Flashcards in Valvular Heart disease Deck (114):
What descriptors are used for murmurs?
What does S1 correspond to?
2. Mitral and tricuspid valves close
When is the beginning of systole?
What corresponds with the carotid pulse?
What does S2 correspond to?
2. Aortic and pulmonic valves close
When is the beginning of diastole?
Define when a systolic murmur occurs
1. Begins after S1 and ends before S2
2. Coincides with upstroke of carotid pulse
Define when a diastolic murmur occurs
1. Begins after S2 and ends before S1
2. Coincides with downstroke of carotid pulse
What is a grade 1 murmur?
What is a grade 2 murmur
soft but easily heard
What is a grade 3 murmur
LOUD WITHOUT A thrill
What is a grade 4 murmur
Loud with a thrill
What is a grade 5 murmur
Loud with minimal contact between stethoscope and chest
What is a grade 6 murmur
Loud with no contact between stethoscope and chest
What grades include a thrill?
What are the different pitch options for murmurs?
What are the different quality options for murmurs?
What position accentuates mitral valve murmurs?
1. Ask pt to lay on left side
2. This brings ventricle closest to chest wall
3. Accentuates mitral murmurs, esp. diastolic murmur of mitral stenosis
What position accentuates aortic valve murmurs?
1. Ask pt to sit up, lean forward, exhale completely and hold breath
2. Accentuates soft diastolic murmur of aortic regurgitation
Where can murmurs radiate?
3. Left sternal border
How does standing change murmur intensity?
1. Upon standing, ↓ venous return to heart (preload) & ↓ PVR (afterload)
2. Leads to ↓ BP, ↓ stroke volume, & ↓ volume of blood in left ventricle
3. Intensity of AS/PS/MR/TR murmurs will also ↓
What murmur increases in intensity when standing?
How does squatting change murmur intensity?
1. ↑ venous return (preload) & ↑ PVR (afterload)
2. Intensity ∆ occurs opposite of standing
3. Intensity of AS/MR murmur increases
What murmur decreases in intensity when squatting?
What physiological maneuvers can bring out a murmur?
Isometric hand grip exercise: similar to squattin
Passive leg raising
Define configuration of a murmur
refers to its shape; a function of intensity and duration
What murmur is usually a crescendo?
What murmur is usually a decrescendo?
What murmur is usually a plateau?
What murmur is usually a crescendo-decrescendo?
What are physiological murmurs primarily due to?
1°due to physiologic conditions outside the heart; NOT structural defects in the heart itself
More rapid blood flow thru valves
When do most physiological murmurs occur?
1. Contraction (systole)
A. After strenuous activity or exercise
B. Due to anemia
C. During pregnancy
-Gr I-II midsystolic murmur @ LSB present in > 90% of pregnant women
What are the characteristics of innocent murmurs?
1. midsystolic grade I-II/VI
2. Common in children and young adults
3. Soft, less than III/VI intensity
4. Often position-dependent
A. Murmurs heard while supine may disappear when upright or sitting
5. Otherwise healthy individual, no concerns about growth, no DOE
6. Occurs during systole or continuously during both systole and diastole.
7. No palpable thrill
When is a murmur always pathogenic?
Murmurs occurring only during diastole are always pathologic
Define mitral stenosis
1. Narrowing of valve orifice
A. Normal 4-6 cm²
B. Audible murmur when < 2 cm²
C. Symptomatic and more critical when ≤ 1 cm²
What is a consequence of mitral stenosis?
1. Left atrial volume & pressure ↑ --> left atrial dilation
2. Greater resistance to blood flow causes pulmonary HTN, RVH and right sided heart failure
3. Inadequate filling of left ventricle leads to ↓ CO
What is the etiology of mitral stenosis?
1. Progressive fibrosis, scarring, & calcifications of mitral valve
2. Rheumatic Heart disease
A. Most common
B. Results from rheumatic fever
C. F>M 4:1
3. Congenital Defect
A. Abnormal fusion of valve, papillary muscles (parachute valve) or short, thick chordae tendinae
4. Rare causes
A. Malignant carcinoid syndrome, SLE
What does a mitral valve stenosis murmur sound like?
1. Opening snap in early diastole
2. Loud S1 heard best with bell over apex w/pt in left lateral decubitus position
3. Apical mid-late diastolic rumble w/no radiation
What are the sxs of late mitral valve stenosis?
A. Irregularly irregular pulse
B. Atrial fibrillation
6. Right sided heart failure
A. JVD, pedal edema, hepatomegaly (late stage)
What are the dx studies for mitral valve stenosis?
