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Flashcards in Valvular Dz Deck (37)
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1

What are the two main types of valvular lesions?

-stenosis (scarring and blockage)
-regurgitation (insufficiency, incompetence/leaky)

2

Causes of Valvular dz

-rheumatic fever
-infective endocarditis
-functional (leaflets)
-Congenital malformations (pediatric/bicuspid)
-Aging valve tissues (Calcification)
-Rupture of papillary muscles
-Collagen Vascular Dz
-Aortic dissection
-Syphillis

3

What are the most common valvular dz?

mitral and aortic

4

What are some causes of Tricupside valvular dz?

-annular dilation (TR)
-rheumatic dz (TR & TS)
-Carcinoid syndrome (TR and TS)
-Endocarditis (TR)
-Ebstein Anomaly (TR)

5

Tricuspid Regurgitation
- pathophysiology

Patho:
-pulmonary HTN developes leading to right ventricular dilation and tricuspid annulus dilation. As dilation progresses the chordal papillary muscle complex becomes functionally shortened preventing leaflet apposition resulting in valvular incompetence.

6

Tricuspid Regurgitation
-clinical presentation
-Physical Exam findings

Presentation:
-fatigue & weakness related to reduction of CO
-Dyspnea on exertion and SOB
-Right heart failure leads to ascites, venous engorgement, hepatosplenomegaly, pulsatile liver, pleural effusion, peripheral edema
-cachexia, cyanosis, jaundice, a-fib.

PE:
-right sided failure
-abnormal pulse in jugular vein
-high pitched systolic murmur

7

Tricuspid Stenosis
-common causes
-sx & signs
-pathophys
-EKG findings

Common cause:
-rheumatic

Signs Sx:
-fatigue, anorexia, & malaise d/t reduction of CO
-edema
-hepatomegaly
-ascities
-pleural effusion
-systolic murmur.


Pathophys:
-right atrial pressure increases leading to venous congestion.
-right atrial wall thickens and chamber dilates.

EKG findings;
-tall P waves, RAE on EKG

8

Infective endocarditis
-most commonly affects which valve?
-common in who?

-Tricuspid valve
-Common in IV drug users

9

What is Ebsteins anomaly? Tx

-developmental defect in which the tricuspid valve is incompletely formed, annulus is depressed into the RV. Small RV cavity, tricuspid regurgitation. Large right atria.

Tx: fluid restriction, diuretics, and treat the complications. Difinitive surgery is to correct the tricuspid valve.

10

Pulmonary Regurgitation
-may be congenital or acquired, what are these?

Congenital: abnormal cusp number, abnormal cusp development, no valve (atresia)

Acquired: pulmonary htn, annular dilation, structural distortion.

11

Pulmonary Stenosis
-may be congenital or acquired, what are these?

Congenital is congenital..

Acquired: rheumatic heart disease, carcinoid, infective endocarditis.

12

Mitral Stenosis:
-etiology
-What are the mitral valve areas that are considered to be mild, moderate, and severe stenosis?
-at what Mitral valve area do sx become apparent?

etiology:
-primarily a result of rheumatic fever
-Congenital
-Carcinoid
-Lupus
-RA
-Amyloid

Mitral Valve Areas:
-Mild: 1.5-2.5
-Mod: 1.0-1.5
-Severe: less than 1.0cm2

-sx are apparent at less than 2.5cm2

13

Mitral stenosis
-sx
-CXR
-Auscultation

-fatigue
-palpitations
-cough
-SOB
-Left sided failure (orthopnea, PND)
-Palpitation
-Hoarseness (d/t compression of the left recurrent laryngeal by the enlarged atria)

CXR:
-congestion and large LA, if severe right heart disease can see ring of calcification (annulus)

Auscultation:
-S1 as loud as S2 in aortic area
-diastolic murmur

14

Mitral Stenosis:
-complications
-pathophysiology

Complications:
-atrial dysrhythmias
-systemic embolization
-CHF
-Hemoptysis (ruptured bronchial veins d/t pulm HTN.)
-Endocarditis
-pulmonary infections

Pathophys:
-Left atrial HTN
-pulmonary interstitial edema & pulmonary HTN.
-Left atria stretch and fibrillation
--increased HR thus decreased LV filling
--decreased atrial kick thus decreasing LV filling
--atrial thrombus formation and embolus
--limited LV filling and CO.

15

EKG findings for Mitral Stenosis

LAE, RVH, PVC, afib/flutter

16

Mitral Valve Stenosis
Tx

-Diuretics for LHF/RHF
-Digitalis/Beta Blockers/CCB: rate control in afib
-anticoagulation: afib
-endocarditis prophylaxis
-balloon valvuloplasty
-surgery: mitral commissurotomy, mitral valve replacement, mitral valve repair usually not possible.

