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Flashcards in valvular heart disease Deck (68):
1

heart sounds

S1: closure of AV valves at start of ventricular systole
S2: closure of semilunar valves at start of ventricular diastole
S3: sound of rapid filling of ventricles during early diastole
S4: sound of late filling from atrial kick in late diastole
Valve opening normally not heard

2

abnormalities

slide 4-6

esp fixed splitting of S2
myxomas and pericardial knot (S3) may mimic valvular disease

3

causes of high frequency sound in early diastole

slide 7
more 8,9

4

how to approach pt with VHD









most important question to ask about valvular condition ??

Correctly diagnosing the affected valve
Estimating severity
Judging its effect on the myocardium
Deciding on antibiotic prophylaxis (not necessary for mitral valve prolapse)
Deciding on timing of surgery or catheter-based intervention

what is the condition's effect on the cardiac muscle?? esp. LV

5

5 finger approach

H/P, labs, EKG, XR, cardiac testing (i.e. ECHO)

6

Aortic Stenosis:

etiology
hx

Etiology
*Senile calcific*
bicuspid: more turbulent flow, have symptoms younger (think associated with aortipathies (coarctation, etc) if with coarctations and headache, think: berry aneurysm
rheumatic HD (more mitral)
congenital (uni/quad cuspid valves, present early-->respond to valvuplasty)
Paget’s, ESRD

History
long latent period
*Angina*, *Syncope* (fixed obstruction and cannot augment CO under conditions of low SVR; ie: meds, vasovagal), *CHF*

FA: syncope, angina, dyspnea on exertion (SAD)

angina: 50% 5 yr mortality
syncope: 50% 3 yr mortality
CHF: 50% 2 yr mortality
no meds shown to reduce progression of aortic stenosis

7

aortic stenosis exam:

Harsh, late-peaking SEM (sys. ejection murmur) radiating to the neck, palpable systolic thrill, sustained LV impulse, pulsus parvus et tardus,
S2 single (A2 is absent), paradoxical split S2 (A2 closure takes longer), S4 gallop (heard when diastolic dysfunction)
Prolongation of LV ejection due to severe outflow obstruction

8

aortic stenosis
EKG??
CXR??
more dx
sx?

EKG: LVH, LBBB

CXR
AV calcification, cardiomegaly, LV prominent without dilation

Echo (test of choice): measure doppler gradients,
severe AS if valvular area:

9

hypertrophic cardiomyopathy

biphasic: old and young
ddx from aortic stenosis

provocative maneuver:
valsalva: gets louder

small LV cavity bc wall is enlarged-->turbulence
make cavity smaller-->lower
dec. venous return into right heart->less blood in LV-->smaller cavity-->louder

softer with squatting: pushing more blood into heart-->larger LV-->less turbulence-->softer murmur

10

hypertrophic cardiomyopathy
ddx from aortic stenosis

after PVC: same PP in AS

PP gets smaller in hypertrophic myopathy

Brockenbrough phenomenon

11

Aortic stenosis time course charts

slide 12
long latent period


12

valve replacement

bioprosthetic (for oldies: last 10-15 yrs) don't need anticoagulation

mechanical: for younger pts (need anticoagulation)

13

TAVR

transaortic valve replacement

access from groin
transapical
typically transferal

valve placed on stent and expanded, "crushing" old bad valves, open/closed based on heart pressure gradients
no opening of chest, good for old ppl

14

aortic stenosis parameters

slide 15

15

criteria for sx

EF falls below 50

16

LV outflow tract obstruction

supravalvar AS

congenital, assoc. with William's syndrome

narrowing above valve

17

Subvalvular membrane:
subvalvular AS

congenital flap of tissue obstructing valve (before it) and may be a/w coarctation as part of *Shone’s syndrome mitral stenosis due to supravalvular MV membrane, LVOT obstruction, coarctation

needs sx

18

mean gradient of 40

get measurement from echo

19

using doppler probe (ECHO) measure velocity and convert velocity into pressure

Bernule formula

20

if CAD (3 vessel disease) along with AS

might as well replace AS w/ angioplasty

21

Aortic Regurgitation/insufficiency (Chronic) etiology

Aortic root dilation from HTN (-->dissection, aneurysm), CMN, bicuspid valve, ankylosing spondylitis, syphilis, RA
(secondary: something stretching leaflets open)

(primary: problem with leaflets)

FA: endocarditis, RF


long latent period
can have combo AI/AS

22

Aortic Regurgitation (Chronic) Hx

Dyspnea, Angina, Fatigue, CHF

23

Aortic Regurgitation (Chronic) exam

Wide pulse pressure, low diastolic pressure, bounding pulses (quick rising), laterally displaced PMI, long decrescendo diastolic murmur along LSB if valvular or RSB if aortic root etiology, Austin-flint murmur at apex (diastolic MR; MV struck by regurgitant jet-->you will not hear loud S1 or OS which is c/w mitral stenosis), S3 gallop (with dilated ventricle)

24

Aortic Regurgitation (Chronic) eponyms (FYI?)

