Valvular Disorders - Part 1 - Exam 1

Question 1

What are the 6 clinical classification categories based on? What are they?

Answer 1

based on anatomy and symptoms

Question 2

What are the risk factors for valvular disease?

Answer 2

congenital defects: bicuspid aortic valve

previous illness: endocarditis or rhematic fever

aging: calcification and degenerative disease

Question 3

What are the 2 types of aortic stenosis? When do they typically appear?

Answer 3

congenital and acquired

congenital: bicuspid is the MC, present prior to age 50

acquired: Rheumatic fever, valve calcification, and degenerative stenosis, present after age 50

Question 4

What does aortic stenosis lead to? What is the MC type of congenital aortic stenosis?

Answer 4

results in left ventricular hypertrophy

bicuspid congenital is the MC

Question 5

What is degenerative/calcified AS a result of? Approx. 25% of patients over 65 and 35% over 75 have evidence of _____ on echo

Answer 5

calcium deposits on valve leaflets, MC in elderly pts

aortic sclerosis

Question 6

What are risk factors for aortic stenosis?

Answer 6

HTN
hyperlipidemia
smoking

Question 7

**What is the MC surgical valve lesion in developed countries?

Answer 7

aortic valve

Question 8

What are the 3 cardinal symptoms of aortic stenosis? **What is the highlighted symptom?

Answer 8

angina
syncope/dizziness** especially on exertion
dyspnea

Question 9

**What does a aortic stenosis murmur sound like? **Where is it best heard and where does it radiate? _____ extra heart sound may be present

Answer 9

Midsystolic, crescendo-decrescendo, medium pitch, harsh quality, often loud with a thrill

Best heard at the right 2nd interspace with the pt sitting and leaning forward

with radiation to the carotids

S4 gallop

Question 10

**What is parvus et tardus? What valve condition is it associated with?

Answer 10

Slow rising carotid pulse contour

aortic stenosis

Question 11

What is the imaging of choice for aortic stenosis? ______ confirms the presence of severe AS and any CAD

Answer 11

echo

cardiac cath

Question 12

The CXR shows how enlarged cardiac silhouette, calcified aortic valve, dilated ascending aorta.

What am I?

Answer 12

aortic stenosis

Question 13

What is a gradient? What is normal?

Answer 13

difference in pressure of the left ventricle in systole and the aorta in systole.

normal should be less than 15mmHg

Question 14

What are the components of a echocardiography? What are the values of each for mild/moderate/severe?

Answer 14

**Know the severe criteria for each section at the very least

Question 15

What is the tx for symptomatic pts with severe AS? What do you need to give to pts after tx?

Answer 15

aortic valve replacement

Mechanical valve → Warfarin +/- ASA 81 mg
TAVR → Plavix x 6 months; lifelong ASA 81 mg

Question 16

______ is useful for patients who are poor/intermediate candidates for open heart surgery

Answer 16

Transcutaneous Aortic Valve Repair (TAVR) or TAVI

Question 17

______ is useful for congenital AS, but not used often for degenerative AS due to complications and high restenosis rate. What is given to help slow the rate of progression?

Answer 17

Balloon valvuloplasty

No medical therapies proven to slow progression!!! statins to control plaque build up and therapies aimed at s/s

Question 18

What is aortic regurgitation caused by? What does it lead to?

Answer 18

Caused by disease of the aortic leaflets, aortic root, or both

Chronic AR leads to LVH and dilation due to the need to accommodate for the additional regurgitant volume

Question 19

What are some causes of aortic root problems?

Answer 19

aortic dissection, aortic root dilation and Marfan’s syndrome

Question 20

aortic regurgitation presentation is determined by how quickly ______. Symptoms are typically due to increase in ______ leading to CHF. What are the 2 MC s/s?

Answer 20

regurg occurs

LV filling pressures

Exertional dyspnea and fatigue +/- angina

Question 21

**What does an aortic regurgitation murmur sound like? Where is the best place to hear it? Where does the sound radiation to?

Answer 21

Early diastolic, decrescendo, blowing

High pitched, best heard in the 2nd to 4th left interspaces (left sternal border) with the pt sitting and leaning forward

radiation to the apex

Question 22

What is widened pulse pressure (SBP-DBP) and “water hammer pulse” associated with? What additional heart sounds can be heard?

