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Flashcards in Valvular heart disease Deck (16):
1

Classification of stenosis and regurgitation

-Mild: 1.5-2cm
-Moderate: 1-1.5cm
-Severe: <1cm
-Severity of regurg: based on imaging and hemodynamic parameters, semiquantitative (mild/moderate/severe)

2

Aortic stenosis 1

-Etiology: bicuspid (congenital, most common, manifests around early life and 4th decade), rheumatic fever sequelae (Sx manifest decades after infection usually 4-5th decade, very often theres mitral valve involvement as well), degenerative (most common in older pts, >65)
-Sx: angina, dyspnea, syncope (HF Sx), once any of these Sx appear the prognosis goes way down (<2 yrs)

3

Aortic stenosis 2

-PE: sustained LV impulse (hypertrophic LV), reduced amplitude and delayed carotid pulse (+/- carotid thrill), harsh systolic (after S1) ejection murmur diamond shaped (crescendo-decrescendo)
-ECG: LVH, LBBB, secondary ST-T abnormalities
-CXR: cardiomegaly, post-stenotic dilatation, Ao calcification, laterally/inferiorly displaced apex

4

Aortic stenosis 3

-Echo: valve morphology, calcification, valve area and gradient abnormalities
-Cardiac cath: very high LVP (200), with low systolic Ao pressure (100), meaning very large difference btwn max ventricular pressure and max Ao pressure
-Rx: no medical Rx, must have surgery (bioprosthetic, mechanical) to replace or valvuloplasty (via catheter)

5

Aortic regurg (AR) etiology

-Depends if its chronic or acute (usually chronic)
-Chronic valve problem: congenital bicuspid, rheumatic, endocarditis, myxomatous degeneration
-Chronic Ao root problem: marfan's, erdheim's medial necrosis, ankylosing spondylitis, syphilis
-Acute: endocarditis, trauma, dissection, rupture of prosthetic valve
-Acute is usually endocarditis, w/ resultant increase in LVP, LAP, pulmonary edema, weakness and reduced CO resulting in death if not Rx

6

Chronic AR Sx, signs, and findings 1

-Sx: pounding pulse (water hammer), wide pulse pressure (systolic HTN from increased SV), orthopnea, PND, volume overload, LVH (from increased LVEDP- HF Sx), chest pain and inadequate coronary perfusion
-Signs: increased LV SV and Ao pulse pressure, S2 (diastolic) decrescendo murmur, to and fro femoral murmur, head bobbing

7

Chronic AR Sx, signs, and findings 2

-ECG: LVH, LBBB
-CXR: cardiomegaly, laterally/inferiorly displaced apex (LVH)
-Echo: abnormal Ao root and valve morpholgy, LVH
-Cath: high systolic Ao pressure (due to greater SV/FoC) and low diastolic Ao pressure (due to regurg) leads to wide pulse pressure
-Rx: no real med Rx, surgery is needed but timing is important for valve repair/replacement

8

Differences btwn AR and AS

-The high Ao resistance in AS leads to high LVP but low SV, thus CO goes down even though there is muscular hypertrophy of LV
-In AR, the regurgitation in to LV causes higher EDV thus increasing SV and leading to dilation hypertrophy of the LV
-Main difference: AR is volume overload, AS is pressure overload

9

Mitral stenosis 1

-Almost always due to rheumatic fever sequelae
-Sx: dyspnea, orthopnea, decreased exercise capacity, sometimes palpitations
-Signs: loud S1 (late diastole when LA contracts), high-pitched opening snap (after S2- early diastole) followed by diastolic rumble (low-pitched) murmur (decrescendo)
-Often see RV lift, loud P2 (due to pulm HTN), may see atrial fibrillation

10

Mitral stenosis 2

-Will not see LVH, but can see LAE (often) and RVH
-ECG: LAE, RVH, afib
-CXR: LAE, double contour R lower border, prominent main pulm artery, RVH
-Echo: hockey-stick valve +/- fish-mouth deformity
-Cath: perpetually high LA pressure, with markedly high diastolic LA pressure
-Rx: BBs to slow rate, anticoagulants (for afib), antiobio prophylaxis (endocarditis), valvuloplasty (#1), surgery

11

Chronic mitral regurg 1

-Etiology (primary): rheumatic (most common), SLE, valvulitis, anorectic drugs, marfan's, ehlers-danlos, degenerative myxomatous, ischemia
-Secondary etiologies: dilation of the LV annulus leading to leaflets unable to seal together
-Sx: dyspnea, decreased exercise capacity, fatigue

12

Chronic mitral regurg 2

-Signs: Laterally displanced PMI (LVH), holosystolic murmur (constant volume) w/ max at apex radiating to axilla, occasional S3
-ECG: LAE, LVH, repolarization abnormalities
-CXR: cardiomegaly, pulm congestion
-Echo: various mechanisms of MR (prolapse, ruptured chord, rheumatic, etc)

13

Chronic mitral regurg 3

-Cath: large "V wave" which is a peak in LAP during late systole due to blood regurg, high LAP and low systolic pressure (due to low SV)
-Rx: can Rx CHF Sx using digoxin, diuretics, ACEIs, anticoagulants for afib, antibio endocarditis prophylaxis
-But only way to Rx the valve is surgical repair/replacement

14

Acute MR

-Etiology: endocarditis, chordae tear, papillary muscle rupture, infarction/ischemia
-Sx: severe DOE
-Rx: vasodilator (nitroprusside), need urgent MV repair/replacement

15

Mitral valve prolapse

-Leaflets fall back into LA
-Sx: atypical chest pain, palpitations, lightheadedness, fatigue, anxiety
-Signs: mobilar mid systolic click, late systolic murmur, tall/thin, hyperdistensible joints, thoracic cage abnormalities
-Rx: most are benign and do not require Rx, some may need BBs to control Sx, some my need endocarditis prophylaxis

16

Choice of prosthetic valves

-Mechanical: very durable (pro) but prothrombotic (con- must be on anticoagulant for life)
-Pts younger than 65, already on warfarin
-Bioprosthetic: non-coagulable, but deteriorates
-For pts 65, those unable to take anticoagulants, women of child-bearing age