Quinckes pulse, DeMusset’s sign (head bobbing from such strong pulse, uvula can vibrate) duroziez sign, bisferiens

25

AR (AI)
EKG?
imaging?

ECG: LVH

CXR
Cardiomegaly, boot-shaped heart, LV enlargement

Echo, cath: can see how much blood flowing backwards

26

AI: timing of sx

Symptoms, EF 55
EDD >75

27

chronic AI tx

Vasodilator therapy (ACE-Inh/ARB/Nifedipine)

don't use B-blocker, will prolong diastole??

28

Remember, in chronic AI, the LV has time to adapt with ?? and ?? with each contraction without increasing LVEDP…eventually, this compensatory mechanism ??

eccentric myocyte hypertrophy
and larger SV

fails
then forward CO will diminish and will have higher LVEDP (back flow) and pulmonary congestion

29

Aortic Regurgitation (Acute)
etiology??

hx?

Etiology
*Endocarditis, *Aortic dissection, ruptured sinus of Valsalva aneurysm

History
Acute pulmonary edema

severe! goes straight back into longs

30

Aortic Regurgitation (Acute) exam

Short diastolic murmur, faint S1
(brief but severe)
may not hear murmur

31

Aortic Regurgitation (Acute) EKG?
imaging?

ECG: Not helpful

CXR
Normal heart size, pulmonary edema

*ECHO
TEE (look for dissection)
cath (no time)

doppler probe: see diastolic flow

32

AI acute timing of sx

urgent

33

causes of AI

slide 23

34

Mitral Regurgitation (Chronic) etiology

primary (leaflet problem) MVP (mitral valve prolapse), mitral myxomatous disease, rheumatic (more likely MS)

FA: LV dilatation

secondary (pulls annulus open: ischemic (dysfunctional papillary muscles), dilated cardiomyopathy)


35

Mitral Regurgitation (Chronic) hx

Late-onset of CHF, later R-heart failure

long latent period

36

C MR: exam

Apical holosystolic murmur radiating to axilla, S3 gallop and wide-split S2

37

C MR: EKG

LAE, LVH, afib (if LA dilates enough)

(LV dysfunction from overloaded state)

38

C MR: imaging

CXR: Cardiomegaly, LV/LA enlargement, pulmonary venous redistribution

Echo, cath

EF should be >65 (supra-normal)

39

C MR: timing of sx

Symptoms,
EF40

almost never for secondary MR

40

Mitral Regurgitation (Acute)
etiology

hx??

*post-MI complication* -
papillary muscle rupture in setting of MI
(supplied by RCA: posterior-medial supply)

Endocarditis
Acute pulmonary edema

41

Mitral Regurgitation (Acute) exam

Decrescendo systolic murmur radiates to neck if posterior leaflet and back if anterior leaflet, loud P2, widely split S2
(may be soft, happens rapidly)
FA: holosystolic, high-pitched "blowing"

42

Mitral Regurgitation (Acute) EKG

Sinus tachy, AMI changes

43

Mitral Regurgitation (Acute) imaging

CXR
Pulmonary edema, normal heart size, cardiomegaly, LA, LV enlargement

Echo, cath
Flail leaflet, large v waves

44

Mitral Regurgitation (Acute) timing of sx

Urgent, can temporize with vasodilators or IABP

put in balloon pump
decrease afterload (not if AI)

does not prolong life for secondary MR unless refractory symps or doing sx anyways

"mitral clip"

45

MVP click changes with maneuvers

Squatting:
The click moves closer to S2 (more blood in R and L heart->more filling-->longer time before click happens-->closer to S2)

Standing:
The click moves closer to S1
(less blood-->valve clicks earlier, closer to S1)

