Valvular heart disease Flashcards

Question

Which systolic murmors should be evaluated by a Echo?

Answer 1

Early systolic murmurs, midsystolic murmurs grade 3 or more, late systolic murmurs, and holosystolic murmurs all need to be evaluated by Echocardiogram. It if is a midsystolic murmur that is grade 2 or less, it needs to be evaluated by an Echocardiogram only if the patient is symptomatic or display other signs of possible cardiac disease

Answer 2

○ Stage A - Individuals at risk for valvular heart disease. ○ Stage B - Asymptomatic individuals with progressive valvular heart disease (mild to moderate severity on Echo). ○ Stage C - Asymptomatic individuals with severe valvular disease. ■ C1: Severe valve lesion (on Echo), asymptomatic, normal LV function ■ C2: Severe valve lesion (on Echo), asymptomatic, abnormal LV function ○ Stage D - Symptomatic individuals as a result of valvular heart disease

Answer 3

● Narrowed, thickened, stiffened, and roughened valve secondary to several possible causes. ○ Most common is calcific, degenerative changes

Answer 4

aging, hypertension, hyperlipidemia, and smoking

Answer 5

○ The narrowing/stiffening of the valve makes it more difficult for the left ventricle to eject blood during systole. ○ Ventricular systole becomes prolonged as the heart struggles to overcome the increased resistance. ○ Left ventricular hypertrophy can develop due to the pressure overload, eventually resulting in LV failure

Answer 6

○ Left ventricular failure, anginal chest pain, and/or syncope may be the presenting signs and symptoms in significant AS ○ In patients with calcific aortic stenosis, 50% have associated coronary artery disease as well. ○ Exertional dyspnea is also a common presentation ○ Harsh, medium-pitched, crescendo-decrescendo systolic murmur. ○ May have a sustained, significant, and heaving PMI. ○ There may be a systolic thrill over the aortic area or carotids. ○ Delayed carotid upstroke (large delay between S1 & carotid pulse). ○ A prominent S4 may be heard in late, severe disease

Answer 7

○ Because of the stress placed on the heart with AS, complications include angina, exertional syncope, heart failure, and sudden death. ○ Symptomatic AS has a poor prognosis with a 25% annual mortality risk

Answer 8

○ EKG often reveals LVH or secondary repolarization abnormalities. ○ CXR can show a normal or enlarged cardiac silhouette, calcifications of the aortic valve ○ Echocardiogram/Doppler is the most useful for AS

Answer 9

○ Treatment of underlying/comorbid cardiovascular disease is important. ○ Medications do not seem to reduce the progression of AS (even statins). ○ Medical Tx may stabilize patients in heart failure, but intervention is indicated for all symptomatic patients with significant AS. ○ Aortic Valve Replacement (AVR) is the treatment of choice when warranted/recommended;

Answer 10

■ Symptomatic patients (stage D) ■ Asymptomatic patients with Severe AS and LVEF < 50% ■ Patients with Severe AS undergoing other cardiac surgery

Answer 11

■ SAVR can be considered anytime AVR is indicated. ■ TAVR should be reserved only for those patients with symptoms. ■ SAVR and TAVR are equivalent in RCTs of symptomatic patients.

Answer 12

A bioprosthetic valve is preferred in those over 70 YOA, while a mechanical valve is preferred in those under 50 YOA (either if 50-70).

Answer 13

AR is characterized by the reflux of blood back through the “closed” aortic valve during diastole. ○ This generally occurs because of structural abnormalities in the valve itself, or in the aortic root

Answer 14

Congenital bicuspid valves, infective endocarditis, and hypertension ● Less common causes include Marfan-related aortic root dilation, aortic dissection, and widespread inflammatory conditions

Answer 15

○ Regurgitation secondary to any cause results in abnormally rapid filling of the left ventricle, increasing the intraventricular pressure. ■ Can be acute or chronic ○ Chronic AR results in substantial LVH, even more than in aortic stenosis

Answer 16

○ The murmur of AR is a holodiastolic, somewhat decrescendo murmur that is often loud and blowing in early diastole. ■ This is generally heard best along the lower left sternal border. ○ Patients who develop sudden, acute AR present with LV failure manifested primarily as pulmonary edema (life-threatening). ○ In chronic AR, patients may be asymptomatic ○ The heart gradually compensates for the increased LV pressure and volume, resulting in a large stroke volume. ○ The chronic increased LV pressure eventually results in LV dilation and failure, with symptoms of dyspnea on exertion, etc.