3. ECHO: dx study of choice!!
4. Cardiac cath
What are the cxr results in mitral valve stenosis?
1. Left atrial & right ventricular enlargement
2. Enlarged pulmonary arteries
3. Mitral valve calcification
What are the EKG results in mitral valve stenosis?
1. Left atrial hypertrophy: large or biphasic P waves
2. Atrial fibrillation
What is the dx study of choice for MVS? What does it show?
Left atrial and right ventricular hypertrophy
Enlarged pulmonary arteries
Mitral valve calcification
What is cardiac catheterization used for in MVS?
Used to detect other valve, coronary or myocardial disease prior to surgery
How is MVS monitored?
1. Annual H&P
2. Assess for Dz progression & development of indications for intervention
3. Echo performed based upon severity of disease
4. Re-evaluate upon change in clinical status
5. Delaying intervention may cause irreversible pulmonary HTN &/or right HF
How is MVS treated medically?
1. Anticoagulation (warfarin INR 2.5-3.5)
A. Atrial fibrillation ONLY (paroxysmal, persistent, or permanent)
B. Prior embolic event
C. Left atrial thrombus
2. Loop Diuretics & Na restriction
A. ↓ Pulmonary vascular congestion
3. Beta Blockers or CCB
A. Control ventricular rate
A. 2nd line for rate control or ventricular systolic dysfunction
How is MVS treated surgically?
1. Mitral valve replacement
2. Mitral valve commissurotomy
3. Percutaneous balloon valvuloplasty (PMBV): tx of choice
A. Preferred to surgery
What are the surgical indications for MVS?
1. Episode of pulmonary edema
2. Decrease in exercise capacity
3. Pulmonary HTN
4. Valve orifice ≤ 1.5 cm2
Which MVS pts get a mechanical or biologic valve replacement?
1. Valve orifice < 0.7 cm²
2. Sx’s persist despite medical Tx
3. If mitral stenosis is congenital
4. Severe pulmonary HTN (pulmonary artery systolic pressure >60 to 80 mmHg)
5. Not candidates for PMBV or open commissurotomy
A. Valve not amenable
Define mitral valve commissurotomy
Fused valve leaflets are separated to widen the valve opening
When is mitral valve commissurotomy performed?
1. Pure mitral stenosis w/o significant subvalvular Dz
2. Left atrial thrombus that persists despite anticoagulation
3. Mitral valve is nonpliable or severely calcified
4. Moderate to severe coexisting mitral regurgitation is present
When is mitral valve percutaneous balloon valvuloplasty (PMBV) performed?
1. Chronically symptomatic despite medical Tx
2. Poor surgical candidate
3. Valve is not heavily calcified
4. Asymptomatic patients who plan on childbearing
5. No left atrial thrombus
6. No moderate to severe mitral regurgitation
7. May be done in cardiac arrest, cardiogenic shock, or pulmonary edema
What is the surgical treatment of choice for mitral valve stenosis?
percutaneous balloon valvuloplasty (PMBV) unless contraindications
What are pearls for mitral stenosis?
1. Women can be asymptomatic until first pregnancy
2. Common arrhythmia is A-fib 2°to increased LA pressure
3. The first presentation of mitral stenosis can be an embolic event, most commonly cerebral
4. Common complication is Pulmonary HTN
What is the etiology of mitral regurgitation?
1. Major causes of MR are primary diseases of the valve leaflets
B. Rheumatic heart Dz in developing countries
2. Secondary causes
A. Cardiomyopathy or coronary disease
3. Increased left atrial & pulmonary pressures → possible RVFailure
4. Papillary muscle dysfunction (2°to MI)
5. Severe left ventricular failure
6. Ruptured chordae tendinae
7. Infective endocarditis
8. Calcified mitral valve annulus
9. Rheumatic valvulitis
define mitral regurg
Retrograde blood flow thru left atrium 2°to incompetent mitral valve
What are the exam characteristics of mitral valve regurg?
1. Holosystolic murmur @ apex, may radiate to base or left axilla
2. Left ventricular lift w/apical thrill
What are the sxs of late mitral valve regurg?
4.. Palpitations: may lead to A. Fib
A. Sometimes irregularly irregular
6. Holosystolic murmur @ apex, may radiate to axilla or base
7. Often w/apical thrill
8. Left sided heart failure (S3)
A. Exertional dyspnea
B. Pulmonary edema (acute MR)
What are the dx studies for mitral valve regurg?
3. ECHO: study of choice
4. Cardiac cath
What are the CXR results in MVR?