Answer 22

aortic regurgitation

S3 or S4 gallops may be present

Question 23

**What is an Austin Flint murmur? What cardiac dz is it associated with?

Answer 23

A low-pitched, diastolic mitral murmur, may be heard at the apex

aortic regurgitation

Question 24

What is the imaging modality of choice for aortic regurgitation?

Answer 24

Echocardiography (TTE)

Question 25

What is the tx for aortic regurgitation? What is the criteria? What medication is recommended? Why?

Answer 25

aortic valve replacement for patients with symptomatic severe AR or with LV changes Recommend AVR prior to progression to LV dilation > 5.0 cm or reduction in EF to < 50% vasodilators (hydralazine, minoxidil, nitrates, and nitroprusside and/or normal BP meds) to unload the ventricle but does NOT slow down the progression of aortic regurgitation

Question 26

What is a normal ejection fraction?

Answer 26

normal ejection fraction is greater than 50%

Question 27

What is acute aortic regurgitation caused by? What is it a result of? What does it lead to?

Answer 27

Infective endocarditis, traumatic rupture of aortic leaflets, aortic root dissection, and acute dysfunction of a prosthetic aortic valve Results in hemodynamic instability because the LV is unable to accommodate the increased diastolic volume aka blood backs up into the lungs and they cant breathe then they die cardiogenic shock (pale, cool extremities, weak, rapid pulse, low pitched early diastolic murmur)

Question 28

What is the tx for acute aortic regurgitation? What is the tx of choice?

Answer 28

Medical treatment includes vasodilator therapy and diuretics if BP is stable. Inotropic agents and vasopressors may be necessary need to take pressure off heart urgent aortic valve replacement!!!

Question 29

**What is the MC cause of mitral stenosis? 2/3rd of patients are _____. What does it lead to?

Answer 29

rheumatic fever women!! Fusion of the leaflet commissures and thickening, fibrosis, and calcification of the mitral leaflets and chordae

Question 30

Initial hemodynamic changes with mitral stenosis include elevated ____ pressure, causing ___ enlargement. This is transmitted back to the pulmonary venous system and may result in _______. Chronic elevations in pulmonary venous pressure leads to ______

Answer 30

left atrial Left atrium pulmonary congestion right ventricular failure

Question 31

As mitral valve stenosis becomes severe, _____ filling is impaired, reducing the _____ and _____

Answer 31

left ventricle stroke volume and cardiac output

Question 32

When do patients with mitral stenosis start developing symptoms? What are the s/s related to?

Answer 32

40s-50s pulmonary vascular congestion and right ventricle failure

Question 33

What are the MC s/s of mitral stenosis?

Answer 33

Fatigue, exertional dyspnea, orthopnea (SOB when lying flat) may have peripheral edema

Question 34

**_____ is also common in mitral stenosis. What does it lead to?

Answer 34

atrial fibrillation leads to blood clots

Question 35

**What is Ortner syndrome? **What valve dz is it associated with?

Answer 35

Compression of the left recurrent laryngeal nerve from a severely dilated LEFT ATRIUM may result in hoarseness mitral stenosis

Question 36

**What does a mitral stenosis murmur sound like? Where is the best place to hear it? What pt position?

Answer 36

Low-pitched, rumbling, diastolic murmur best heard at the apex with patient in left lateral decubitus position

Question 37

______ extra heart sound is heard in mitral stenosis. Why?

Answer 37

opening snap following S2 valve has to push itself open

Question 38

What happens in mitral stenosis if pulmonary artery pressures are elevated?

Answer 38

a palpable P2 (light tap felt over pulmonary artery/vein) may be detected at the upper left sternal border, also associated with a prominent pulmonic component of S2 on auscultation

Question 39

**Characteristic rheumatic deformity observed is doming ______ of the anterior mitral valve leaflet. What is this due to?

Answer 39

“hockey stick” in mitral stenosis This is secondary to fusion of the commissures and tethering of the leaflet tips

Question 40

What is the tx for mild/moderate mitral stenosis? Give the reason why with each

Answer 40

Beta Blockers for HR control Diuretics are used to relieve pulmonary congestion and signs of RV failure BP control for afterload reduction

Question 41

What is the tx for moderate/severe mitral stenosis and severe symptoms? What is considered moderate/severe s/s?

Answer 41

refer for sx s/s when sitting down not moving/doing anything

Question 42

Why is percutaneous balloon valvuloplasty not a common tx option for mitral stenosis?