Answer 17

Wide Pulse Pressure (pulse is a rapid rise and fall, with elevated systolic BP and low diastolic BP;

Answer 18

May see head bob with each pulse with an aortic regurgitation

Answer 19

○ Because the reflux of blood back into the left ventricle causes significant distress to the ventricle, complications of long-term AR include heart failure, mitral valve regurgitation, and left ventricular hypertrophy

Answer 20

○ Medications that decrease afterload can reduce regurgitation severity, although there is no convincing evidence that this alters mortality ■ Only treat with these medications if the patient has systolic HTN. ○ Asymptomatic patients can be monitored with periodic echocardiogram (approx q 6 months) to watch for progression to severe AR.

Answer 21

■ Symptoms attributable to AR ■ LV ejection fraction less than 50% ■ LV end-systolic diameter at > 50 mm or end-diastolic at > 65 mm ■ Having cardiac surgery for other indications ■ Moderate AR and undergoing other heart surgery ○ In addition, those with aortic root dilation of greater than 55 mm should undergo surgery for AVR and aortic root replacement.

Answer 22

Mitral stenosis is narrowing of the mitral valve occurring secondary to leaflet thickening, commissural fusion, and/or shortening and fusion of the chordae tendineae

Answer 23

rheumatic heart disease

Answer 24

○ The thickened, stiff leaflets of the mitral valve prevent normal, quick flow of blood from the left atrium into the left ventricle ○ In more severe disease, LA pressure can be increased, causing increased hydrostatic pressure in the pulmonary vasculature, and may result in RV dilation. ○ Dilation of the LA dramatically increases the risk of developing Atrial Fibrillation

Answer 25

○ Patients with mild disease may be asymptomatic. ○ When symptoms develop, the classic presentation is that of dyspnea on exertion, fatigue, and/or symptoms of RV failure ○ Classic findings include an early diastolic Opening Snap and/or a late diastolic, low-pitched grumble at the apex in left-lateral position ○ 50-80% of mitral stenosis patients will develop either paroxysmal or chronic atrial fibrillation

Answer 26

Atrial Fibrillation is one of the most common complications ○ Other important complications include: ■ Heart failure, right-sided ■ Pulmonary hypertension ■ Pulmonary edema ■ Thromboembolism

Answer 27

○ As is the case with the other valvular disorders, Echocardiogram is the most valuable diagnostic technique for assessing mitral stenosis ○ Echo can also measure the effective mitral valve area

Answer 28

○ Indications for intervention focus on symptoms such as pulmonary edema, decline in exercise capacity, or evidence of Pulmonary HTN ■ Percutaneous Balloon Valvuloplasty ■ Mitral Valve Replacement

Answer 29

Also commonly called Mitral Insufficiency, mitral regurgitation is the systolic retrograde flow of blood from the left ventricle through the mitral valve into the left atrium

Answer 30

○ Endocarditis ○ Myocardial Infarction ○ Trauma ○ Chronic degenerative (primary) ○ Chronic functional (secondary

Answer 31

○ This increases LV preload and decreases afterload, resulting in an enlarged LV and LA with an increased LV ejection fraction. ○ Over time, the stress of the volume overload reduces LV contractile strength.

Answer 32

○ In acute severe MR, patients present with sudden symptoms of left heart failure (such as dyspnea at rest) and may have cardiac shock. ○ Chronic cases may be asymptomatic (even for life). When symptoms do develop, the patient presents with left-sided heart failure. ○ The murmur of MR is a pansystolic murmur heard best at the apex. ○ EKG and Echo in moderate-to-severe disease generally show left atrial enlargement, left ventricular hypertrophy, and commonly A-Fib.

Answer 33

■ Heart failure ■ Pulmonary Hypertension ■ Atrial Fibrillation

Answer 34

○ Mitral Valve Surgery (replacement or repair) ○ Medical therapy for heart failure should be initiated as well, including ACEi/ARBs, Beta Blockers, and/or Aldosterone Antagonists if no contraindications (more on HF Tx in future units)

Answer 35

■ Acute severe mitral regurgitation (emergent surgery). ■ Chronic degenerative (primary) if LV EF is < 60%, LV end-systolic diameter is > 40 mm, and/or Sxs with LV EF greater than 30%. ■ Chronic functional (secondary) if large regurgitant volume and LV EF is greater than 30%

Answer 36

chronic severe secondary MR

Answer 37

Mitral valve prolapse syndrome is when a flap of the mitral valve bulges up and into the left atrium during systole

Answer 38

Marfan Syndrome and other Connective Tissue Disorders ● Secondary causes include CAD, rheumatic heart disease, and cardiomyopathies.

