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Flashcards in Valvular Heart Disease Deck (30):
1

Ventricular anatomy and hemodynamic response to aortic stenosis


  • Ventricular anatomy: aortic valve becomes fused, narrow and unable to open under normal pressures. 




  • Hemodynamic response: ↑end diastolic pressure ↑systolic pressure, ↓aortic diastolic pressure.
     

2

Ventricular anatomy and hemodynamic response to aortic regurgitation (insufficiency)


  • Ventricular anatomy: aortic valve can not close properly to allow the build up of pressure during diastole. Vegetation may be present and causing the destruction of the valve. 



  • Hemodynamic response: ↑stroke volume, ↑pulse pressure,↓ aortic diastolic pressure (blood leaks back)
     

3

Causes, signs, symptoms of aortic stenosis 

  • Causes: bicuspid aortic valve (most common congenital heart disease), senile aortic stenosis, rheumatic heart disease

  • Symptoms

    • Dyspnea on exertion

    • Syncope

    • Angina (hypertrophy, ↑systolic pressure, ↓aortic diastolic pressure, ↑end diastolic pressure)

  • Signs:

    • systolic ejection murmur

    • abnormal heart sounds
  • Possible LV and RV failure
     

     

     

4

Qualities of heart murmur associated w/aortic stenosis

 

  • Ejection + thrill (diamond or crescendo-decrescendo)
  • Peaks later as stenosis becomes more severe.
  • Radiates to neck.





     

 

 

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5

Abnormal heart sounds in aortic stenosis

  • S2: becomes softer as valve becomes more immobile and if myocardium deteriorates.
  • Opening: sudden forceful valve opening or high pressure jet hitting aorta
  • S4: LVH
  • S3: if ventricle fails.

6

Signs/symptoms of L/R HF w/aortic stenosis

  • If LV fails: narrow pulse pressure, peripheral vasoconstriction, rales, S3
  • If RV fails too: ↑JVP, peripheral edema.

7

Cause, hemodynamic effects, signs/symptoms of aortic regurgitation

  • Cause:

    • Aortic leaflet disease: bicuspid valve disease, rheumatic heart disease, endocarditis. 

    • Aortic root disease: aortic aneurysm/dissection, marfan’s syndrome, syphilis.

  • Hemodynamic effects: low aortic diastolic pressure, large stroke volume, high pulse pressure.
  • Symptoms: well tolerated, symptoms of heart failure only after years.
  • Signs: wide pulse pressure bounding (waterhammer) pulses, capillary pulses (quinke), diastolic decrescendo murmur (turbulence), displaced vigorous LV apex impulse.

     

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8

Cause, hemodynamic effects, signs/symptoms of mitral stenosis


  • Cause: rheumatic heart disease (4:1 in females) 



  • Hemodynamic effects: obstruction of flow from left atrium to left ventricle→↑LA pressure↑PA and RV pressure. 





  • Symptoms:






    • ↑ Left atrial and pulmonary capillary pressures: dyspnea, cough, pulmonary edema 



    • RV failure: ↑elevated jugular venous pressure, edema. 



  • Signs:
    • Diastolic murmur: heard best in left lateral decubitus, soft, accentuated when flow is greatest; loud S1; opening snap (as mitral valve gets more severe).


    • CXR: signs of ↑LA pressure→LA enlargement, Kerley B-lines and heart failure, pulmonary artery enlargement. 

 

 

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9

Characteristics of bicuspid valve disease

  • common congenital heart defect

  • increased risk for aortic stenosis, aortic insufficiency, endocarditis, and vascular complications

  • should be monitored routinely via echo

10

Signs of aortic regurgitation

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11

CXR findings in aortic stenosis, mitral stenosis

  • Aortic stenosis: post-stenotic dilation of aorta, enlarged LA and LV if failure occurs.

  • Aortic regurgitation: LV enlargement, dilated aorta. 


  • Mitral stenosis: signs of elevated LA pressure—LA enlargement, Kerley B-lines and heart failure, pulmonary artery enlargement.






