Valvular Heart Disease Flashcards Preview

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Flashcards in Valvular Heart Disease Deck (21):
1

Cardiac Valves

  • Components
  • Covered in...

  • Components
    • Leaflet/cusp
    • Commissure
    • Annulus: anchors to heart wall
    • Chordae tendineae & papillary muscle
  • Covered in...
    • Endothelium / endocardium w/ a fibrocollagenous core

2

Types of Valvular Pathology

  • Prolapse
  • Stenosis
  • Insufficiency
  • Regurgitation

  • Prolapse
    • Leaflets reflect backwards
  • Stenosis
    • Orifice is narrowed
  • Insufficiency
    • Leaflets don't come together
  • Regurgitation
    • Blood flows backwards

3

Valve Disease

  • Most common affected valves
  • Most common etiology
  • Pulmonic stenosis etiology

  • Most common affected valves
    • Mitral
    • Aortic
  • Most common etiology
    • Calcific degeneration
  • Pulmonic stenosis etiology
    • Congenital

4

Mitral Valve Prolapse

  • General
  • Signs & symptoms
  • Pathology
  • Histology
  • Complications

  • General
    • Most common mitral valve disease
    • Young to middle aged women
    • ~3% of the adult population
  • Signs & Symptoms
    • Mid systolic click w/ late systolic murmur
      • Click: valve flapping backward
      • Murmur: blood flowing backward
    • Cardiac arrhythmia
    • "Chest fluttering"
    • No symptoms at all
  • Pathology
    • Myxomatous degeneration of the mitral valve
    • Sometimes associated w/ connective tissue diseases (i.e. Marfan's)
    • Hooding of valve leaflet
      • AKA parachute deformity, billowing
    • Redundant folds in valve leaflet
  • Histology
    • Acellular material accumulates in valve
    • Disrupts normal fibrous structure of the valve
    • Looks pink on H&E
  • Complications
    • Cardiac arrhythmia
    • Valve incompetence or rupture
      • Chordae tendinae can get thinned & elongated --> rupture
    • Infective endocarditis (problem w/ all abnormal valves)
    • Stroke from thrombus (problem w/ all abnormal valves)

5

Mitral Valve Stenosis

  • General
  • Pathology
  • Clinical findings & complications
  • Which heart chamber would first become abnormal as a result of mitral stenosis
  • Why atrial fibrillation
  • Common causes

  • General
    • Thickenign & calcificaiton of mitral valve
    • Almost always a result of rheumatic heart disease
    • Can be a result of calcific degeneration of valve annulus (ring)
      • Age-related change
  • Pathology
    • Annular calcification
    • Leaflet calcification
  • Clinical findings & complications
    • Diastolic murmur
    • Cardiac arrhythmia (atrial fibrillation)
    • Infective endocarditis (problem w/ all abnormal valves)
    • Stroke from thrombus (problem w/ all abnormal valves)
  • Which heart chamber would first become abnormal as a result of mitral stenosis
    • Left atrium
  • Why atrial fibrillation
    • Atrial chamber dilates --> improper electrical signal conduction
    • Mitral valve narrowed or blocked
  • Common causes
    • Degenerative (old age)
    • Rheumatic heart disease

6

Aortic Stenosis

  • General
  • 3 main causes
  • Degenerative calcification
  • Congential bicuspid valve
    • General
    • Clinical complications
    • Clinical complications (regardless of cause)
    • Difference b/n bicuspid & tricuspid aortic stenosis
  • Rheumatic heart disease

  • General
    • Most common valvular disease
  • 3 main causes
    • Degenerative calcification
    • Congenital bicuspid valve
    • Rheumatic heart disease
  • Degenerative calcification
    • 2% prevalence
    • In a normal 3-cusp valve
      • Age related (degenerative)
      • 50-70 years old
    • Cacified & stenotic valve
  • Congenital bicuspid valve
    • General
      • Most common congential CV abnormality (~1% incidence)
        • Responsible for ~50% of aortic stenosis cases
      • Aortic valve composed of 2 cusps instead of 3
        • Cusps may be of equal size, or one might be slightly larger
    • Clinical complications
      • Aortic dissection
      • Endocarditis (abnormal valve)
    • Clinical complications (regardless of cause)
      • Massive left ventricular hypertrophy (caused by...)
        • ​Aortic stenosis: valve disease
        • Hypertension
        • Hypertrophic cardiomyopathy: disease of young athletes
      • Mitral regurgitation
        • Increased pressure in left ventricle
      • Aortic dissection
      • Aortic valve perforation
        • As valve degenerates
      • Myocardial infarction
        • Difficulty perfusing coronary arteries
        • Supply-demand mismatch
      • Cardiac arrhythmia
      • Heart failure
    • Difference b/n bicuspid & tricuspid aortic stenosis
      • Bicuspid: younger (50s)
      • Tricuspid: older (70s+)