Answer 42

because of the valve location. Have to go through atrial septum to access the valve NOT a definitive tx, only used in pliable, noncalcified leaflets and chords

Question 43

What is the definitive tx for mitral stenosis?

Answer 43

Valve Replacement Surgery is otherwise definitive treatment with bioprosthetic or mechanical valve replacement

Question 44

mitral regurgitation is the result of abnormalities of the _____, _____, _____ or ______. What are some common causes?

Answer 44

MR results from abnormalities of the mitral leaflets, annulus, chordae, or papillary muscles MV prolapse LV dilation (cardiomyopathy) Posterior wall MI Rheumatic fever Endocarditis

Question 45

What does mitral regurgitation result in?

Answer 45

Results in regurgitant blood flow from the LV to the LA during systole

Question 46

complication of mitral regurgitation, _____ and ______ dilate to compensate for increased volume

Answer 46

left atrium and left ventricle

Question 47

In mitral regurgitation, what does left ventricle dilation cause? then what happens?

Answer 47

LV dilation continues causing elevation in diastolic filling pressures and a reduction in LV systolic function LA pressures build and pulmonary venous pressures increase resulting in pulmonary congestion LA and LV dilate to compensate for the increased volume

Question 48

What is the presentation of mitral regurgitation?

Answer 48

most remain asymptomatic and well-compensated for many years s/s will appear due to depressed left ventricle systolic function (fatigue, dyspnea on exertion, peripheral edema)

Question 49

**What does a mitral regurgitation murmur sound like? Where is the best place to hear it? What can also be heard if there is mitral valve prolapse?

Answer 49

Holosystolic murmur **best heard at the apex and radiates to the axilla and back** Mid-systolic click may be present if mitral valve prolapse present

Question 50

______ is the diagnostic modality of choice to dx mitral regurgitation. What is the monitoring recommendations? What is also recommended to asses severity?

Answer 50

TTE echo TTE monitoring every 3-5 years for mild, 1-2 years for moderate, and 6 mos for severe depending on symptom severity may be useful cardiac cath

Question 51

What is the medical management of mitral regurgitation?

Answer 51

ACE/ARB or BB to reduce afterload diuretics to treat pulmonary congestion and reduce overall volume

Question 52

What is the definitive tx for mitral regurgitation? ______ or ______ may also indicate the need for intervention regardless of left ventricular size and function

Answer 52

sx BEFORE irreversible myocyte damage and left ventricular remodeling occurs Afib or pulonary HTN

Question 53

What are the different types of mitral regurgitation surgeries?

Answer 53

MV repair: annuloplasty, when a prosthetic ring is sewn in or mitral valve replacement

Question 54

When is mitral valve repair NOT indicated?

Answer 54

Not indicated if the MV is heavily calcified or disrupted secondary to papillary muscle disease or endocarditis

Question 55

Why is acute mitral regurgitation considered life threatening? What does it result in?

Answer 55

because the left atrium does NOT dilate to accommodate the regurgitant volume Results in abrupt increase in LA and pulmonary venous pressures which leads to pulmonary congestion

Question 56

What are the causes of acute mitral regurgitation?

Answer 56

Acute MI Trauma Endocarditis Tachyarrhythmia in patient with chronic MR MVP – papillary muscle / chordae tendineae dysfunction

Question 57

What are the s/s of acute mitral regurgitation? What does the murmur sound like? What is the tx?

Answer 57

hypotension tachycardia syncope pale sweating SOB soft, low-pitched sound in early systole urgent valve replacement sx

Question 58

mitral valve prolapse is MC in ______. What is it defined as?

Answer 58

MC in women Defined as superior displacement in ventricular systole of one or both mitral valve leaflets across the plane of the mitral annulus toward the left atrium

Question 59

Nonspecific symptoms of chest pain, palpitations, dizziness, anxiety, fatigue. Most patients are asymptomatic What am I? **What will auscultation reveal?

Answer 59

mitral valve prolapse **mid-systolic click** usually followed by late-systolic murmur

Question 60

What is the diagnostic imaging of choice for mitral valve prolapse? What is the tx? What if severe mitral regurgitation is present?

Answer 60

echo Most patients with mild prolapse and insignificant MR are asymptomatic and require **no intervention** mitral regurgitation present: MV repair or replacement is indicated

Question 61

Consider looking at this flow chart again :) maybe idk idk

Answer 61