46

MVP in who

thought to be female, palpitations, anxiety

actually equally men as well: serious progression (also with oldies)

mid-systolic opening click
late systolic crescendo murmur

predispose to inf. endocarditis
etiology: myxomatous degeneration (often 2nd to Marfan/Ehlers-Danlos syndrome), RF, chordae rupture



47

Mitral Stenosis etiology

*RHEUMATIC* esp. immigrants
calcific
FA: can result in LA dilatation

48

Mitral Stenosis hx

Late-onset of CHF, later R-heart failure, a fib, dyspnea (criteria for sx)

(LV is protected?? eventually doesn't fill, low CO)

49

Mitral Stenosis exam

Diastolic rumble at apex, short S2-OS (opening snap) interval, loud P2, RV heave

*The longer the murmur and the shorter the time from S2-OS-*more severe* , high pressure
(if no longer hear OS: no longer pliable, end stage)

Anything that increases the gradient will increase the murmur intensity
(diff to hear)

increase HR-->higher the diastolic gradient -(should be zero), louder the murmur

50

MS EKG

LAE, afib

51

MS imaging

CXR
Pulmonary vein congestion, LAE, *huge LA*, compression of esophagus and recurrent laryngeal nerve (hoarse voice)

Echo, cath

52

MS timing of sx

depends on MVA, pressure gradient

tx with balloon valvatomy; need favorable valves
-know if meet criteria via ECHO

if primary MR: try to repair valve
MS: can't repair, have to replace

53

Tricuspid Regurgitation etiology

could be rheumatic (would have MR, AR before)
*functional from RV failure (TR secondary to pulmonary HTN)

**Ebstein’s anomaly: congenital displacement of ant. tricuspid leaflet-->atrialization of RV-->sev. TR (assoc. with WPW, ASD)

**carcinoid tumor against liver-->release of vasoactive substances; serotonin-->glistening appearance "smoldering" of tricuspid valve
-may have pulmonic valve involvement but lung filters out

FA: RV dilitation, endocarditis

54

Tricuspid Regurgitation hx

R-sided CHF predominates

55

TR exam

Holosystolic murmur at LLSB, louder with inspiration (Carvallo’s sign), prominent *cv waves* and rapid y descent

56

TR EKG

nothing?

57

TR: imaging

ECHO

58

TR tx

Tx underlying condition,
-sx if carcinoid or Ebsteins
annuloplasty can be considered

59

normal JVD

JVP estimation

8 cm H2O

should be same as LVEDP


60

ACVXY for JVP

see chart

A: atrial contraction (end of ventr. diastole: A-wave (S4)
C: closure of TV in early ventricular systole raises pressure in RA (FA: RV contraction)
X: atrial relaXation (descent)
V: ventricular systole nearly over (RA filling occurs and pressure rise in RA) big V wave if backwards flow (TR, MR)
Y: opening of TV (FA: RA emptying into RV, descent)

61

2 types TR

Secondary (Functional)
Left-sided CHF, MS, MR, primary pulmonary disease, L to R shunt, pulmonic valve stenosis, PA stentosis

Primary
Carcinoid, due to pacemaker, endocarditis, rheumatic fever, marantic, drug-induced, Ebsteins

62

Tricuspid stenosis (rare)

Rheumatic, carcinoid (once metastatic carcinoid to liver, the neuroendocrine tumor releases serotonin and other vasoactive substances which directly affect R-sided valves and these substances are usually cleared by lungs so L-sided vlave typically not affected)

Prolonged y descent, prominent a wave

Diastolic murmur, LLSB; increases with inspiration

63

Pulmonic stenosis

Noonan’s, TOF, congenital rubella, acquired form carcinoid

Valvular, subvalvular, supravalvular

Indication for balloon valvuloplasty
Symptoms: > 30 mmHg peak
Asymptomatic: > 40 mmHg peak

64

Pulmonic regurgitation

Secondary to TOF(tetralogy of fallot) tx of RVOT obstruction

Carcinoid; endocarditis

Graham Steell murmur:
High-pitched blowing murmur louder with inspiration (not in isolation)

65

Drug-induced valve disease

Ergot alkaloids (for migraines)
Fen-fen
Pergolide
MDMA (ecstasy)
IVDA (endocarditis)

66

cannon a waves in

heart block
atria contract (have p wave) but valves can't open-->pressure transmitted backwards

67

VSD (FA) murmur

holosystolic, harsh-sounding
loudest @ tricuspid area

68

PDA (FA) murmur

continuous machine-like murmur
loudest at S2, best heard @ left infraclavicular area
often due to congenital rubella or prematurity