7

Carcinoid Heart Disease

  • General
  • Clinical considerations

  • General
    • Unique cause of right-sided valve disease
    • Carcinoid syndrome
      • Tumor produces serotonin or other vasoactive compounds (bradykinin, histamine, prostaglandins, etc.)
    • Thickened valvular plaques made of smooth muscle, collagen, & matrix
  • Clinical considerations (not important)
    • Severity of lesions corresponds w/ amount of vasoactive peptide produced by tumor
    • GI carcinoids don't really caues heart lesions
      • Carcinoids that would be exposed to the heart are filtered throught the liver
    • Left-sided lesions are rare but can be seen in "exogenous" vasoactive peptide use
      • i.e. Diet pills "fen-phen," ergotamine for migraines

8

Endocarditis

  • General
  • 4 types

  • General
    • Inflammation / infection of heart valves
  • 4 types
    • Bacterial (infective) endocarditis
    • Rheumatic endocarditis
    • Non-bacterial thrombotic endocarditis
    • Libman-Sacks endocarditis

9

Rheumatic Heart Disease

  • Causes...
  • Rheumatic fever
  • Etiologic theory
  • Endocarditis
  • Summary

  • Causes...
    • Endocarditis: vegetations on heart vavle surfaces
    • Myocarditis: inflammation of the mycoardium
    • Pericarditis: inflammation of the pericardium
  • Rheumatic fever
    • Children (5-15 years old)
    • 1-4 weeks after group A Streptococcal infection ("Strep throat," Strep. pyogenes)
    • Sydenham chorea, erythema marginatum, subcutaneous nodules, carditis, migratory polyarthritis
    • Major Jones Criteria: carditis
  • Etiologic theory
    • Antigenic cross-reaction b/n Streptococcus & heart tissues
    • Direct invasion by bacteria?
  • Endocarditis
    • Fibrinous necrosis on cusps & cords
    • Vegetations (verrucae) overlying these areas of necrosis
    • NOT INFECTIOUS
    • Composed of fibrin, inflammatory cells
    • Eventually leads to scarring & deformity of valve
    • Result: valve stenosis or insufficiency
    • Typical course of RF DOES NOT involve rheumatic heart disease
  • Summary
    • Gropu A Streptococcal infection (Strep throat)
    • Immune cross-reaction to heart tissues
    • Inflammation fo heart (i.e. myocarditis, endocarditis, & pericarditis [sudden death])
    • Damage to heart tissues (i.e. valve stenosis, valve insufficiency, myocardial scarring [later in life])

10

Non-Bacterial Thrombotic Endocarditis (NBTE)

  • General
  • Clinical manifestations

  • General
    • Bland thrombus that sits on valve surface
    • No bacteria, no inflammation
    • AKA Marantic endocarditis
    • Occurs in debilitating disease (i.e. cancer or "wasting diseases")
    • Can flick off clots to other organs or tissues
  • Clinical manifestations
    • Valve stenosis or insufficiency
    • Stroke
    • Lower extremity ischemia
    • Associated w/ hypercoagulable states

11

Libman-Sacks Endocarditis

  • General
  • Valve lesions

  • General
    • Occurs in Systemic Lupus Erythematosis (SLE)
    • Non-infectious small thrombi on outer & inner surfaces of mitral & tricuspid
    • May also occur on chordae & ventricular wall
  • Valve lesions
    • Composed of fibrin, cellular debris (from ANA damage)
    • Can become "active" w/ valvulitis

12

Who is most likely to get marantic endocarditis?

  • Patient w/ metastatic lung cancer

13

Prosthetic Heart Valves

  • 2 types
  • Mian things to remember
  • Complications

  • 2 types
    • Mechancial: made of metal or other material
    • Biolgoical: composed of human heart or porcine valves
  • Main things to remember
    • Can act as nidus of infection (i.e. endocarditis) or thrombus
    • Mechanicals can damage erythrocytes
    • Biologicals dont' last as long (calcification primary problem)
  • Complications
    • Thrombosis
    • Infection
    • Valve failure
    • Calcification

14

Scenario 1

  • 38-year-old woman with "chest fluttering"
  • You hear a mid-systolic click w/ late systolic murmur

Mitral valve prolapse

15

Scenario 2

  • 53-year-old man w/ diastolic murmur
  • Has history of rheumatic fever as a child

Mitral valve stenosis - rheumatic heart disease

16

Scenario 3

  • 53-year-old man w/ holosystolic murmur
  • Has histoyr of rheumatic fever as a child

Mtiral valve insufficiency & regurgitation - rheumatic heart disease

17

Scenario 4

  • 78-year-old man w/ systolic murmur
  • EKG suggests left ventricular hypertrophy

Aortic stenosis - calcific degenerative

18

Scenario 5

  • 52-year-old man w/ systolic murmur
  • EKG suggests left ventricular hypertrophy

Aortic stenosis - bicuspid aortic valve

19

Scenario 6

  • 52-year-old man w/ history of systolic murmur
  • Now presents w/ sudden onset of severe "tearing" chest pain radiating to back

Aortic dissection - bicuspid aortic valve w/ stenosis

20

Scenario 7

  • 56-year-old woman w/ Lupus
  • Sudden onset of stroke symptoms

Endocarditis - Libman-Sacks, embolic event

21

Scenario 8

  • 58-year-old man w/ terminal head & neck cancer
  • Sudden onset of stroke symptoms

Endocarditis - non-bacterial thrombotic endocarditis, embolic event