     

12

ECG findings in aortic stenosis, mitral stenosis

  • Aortic stenosis: LVH, occasionally L or R Bundle Branch Block.
  • Aortic regurgitation: LV enlargement, dilated aorta
  • Mitral stenosis: left atrial enlargment, RVH






     

13

Echo findings in aortic stenosis, aortic regurgitation, mitral stenosis

  • Aortic stenosis: abnormal valve structure, ventricular hypertrophy, dilated aorta, pressure gradient, aortic valve area.
  • Aortic regurgitation: valve or root pathology, ventricular enlargement, amount of aortic insuffiency.
  • Mitral stenosis: abnormal valve, pulmonary pressures, mitral valve area.

14

General course of aortic stenosis

  • can occur early in life due to a congenital malformation (bicuspid aortic valve) or late in life (senilar aortic stenosis, or somewhere in between (rheumatic heart disease).
  • Good health and youth can mask the symptoms making younger people more at risk for sudden death.
  • After the onset of symptoms however, there is a sharp decrease in survival, thus, treatment and therapeutic interventions should take place right away

15

General course of aortic regurgitation

  •  generally well tolerated until symptoms of heart failure appear (generally takes years).
  • quick response to treat the ventricular hypertrophy associated with aortic insufficiency via replacement of the valve can result in the ventricle returning back to its near normal state.

16

Course/tx of mitral stenosis

  • can cause heart failure and atrial fibrillation
  • treat urgently

17

Components of mitral valve anatomy (4)

  • annulus
  • leaflets (2)
  • chordae
  • papillary muscles

18

Mitral valve annulus characteristics

  • fibrous structure that supports valve @ AV groove
  • saddle-shaped

19

Causes of mitral valve regurgitation

  • primary valve disease (e.g. myxomatous, endocarditis, chordae rupture)
    • mitral valve prolapse
  • fxnl mitral valve disease
    • primarily a LV problem

20

Mitral valve prolapse disease course

  • long, asymptomatic @ first
  • L atrial enlargement (--> arrhytmias)
  • LV volume overload (LV dilation/dysfxn)
  • HF symptoms
  • risk of endocarditis

21

Mitral valve physical exam findings

– Mid systolic click 
– Late diastolic or holosystolic murmur; Classically @ apex 
– Maneuvers that Decrease LV size intensify 
and prolong the Murmur: Valsalva, dehydration 
– Maneuvers that Increase LV size decrease 
murmur: Squatting, Hydration 

 

22

Primary Mitral valve disease tx

  • surgical repair, replacement
  • afterload reduction (reduce BP)
  • treat CHF (diuretics)

23

Fucntional mitral regurgitation characteristiscs (physical exam)

-- Holosystolic murmur a apex: Quiet S1 
– Signs of LV dysfunction: 

S3, S4 
Loud P2 – associated with Pulmonary 
Hypertension 
Lateral displacement of the apical impulse 
Edema, crackles, Jugular venous distension 

 

24

Functional mitral regurgitation treatment

  • treat underlying cardiomyopathy: ACEi, beta-block, spironolactone, revascularization, bi-ventricular pacing, transplant
  • primary mitral valve surgery is controversial

25

Main causes of mitral valve stenosis

– Rheumatic Heart Disease 
Rheumatic fever produces antibodies 
Attack the valve many years later 
– Rarely senile Calcification 
Age 
Renal disease 

 

26

Mitral stenosis disease course

Long asymptomatic period 
Left atrial enlargement (can be massive) 
– Atrial arrhythmias 
– Clots, strokes 
Heart failure symptoms 
– Dyspnea, edema, orthopnea 
Pulmonary Hypertension 
– Right ventricular dysfunction 
– Tricuspid regurgitation 

 

27

Mitral stenosis physical exam findings

Loud S2 
– Opening snap 
S2-OS time shorter with more severe stenosis 
– Diastolic rumble 
At apex 
– Signs of pulmonary hypertension 
Loud P2 
RV thrill or lift 
Jugular venous distension 
Tricuspid regurgitation murmur

28

Mitral stenosis tx

Valvuloplasty 
Surgical replacement 
Medical treatment 
– Not curative 
– Beta blockers 
– Diuretics (to treat heart failure) 
– Anticoagulation 
– Antibiotics 

 

29

Tricuspid valve anatomy

  • 3 leaflets
  • 3 papillary muscles

30

Characteristics of tricuspid valve disease

Tricuspid Regurgitation is almost always secondary to Right heart failure or 
pulmonary Hypertension 


Primary Tricuspid Valve disease is rare 
– Congenital heart disease
– Endocarditis 
– Carcinoid 
– Rheumatic (less common than mitral valve)
 

 

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