean? In aortic stenosis which vessels is this especially seen in?
A
Pulses are weak and delayed
seen at the carotids
22
Q
How do you diagnose aortic stenosis?
A
echo
23
Q
T or F: Severe aortic stenosis would not qualify a patient for hospice care.
A
False
24
Q
What 2 conditions do you need to manage in a patient with aortic stenosis?
A
Manage HTN
Manage heart failure
25
Avoid the use of what 3 meds in patients with aortic stenosis? Why?
Nitrates
Hydralazine
Nitroglycerine
Can exacerbate syncope from vasodilation
26
What is the mainstay treatment for aortic stenosis?
AVR - aortic valve repair (surgery)
27
What do SAVR and TAVI stand for?
SAVR - surgical aortic valve repair
| TAVI - transfemoral transcatheter aortic valve implantation
28
T or F: SAVR is most recommended surgical treatment for aortic stenosis.
False
| TAVI is recommended over SAVR for most patients
29
SAVR is preferred in patients with: (3)
- Bicupid or unicuspid aortic valve
- Poor transfemoral access
- severe LV outflow tract calcification
30
What is an alternative procedure to open surgery in aortic stenosis?
Balloon Valvuloplasty
31
T or F: Balloon valvuloplasty has a low complication rate.
False - has a high complication rate
| MI, perforation, aortic regurgitaiton
32
4 major complications of aortic stenosis?
- Heart failure (diastolic dysfunction common)
- sudden cardiac death
- Increased bleeding risk (Heyde syndrome)
- Pulmonary HTN
33
Patients with aortic stenosis have a ________ prognosis if they do not undergo valve replacement.
Poor prognosis
34
T or F: aortic stenosis mortality increases dramatically after developing symptoms.
True
Mean survival after onset of CHF -- 0.5 - 2.8 yrs
onset of syncope -- 0.8 - 3.8 yrs
onset of angina -- 2 - 4.7 yrs
35
Where does a homograft valve come from?
Valve from a cadaver, deceased heart donor, or the patient
36
Where does an allograft valve come from?
Valve from pigs or cows
37
What is a bioprosthetic valve?
a valve from animal valves or reconstructed
38
What is a mechanical valve?
a valve from non-living material
39
________ _________ is recommended to prevent valve thrombosis and thrombotic events for mechanical valves.
Antithrombotic therapy
40
What combination anticoagulation therapy is recommended for mechanical valve patients?
Warfarin + ASA (75-100mg/day)
41
T of F: patients with mechanical valves CANNOT use NOAC's.
True
NOAC = non-vitamin K antagonist oral anticoagulant
(yeah NOAC is much better)
42
After the mechanical valve is placed you bridge with _______ until INR is within therapeutic for _____ consecutive days.
Heparin
| 2 consecutive days
43
INR goal after mechanical valve placement?
| Except for those with__ - __ __________ aortic valve.
2.5-3.5 INR
| Except in On-X mechanical AORTIC valve
44
For patients with implanted bioprosthetic valves the ACC/AHA guidelines for anticoagulation therapy is _____mg/day and _______ for 3 months with INR goal of _____-____.
ASA 75-100 mg/day
| Warfarin for 3 months, INR goal of 2-3
45
______ _______ is the condition where blood leaks backwards though the aortic valve due to inadequate closure of the valve.
Aortic Regurgitation
46
Aortic Regurgitation can lead to which 2 conditions?
LV dilation
| LV hypertrophy
47
What are 4 causes of Aortic regurgitation?
Rheumatic Heart Disease
Aortic root dilation
Congenital bicuspid valve
Calcific Valve disease
48
Signs and symptoms of aortic regurgitation
Asymptomatic
Exertional dyspnea
Exertional angina
Symptoms of Heart Failure
49
What are some clinical manifestations of aortic regurg?
Wide pulse pressure
Bounding pulses
Displaced apical impulse (lateral and inferior)
50
What type of murmur will you hear with aortic regurgitation?
Diastolic decrescendo murmur, high pitched and blowing
51
T/F: An aortic regurgitation murmur is heard best when the patient is sitting straight and inhaling
False: heard best with patient leaning forward and exhaling
52
Traube Sign
Pistol shot pulse (systolic & diastolic sounds) heard over the femoral arteries
53
Mitral stenosis causes dilation and increased pressure of the ________ atrium, pulmonary vasculature and _______ side of the heart. This can lead to ______
Mitral stenosis causes dilation and increased pressure of the LEFT atrium, pulmonary vasculature and RIGHT side of the heart. This can lead to A-FIB. (due to stretching of the electrical fibers)
54
Mitral stenosis is almost exclusively secondary to ______ ________ _______.