17

Mitral Regurgitation
- Etiology

Etioloy:
-valvular leaflets: rheumatic, endocarditis, congenital
-chordae: fused, ruptured, degenerative, infectious endocarditis
-Annulus: calcifications, Infectious endocarditis
-Papillary Muscles: CAD (ischemia, infarction, rupture)
-LV dilatation & functional regurgitation

18

Mitral Regurgitation Pathophysiology
-sx

-chronic LV volume overload leads to LVH and decreased CO.
-backflow into atria leads to LAE and pulmonary HTN

Sx:
-dyspnea
-orthopnea, PND
-fatigue
-Pulm HTN, Right sided failure
-Hemoptysis
-Systemic Embolization in a-fib

19

Describe Mitral Valve murmur and heart sounds

murmur: pansystolic, heard loudest apex to axilla

-laterally displaced apex
-wide split S2

20

Mitral Valve Regurgitation
-EKG findings
-CXR findings
-echo findings

EKG:
-LAE, afib, LVH, RVH

CXR:
-enlarged LV and LA, increased pulmonary vascularity

Echo:
-can tell you the severity and etiology of MVR.
Etiology:-flail leaflets, thick (RHD), post movement of leaflets(MVP), vegetations (IE)
Severity: -regurgitant volume/fraction/orifice area, LV systolic function, increased LV/LA size, EF

21

Mitral Valve Prolapse
-aka
-etiology
-pathophys
-presentation

aka: floppy valve, Barlows

Etiology:
-congenital
-Marfans Syndrome
-RHD
-Sequelae of cardiomyopathy or MI

Pathophys:
-valve leaflet has redundant tissue
-extra tissue balloons into LA, click sound.

Presentation :
-asymptomatic
-symptomatic:
--palpitations
--arrhythmias
--atypical chest pain (not typical of angina pectoris)

22

Mitral Valve Prolapse
-EKG findings
-Echo findings
-heart sounds
-Tx

EKG:
-normal or abnormal
-SVT
-Wolf parkinson white syndrome
-nonspecific ST-T changes

Echo:
-confirms dx

Heart sounds:
-mid systolic click

Tx:
-Reassurance
-Beta blockers
-Subacute Bacterial Endocarditis prophylaxis

Complications:
-rare: endocarditis, progressive MR, thromboembolism, atrial and ventricular arrhythmias

23

Chronic Mitral Regurgitation
-Tx
-what class of sx indicate surgical intervention?

-ACEi if hypertensive
-afib requires rate control, anticoagulation and attempt at restoration of sinus rhythm.
Preload reduction:
--low sodium diet
--diuretics
Afterload reduction:
--vasodilators(ACEi, hydralazine)
--Digoxin
--Subacute Bacterial endocarditis prophylaxis
-Surgery:
--mitral valve repair/replacement
*repair is preferred over replacement!
*surgery should be performed before onset of severe sx or development of LV contractile dysfunction.

-Class III or IV sx ALWAYS indicate need for surgery
-Class II sx indicate need for surgery in pts with repaireable valves

24

Acute Mitral Regurgitation
-pathophys

pathophys:
-abrupt volume overload, no time for adaptation. Sudden decrease in forward stroke volume, sudden increase in LA volume leading to increased Pulmonary volume/pressure. Decrease in forward CO...cardiogenic shock.

call the surgeon!!

25

Acute mitral Regurgitation
-sx
-dx

sx:
-acute severe dyspnea, CHF, and hypotension
-LV size is normal
-loud S1
-systolic murmur
-S3 --may be only abnormality present

Dx:
TEE for dx
-chordal or papillary muscle rupture/tear
-infarction with papillary muscle ischemia or tear
-infectious endocarditis with leaflet perforation

26

Aortic Stenosis
-pathophys
-etiology

patho:
-left ventricular outflow obstruction
-concentric LVH resulting in impaired LV diastolic compliance
-LA hypertrophy and enlargement, diastolic dysfunction
-limits ability to increase stroke volume
-progressive LV dilation and contractile failure leads to systolic dysfunction..

Etiology:
-congential bicuspid aortic valve
-rheumatic aortic valve disease
-Calcific (senile) aortic stenosis

27

Aortic Stenosis :
-sx
-complications

sx:
-long asymptomatic latent period
-cardinal sx of severe aortic stenosis are dyspnea, angina, and syncope.

Complications :
-sudden death
-Left ventricular dilatation and contractile failure
-endocarditis
-arrhythmias (vtach, afib)

28

Why does aortic stenosis cause angina?
-syncope

Angina:
-increased wall stress leading to increased myocardial oxygen demand, exceeds ability of coronary flow to meet demands.

Syncope:
-fixed CO
-heart block: Ca2+ deposits in aortic ring encroach upon conduction tissue
-ventricular arrythmias

29

Key Physical Findings in Severe Aortic Stenosis

-carotid bruits
-Systolic ejection murmur
-Rales/crackles (heart failure)
-Cold and decreased pulses in extremities

30

Aortic Stenosis Dx Findings
-ekg
-CXR
-echo
-doppler
-cath

ekg: LVH w/ repolarization changes "strain pattern"

CXR: aortic root dilation and failure

Echo: aortic valve thickening and restrictive motion

Doppler:
increased flow velocity across aortic valve

Cath: measures gradient across aortic valve and calculates valve area