Answer 39

mitral regurgitation

Answer 40

Mid-Systolic Click

Answer 41

● Beta Blockers ● Mitral Valve Repair

Answer 42

● Tricuspid Regurgitation may be due to an acute event, such as endocarditis or trauma. It can also be chronic and secondary to congenital deformity, rheumatic heart disease, etc ● Tricuspid Stenosis is often secondary to rheumatic heart disease or congenital deformity. Bacterial endocarditis is a possible cause as well. ○ Considered rare, affecting less than 1% of the population

Answer 43

○ Whether it be due to stenosis or regurgitation, an overload of right-sided pressure develops ○ Sometimes the pressure overload is too much and results in right-heart failure with right-sided cardiomegaly, enlarged right atria, decrease in right ventricular function, peripheral edema, and possible Atrial Fibrillation

Answer 44

○ Tricuspid stenosis murmur: Not much of a murmur most of the time. If present, it may be increased with inspiration, heard best along the left sternal border, and has a quiet, late diastolic rumble. ○ Tricuspid regurgitation murmur: May have pansystolic murmur heard best at the lower left sternal border that may radiate to the left clavicle. ○ When symptoms do develop, they are consistent with right-sided heart failure, which includes: Fatigue, JVD, palpable liver pulsations, peripheral edema, ascites. ○ A right Parasternal Lift and/or Thrill may be felt in RV enlargement.

Answer 45

○ Consider diuretics to control volume status in symptomatic patients. ○ A percutaneous balloon valvuloplasty may be attempted in patients with symptomatic tricuspid stenosis (although not often helpful) ○ Open tricuspid valve surgery is recommended for some patients with symptoms of right heart failure ○ Referral to cardiothoracic surgery for evaluation is always appropriate

Answer 46

● Pulmonic Regurgitation may be due to pulmonary hypertension (often from pulmonary conditions), bacterial endocarditis, iatrogenic after pulmonary balloon valvuloplasty, or congenital causes. ● Pulmonic Stenosis is almost always congenital and a disease seen in infants. Rubella has been associated in some cases.

Answer 47

○ Whether it be due to stenosis or regurgitation, an overload of right-sided pressure develops. ○ Sometimes the pressure overload is too much and results in right-heart failure with right-sided cardiomegaly, decrease in right ventricular function, and signs and symptoms of right-heart failure

Answer 48

○ Severe pulmonic stenosis may present as heart failure in the neonatal period. Or it may also progress to heart failure later in childhood ○ Pulmonic Stenosis murmur: Harsh mid-systolic crescendo-decrescendo murmur, heard best at upper left sternal border; can radiate to neck. ○ Pulmonic Regurgitation murmur: Decrescendo early to mid-diastolic murmur heard best at the upper left sternal border.

Answer 49

○ Diuretics should be considered in patients with pulmonic valve disease and right-heart failure. ○ Cardiothoracic surgery referral for other possible interventions, which include:

Answer 50

aortic and mitral

Answer 51

○ Mechanical valve- Long-lasting and made of durable material ○ Bioprosthetic “tissue” valve- Made of mammal donor tissue ○ Ross Procedure- Moving pulmonic valve to replace aortic valve ○ TAVR- Transcatheter Aortic Valve Replacement

Answer 52

● Bioprosthetic heart valves last about 10-15 years, where mechanical heart valves last decades (usually for the rest of the patient’s life)

Answer 53

● The risk of thromboembolism is much higher with a mechanical heart valve than it is with a bioprosthetic heart valve. ○ For this reason, patients with mechanical heart valves should be anticoagulated with Warfarin

Answer 54

● Because pregnancy is a prothrombotic state, the risk of morbidity and mortality is high for pregnant patients with mechanical heart valves ● When patients with mechanical heart valves and systemic anticoagulation need to undergo noncardiac surgery, the risk of thrombosis from stopping warfarin versus the risk of excessive bleeding from continuing warfarin must be weighed

Valvular heart disease Flashcards

(80 cards)