Rheumatic heart disease
55
What is the most common and often the only symptom of mitral stenosis?
Exertional dyspnea
56
What are some other symptoms seen with mitral stenosis?
- Decreased exercise tolerance
- Hemoptysis
- Palpitations/a-fib
- Thromboembolic event
- Right HF (increased JVP, edema)
- Hoarse voice (from compression of recurrent laryngeal n.)
57
T or F: To evaluate aortic regurgitation you would do a TTE?
True
58
What position should the patient be in to best hear a mitral stenosis murmur? What side of the stethoscope should you use?
Heard at the apex with the patient in left lateral decubitus position while patient exhales. Use the BELL of the stethoscope
59
You should anticoagulate a patient who has mod-severe mitral stenosis and at least one of what 3 conditions?
Mod-severe stenosis PLUS:
- Afib
- Prior embolic event -or-
- LA thrombus (new sports team name? The LA thrombi?)
60
What three complications from mitral stenosis can generally lead to death?
- progressive right-sided heart failure -and/or-
- pulmonary edema -and/or-
- thromboembolic event (CVA/PE)
61
Mitral stenosis can lead to ______ ________ from stretching of the electrical fibers.
Atrial fibrillation
62
What is the most common cause of secondary mitral regurgitation?
Coronary heart disease
63
What are 3 other causes of mitral stenosis (other than rheumatic heart disease)?
Annular calcification
Radiation
congenital
64
What are 5 common mitral regurgitation symptoms?
- Asymptomatic
- Weakness
- Fatigue
- Exercise intolerance
- Symptomatic HF or pulm edema
65
Symptoms of mitral stenosis (7)
```
exertional dyspnea
Decreased exercise tolerance
Hemoptysis
Palpitations / afib
Thromboembolic event
Right heart failure (increased JVP, edema)
Hoarse voice
```
66
Where does a mitral regurg murmur radiate to?
To the left axilla
67
Best place and best patient position to hear mitral stenosis during auscultation?
Best heard at the apex
| Left lateral decubitus position while patient exhales
68
When is surgical repair indicated for mitral regurgitation?
```
If symptomatic (i.e. dyspnea or fatigue)
-Asymptomatic patients should be monitored with echo
```
69
T/F: surgical repair of mitral regurgitation improves symptoms and survival
FALSE: repair only improves symptoms, there is no evidence that it improves survival
70
What do patients with ACUTE mitral regurgitation present with? What is the treatment?
Acute pulmonary edema (SOB), they may need emergency surgery.
(Acute MR develops rapidly due to: valve perf from endocarditis, papillary muscle dysfunction after MI, trauma, ruptured chordae tendinae from MVP)
71
What type of valvular disorder is almost always due to a congenital defect?
Pulmonic stenosis (often associated with Tetralogy of Fallot)
72
what are some complications of mitral stenosis?
Afib
Thromboembolic event
Development of tricuspid regurgitation
73
What type of murmur is heard with pulmonic stenosis? Where is it heard best?
Crescendo-decrescendo systolic ejection murmur with an ejection click. Splitting of the 2nd heart sound increases with severity of stenosis.
-Heard best at left upper sternal border
74
T/F: An S4 heart sound can be heard with pulmonic stenosis
TRUE
75
What is the treatment for mod-severe pulmonic stenosis?
Balloon valvotomy
76
T/F: Prognosis is very poor in patients with pulmonic stenosis
FALSE, prognosis is pretty good, survival into adulthood is common even without surgical intervention.
There is increased incidence of arrhythmias, however.
77
What are 3 causes of PRIMARY pulmonic regurgitation?
- Iatrogenic (usually from valvotomy when repairing Tetrology of Fallot)
- infectious (endocarditis)
- immune-mediated (Rheumatic fever)
78
What condition commonly causes SECONDARY/functional pulmonic regurgitation when the pulmonic valves are morphologically normal?
Pulmonary HTN
79
Pulmonic regurgitation leads to volume overload in which ventricle? What can this lead to?
Right Ventricle volume overload--> RV enlargement, RV dysfunction, and triscuspid regurgitation (the whole right side has issues)
80
Ascites and edema are symptoms of what type of valvular abnormality?
Pulmonic regurg
81
An early diastolic decrescendo murmur heard over the left 2nd and 3rd ICS is associated with what type of valve disorder?
Pulmonic regurgitation
82
Graham-Steele murmur of pulmonic regurgitation is associated with _______ ________.
