Flashcards in Valvular Heart Disease 4 Deck (17):
Contrast catheter placed valve and open heart surgery to repair aortic valve replacement.
important to chose the correct candidates, cath placement can be more appropriate for those who are not surgical candidates, relatively same mortality outcomes both are resource are intensive
Discuss the pathological changes in volume and pressure in the left heart due to mitral insufficiency.
mitral regurgitation volume overloads the left ventricle so the ventricle operates under a state of increased preload but reduced after load
the LV compensates by both dilation and more complete section to a reduced end-systolic volume (usually generates less systolic pressure and typically less ventricular enlargement)
What occurs with acute mitral insufficiency to heart structure and function?
ejection fraction has gone up so total stroke volume stays high, even through some output is leaking back into the atrium, the ventricle cannot enlarge acutely so pressure in the atrium rises creating rapid filling during early diastole and S3 and exaggerated V wave; left atrial pressure is unable to fall to 0
systolic murmur is reaches its peak relatively early in systole and diminishes to nothing before end-systole
Describe the pressure and volume changes that occur with chronic mitral insufficiency.
left ventricle is enlarged and an intermediately sized atrium, the increased compliance of the enlarged left atrium allows it to fill with considerable regurgitant volume at a stable pressure
Describe the changes as the heart with mitral valve insufficiency becomes decompensated.
the extended and weakened ventricle can no longer contract well and end-systolic volume increases while stroke volume is reduced
while EF may be "normal" ventricular function is markedly reduced and LA and LV pressures are increased
What is the primary hemodynamic problem of pulmonic stenosis? Contrast congenital and acquire pulmonic stenosis regarding their disease time course.
pressure overload that produces compensatory right ventricular hypertrophy
in acquired pulmonic stenosis, the progression is much more rapid because pressure overload is poorly tolerated by the right ventricle
(note in utero obstruction can stimulate right ventricular hypertrophy AND myocyte hyperplasia)
What are the primary symptoms from pulmonic stenosis?
fatigue from reduced cardiac output, both at rest and during exercise
dyspnea may occur with exertion not due to congestion but poor perfusion of the intercostal muscles and the mimicked sensation of dyspnea
What type of treatment would you consider for pulmonic stenosis given the natural history of this disease?
there is a very small pressure gradient across the pulmonic valve and therefore often has a pretty constant severity over long periods of time leading to more rare surgical intervention (>50mmHg) for these patients, balloon valvuloplasty may be the best treatment, it is unusually for a patient to require pulmonic valve replacement
What are likely causes of pulmonic valve insufficiency?
most common cause is dilation of the main pulmonary artery (chronic pulmonary HTN or connective tissue disease)
congenital abnormality or secondary to balloon valvuloplasty or surgery of the pulmonic valve
What is the common natural history of pulmonic valve insufficiency?
pulmonic insufficiency in isolation is rarely a significant problem and usually does not cause significant right ventricular dysfunction by itself; pulmonary circuit is on such low pressure it is unlikely that small volumes are regurgitated
What are the likely causes and symptoms of tricuspid stenosis?
almost always caused by rheumatic disease, also carcinoid tumor or congenital abnormality
tricuspid stenosis predominantly reduces cardiac output response to exercise; the most common signs are fatigue and edema
What is the natural history of tricuspid valve insufficiency?
the disease will show progressive fatigue and symptoms of low cardiac output, increasing fluid retention and liver congestion, edema, even cardiac cachexia
therapy consists of either valvular commissurotomy or valve replacement
What are the most common causes, symptom and treatment of tricuspid insufficiency?
most common cause of tricuspid insufficiency is due to annular enlargement (also trauma or carcinoid or rheumatic disease)
while isolated mild to moderate forms may be tolerated for decades, more severe forms create change that are analogous to those seen with mitral valve
tricuspid regurgitation is managed whenever possible by valve repair when possible, valve replacement is sometimes necessary and excision of valve results are not clear
Contrast the clinical manifestations based on causes of endocarditis: systemic infection (local tissue destruction), intravascular lesion (embolic event) or immune reaction (immune complexes)
SI: fever chills, rigors etc. labs show anemia, hi sedimation rate and elevated WBC
IL: dsypnea, chest pain, emboli, new murmur, , stroke or abdominal pain
IR: arthralgias, myalgias and tenosynovistis, abnormal joint exam, immune mediated labs posistive
What are the most common criteria for endocarditis diagnosis?
evidence of microbiologic infection by blood culture
evidence of new murmur or vegetation by echo
min. criteria: predisposition to infective endocaritis, and injection-drug use
Give the top three organisms to cause endocarditis
Strep viridans (oral), strep bovis (bowel), strep faecalis (bowel)