1. Left atrial & left ventricular enlargement
2. Pulmonary venous congestion
3. If CXR nl, suggests mild MR or acute MR
What are the EKG results in MVR?
1. Left atrial and LVH
2. Sinus tachycardia
3. Sometimes A fib
What are the Echo results in MVR?
1. Abnormal mitral leaf motion
2. Left atrial enlargement
3. Mitral regurgitation
When is cardiac catheterization indicated in mvr?
To define coronary anatomy, assess degree of regurgitation and assess LV function prior to surgery
When is tx for asymptomatic mvr pt?
In asymptomatic pts, follow with H&P and ECHO which helps to determine when to surgically intervene
What is the tx for mvr pts with a fib?
If A-fib, anticoagulate and rate/rhythm control
What are the indications for surgery in ps with mvr?
Acute MR due to endocarditis, MI or ruptured chordae tendinae often requires emergency surgery
What are the treatment options for MVR pts?
1. If symptomatic, reduce afterload
A. CCB (amlodipine/Norvasc, nifedipine/Procardia)
B. ACE’s (lisinopril/Zestril, etc)
C. Nitrates (hydralazine/Apresoline, isosorbide dinitrate/Isordil)
Define mitral valve prolapse
1. Floppy mitral valve syndrome”
2. “Click murmur syndrome”
3. Characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole
What is the etiology of MVP?
1. Myxomatous degeneration of connective tissue of mitral valve
3. Secondary to other disorders
A. Ehlers-Danlos syndrome
B. Pseudoxanthoma elasticum
What are the characteristics of MVP?
1. Posterior bulging of interior & posterior leaflets in systole
2. Mid to late click, heard best at apex
3. Crescendo mid to late systolic murmur
4. Accentuated by standing
5. Decreased intensity w/ squatting
6. Usually asymptomatic
A. Chest Pain or palpitations can occur
What is the treatment for MVP if symptomatic?
1. Beta blockers if symptomatic
A. ↓ HR= ↓ stretch on leaflets
2. No longer requires antibiotic prophylaxis
3. Repair or replacement if severe prolapse/regurg
Define aortic stenosis
Obstruction to systolic left ventricular outflow across the aortic valve
What is the etiology of aortic stenosis?
1. Rheumatic fever
2. Idiopathic calcification of valve
3. Progressive stenosis of congenital bicuspid aortic valve
A. Usually asymptomatic until middle or old age
A. Major cause < 30 yr
A. Degenerative or calcific aortic stenosis
What percentage of pts >65 and >70 have aortic sclerosis?
Approx 25% of pts > 65 yrs and 35% pts > 70 yrs have aortic sclerosis or valve thickening
What is the pathophys of mitral valve stenosis?
1. Over time, LV pressure rises to overcome resistance of narrowed valvular opening
2. Added workload increases demand for O2
3. Diminished CO causes poor coronary artery perfusion
What are the PE findings for aortic stenosis?
1. Systolic crescendo-decrescendo ejection murmur in right 2nd ICS that radiates to neck
2. Also heard at apex
3. Harsh quality
4. As stenosis becomes severe, ↓ quality of S2
What are the sxs of late aortic stenosis?
1. Dyspnea, weakness, fatigue
2. Exertional syncope
A. Rising LV pressure stimulates baroreceptors --> vasodilation
5. Left sided heart failure
A. Exertional dyspnea, pulmonary edema
6. Systolic crescendo-decrescendo ejection murmur in right 2nd ICS that radiates to neck
A. Harsh quality
B. As stenosis becomes severe, ↓ quality of S2 (soft S2)
What are the dx studies for aortic stenosis?
4. Cardiac cath
What are the CXR results in aortic stenosis?
1. Valvular calcification
2. Left ventricular enlargement (boot-shaped ♥)
3. Pulmonary vein congestion
What are the EKG results in aortic stenosis?
2. A. Fib common
What are the ECHO results in aortic stenosis?
1. Thickened aortic valve
3. May have co-existing mitral stenosis
When is a cardiac cath indicated in aortic stenosis?
1. Provides assessment of hemodynamic consequence of AS as well as providing a view of the coronary artery anatomy
2. Estimation of valve area can be calculated
A. Valve area < 1.0 cubic cm indicates significant stenosis
What are the treatment options for aortic stenosis?
1. Medical management until pt symptomatic
2. Loop diuretics & Na restriction for CHF
3. CCB used for rate control if A. Fib
4. Antiocoag if A. Fib
5. ACEI used sparingly due to presence ACE in diseased aortic valve
A. Use sparingly until further studies
When is aortic valve replacement indicated?