Pulmonary HTN
83
T/F: Tricuspid stenosis is very common.
FALSE: it's uncommon, especially alone. Usually occurs in combination with tricuspid regurg and/or other valvular abnormalities
84
What usually causes tricuspid stenosis?
Rheumatic heart disease
85
Abdominal discomfort from hepatomegaly and hepatic congestion is associated with what type of valvular disorder?
Tricuspid stenosis
86
T/F: elevated JVP is not associated with tricuspid stenosis
FALSE, you will see an elevated JVP with prominent A waves in tricuspid stenosis
87
An early/mid diastolic murmur with an opening snap heard at the left sternal border during inspiration is associated with what valvular disorder?
Tricuspid stenosis
88
What type of symptoms might you see with tricuspid regurgitation?
- Asymptomatic
- Distended/pulsatile jugular veins
- Symptoms of Right HF (edema, HSM, ascites)
89
What sound might you hear over the jugular vein in someone with tricuspid regurgitation?
Systolic thrill
90
T/F: a holosystolic murmur is heard with tricuspid regurgitation
TRUE, you may also hear an S3 or S4 with tricuspid regurg
91
What would you use to treat the S/sx of heart failure associated with tricuspid regurgitation?
Diuretics
92
Severe tricuspid regurgitation is an __________ predictor of mortality in those with LVEF < ___%
Severe tricuspid regurgitation is an INDEPENDENT predictor of mortality in those with LVEF < 35%
93
Corrigan's Pulse (aka water-hammer pulse)
A pulse that is forceful and then suddenly collapses
94
DeMusset's Sign
Rhythmic head bobbing along with the heartbeat
95
Traube Sign
Pistol shot pulse (systolic & diastolic sounds) heard over the femoral arteries
96
Quincke's Sign
Capillary pulsation in the fingertips
97
Bounding pulses are a clinical manifestation of Aortic regurgitation. What are the 4 types of bounding pulses you can see?
Corrigan's Pulse (Water-hammer pulse)
DeMusset's Sign
Traube Sign
Quincke's Sign
98
What murmur would you hear in Aortic regurgitation?
Diastolic decrescendo murmur
- High pitched and blowing
- heard best with patient sitting, leaning forward
99
Describe an Austin Flint Murmur. What condition would you hear it in?
Low pitched mid to late diastolic rumble at the apex
| Severe Aortic Regurgitation
100
T or F: To evaluate aortic regurgitation you would do a TTE?
True
101
What is the treatment for severe symptomatic aortic regurgitation?
AVR
102
_______ _______ is a narrowing of the mitral valve.
Mitral stenosis
It blocks blood flow from LA to LV.
103
T or F: Mitral stenosis causes dilation and decreased pressure of the LA, pulmonary vasculature and right heart.
False - causes dilation and INCREASED pressure of the LA, pulm vasculature and Rt heart
104
Mitral stenosis can lead to ______ ________ from stretching of the electrical fibers.
Atrial fibrillation
105
Mitral stenosis is almost exclusively secondary to what condition?
Rheumatic heart disease
106
What are 3 other causes of mitral stenosis (other than rheumatic heart disease)?
Annular calcification
Radiation
congenital
107
What is the most common and often the only symptom of mitral stenosis?
Exertional dyspnea
108
Symptoms of mitral stenosis (7)
```
exertional dyspnea
Decreased exercise tolerance
Hemoptysis
Palpitations / afib
Thromboembolic event
Right heart failure (increased JVP, edema)
Hoarse voice
```
109
how does mitral stenosis cause a horse voice?
compression of the recurrent laryngeal nerve
110
Best place and best patient position to hear mitral stenosis during auscultation?
Best heard at the apex
| Left lateral decubitus position while patient exhales
111
What will you hear during auscultation of mitral stenosis?
Opening snap
Accentuated / loud S1
Rumbling low pitched mid-diastolic murmur
112
Give you one guess what test is used to evaluate mitral stenosis....
ECHO
| are you surprised???
113
The definitive treatment for mitral stenosis.
surgery; either
- PMBC (percutaneous mitral balloon commissurotomy)
- concomitant mitral valve surgery
114
How do you medically manage patients with mitral stenosis?
Anticoagulate if have moderate-severe mitral stenosis and one of the following:
Afib
prior embolic event
LA thrombus
115
T or F: Rheumatic MS is generally progressive.
True
116
Deaths from mitral stenosis are generally from...
Progressive right-sided heart failure
and/or
pulmonary edema, thromboembolic events (CVA or PE)