1. Surgery indicated for all symptomatic pts
A. Angina, syncope or HF develop → immediate AVR
B. Bioprosthetic valves (porcine or bovine) are often used in elderly
-Life expectancy 10-15 years
-Can avoid long term anticoagulation
C. If mechanical valve used, life long anticoagulation necessary
2. Prophylactic antibiotic x 6 mo post valve replacement only
Define aortic regurgitation
1. Retrograde blood flow into the LV from the aorta 2°to incompetent aortic valve
2. Slow progressive disorder
3. Chronic AR well tolerated
4. Acute decline if 2°to infective endocarditis
What is the etiology of aortic regurg?
1. Congenital bicuspid valve
4. Rheumatic fever
5. New AR murmur, think aortic dissection!
What are the exam findings for aortic regurg?
1. Widened pulse pressure
2. Decrescendo, blowing diastolic murmur heard along LSB
3. Possible S3 over apex
4. PMI displaced down and left
What are the late sxs of aortic regurg?
4. Diastolic, blowing, decrescendo murmur that is high pitched
5. Wide pulse pressure
6. Left sided heart failure
A. Exertional dyspnea
C. Pulm edema
7. ↑ Intensity w/squatting, ↓ w/ valsalva
What is the full description of an aortic regurg murmur?
A high-pitched, grade III/VI, blowing decresendo murmur heard best in the 4th ICS with radiation to the apex
(The more severe the AR, the murmur becomes longer, but will usually decrease in intensity)
What are the dx studies of aortic regurg?
4. Cardiac cath
What are the CXR results for aortic regurg?
What are the EKG results for aortic regurg?
1. Severe AR-LVH
What are the ECHO results for aortic regurg?
Assess aortic root, valves, LV function, LV size, severity of regurg
When is cardiac cath indicated for aortic regurg pts?
Defines hemodynamics, aortic root abnormalities and asst CAD prior to surg
What is the medical tr for aortic regurg pts?
1. Medical management until surgery
2. Decrease afterload reduces regurgitation
A. ACEI whenever LV diastolic size is increased
When is surgery indicated for aortic regurg pts?
Surgery indicated once sx’s emerge or if EF < 55%
When is aortic regurg a medical emergency?
1. Most cases caused by infective endocarditis
2. Can be caused by aortic dissection
3. Sudden decreased CO, hypotension and sudden rise in LV diastolic pressureboth cause reduction of coronary blood flow
4. Pulm edema occurs 2°LV failure
What are the characteristics of tricuspid stenosis?
1. Rheumatic fever (almost always occurs w/mitral valve Dz and some aortic valve Dz)
2. Carcinoid disease
3. Previous tricuspid valve repair or replacement
What are the characteristics of tricuspid regurgitation?
1. Can be functional
2. Incidental finding on echo
3. Infective endocarditis
4. From pacemaker lead placement
5. Often due to left-sided valve disease
What is the etiology of pulmonic stenosis?
1. Congenital valve defect (>95%)
2. Assoc w/ Tetrology of Fallot
What is the etiology of high pressure pulmonary regurg?
Most d/t pulm HTN
Treat to control causes of pulm HTN
What is the etiology of low pressure pulmonary regurg?
1. Congenital valve/heart disease (in adults, most often consequence of prior sx for CHD)
2. Plaque from carcinoid disease
3. Usually well-tolerated for years
What do right sided valve issues lead to??
Right sided cardiomegaly
Systemic venous congestion
Right sided heart failure
What are the late sxs of right sided valve issues?
4. Right sided heart failure
C. Dependent edema
What are the pe findings for tri stenosis?
Diastolic rumbling murmur along lower 3rd -5th left ICS
S1 often loud
What are the pe findings for tri regurg?
Holosystolic murmur along LSB
S3 may accompany murmur (related to high flow returning from RA)
What are the pe findings for pulmonary regurg?
High pitched diastolic blowing decrescendo (like AR)
What are the pe findings for pulmonary stenosis?
Split S2 with systolic murmur in left 2nd ICS, click ↓ w/ insp
What are the dx studies for right sided valve problems?
What are the EKG findings for right sided valve problems?
What are the CXR findings for right sided valve problems?
Prominent right heart border with dilated SVC
What are the ECHO findings for right sided valve problems?
What are the medical treatments for sided valve problems?
Diuretics to ↓ fluid volume
Na restrictive diet
PPVI- pulm valve dysfunction (stenotic or regurgitant) – RV pressures high