Term 5 - PathoPhysio > VALVULAR HEART DISEASES 2 > Flashcards

Flashcards in VALVULAR HEART DISEASES 2 Deck (17):

  • AS: pulsus parvus et tardus or Anacrotic pulse
  • AR: Water-hammer,, Bisferiens pulse
  • HOCM: Bisferiens pulse
  • CHF: Pulsus Alternans
  • Cardiac Tamponade: Pulsus Paradoxus

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Hypertrophic obstructive cardiomyopathy (HOCM):

  • Subvalvular aortic stenosis due to severe hypertrophy of the septum of the left heart
  • Manifested by a systolic murmur noted on physical examination
  • Obstruction of outflow tract in this case is dynamic
  • Greater obstruction occurs when preload is decreased - Standing and Valsalva's maneuver (both decrease venous return) and the murmur becomes intense
  • Both of these maneuvers cause a decrease in the intensity of murmur in case of organic AS, because less volume of blood flows across the stenotic aortic valve

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An early diastolic blowing murmur, heard best at the lower left sternal border;

Aortic Regurgitation


Causes for AR:

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Pathology of AR:

  • Valvular cusp abnormality 
  • Aortic dilatation 
  • Aortic inflammation 
  • Aortic tears with loss of commissural support


Pathophysiology of AR:

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Aortic insufficiency (A. regurgitation): Hemodynamic changes

  • An incompetent (leaky) aortic valve allows blood to regurgitate from aorta to LV during ventricular diastole 
  • An elevated left ventricular end diastolic volume and pressure (↑ preload) 
  • Increased left ventricular and aortic systolic pressures 
  • Decreased aortic diastolic pressure 
  • Widened aortic pulse pressure 
  • Diastolic murmur appears

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Clinical Manifestations of AR and basis:

  • Patient remains asymptomatic as the heart responds to the volume load
  • When the compensatory mechanisms fail, symptoms appear
  • Symptoms:
    • Shortness of breath (due to pulm edema) 
    • Hypotension often with cardiovascular collapse


Physical examination in AR: (i-iv)

  1. Hyperdynamic (pounding) arterial pulses:
    • A widened pulse pressure is responsible for several characteristic peripheral signs
    •  Palpation of the peripheral pulse reveals a sudden rise and then drop in pressure (water-hammer or Corrigan's pulse)
    • Head bobbing (DeMusset's sign)
    • Rhythmic pulsation of the uvula (Müller's sign)
    • Arterial pulsation seen in the nail bed (Quincke's pulse)
  2. Apical impulse:
    • Hyperdynamic and displaced laterally – due to the increased volume and forceful contraction of the left ventricle
  3. Soft S1 & S2:
    • S2 is soft due to improper closure S1 will be soft because of early mitral valve closure from aortic regurgitation and elevated ventricular pressures
  4. Auscultation for murmurs in AR:
    • Three murmurs may be heard:
    1. A high-pitched, blowing, decrescendo early diastolic murmur heard best along the left sternal border - due to regurgitant flow into left ventricle (hall mark sign).
    2. A crescendo-decrescendo, early systolic murmur due to an increased stroke volume flowing across the aortic valve, can be heard at the right upper sternal border with radiation into the neck.
    3. Austin Flint murmur at the apex: a diastolic rumble from regurgitant flow from the aortic valve impinging on the anterior leaflet of the mitral valve producing functional mitral stenosis


Common causes of Mitral Stenosis (MS)

  1. Rheumatic: Most common Narrowing results from fusion and thickening of the commissures, cusps, and chordae tendineae
  2. Calcific - Usually causes mitral regurgitation but can cause mitral stenosis
  3. Congenital: Presents in infancy or childhood
  4. Collagenvascular - SLE and rheumatoid arthritis; Rare cause of MS


Mitral Stenosis : Pathophysiology

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Mitral stenosis: Hemodynamic changes

  • Narrowing of mitral valve reduces the amount of blood that flows forward through it
  • The left atrium enlarges and left atrial pressure builds up
  • There will be a pressure gradient between left atrium and left ventricle throughout diastole
  • Mid Diastolic murmur appears

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Pathophysiology of MS:

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Clinical Manifestations of MS:

  • Clinically relevant mitral stenosis usually occurs when the valve area decreases to less than 1 cm2
  • Symptoms:
    • Dyspnea and orthopnea – due to elevated LAP, elevated pulm venous and capillary pressures
    • Fatigue
    • Hemoptysis
    • Palpitations & Tachycardia - Increased left atrial size predisposes to atrial tachyarrhythmias
    • Hoarseness of voice – Enlarged LA can impinge on recurrent laryngeal nerve (Ortner's syndrome)


MS - Physical examination:

  • i) Auscultation of heart:
    • The characteristic murmur of MS is a low pitched diastolic rumble in the apex
    • Diastolic rumble occurs because of turbulent flow across the narrowed mitral valve orifice
    • In addition, an opening snap (OS) may be heard before the diastolic rumble
    • Opening snap is analogous to the ejection click described for AS
    • A2-OS interval is useful in determining the severity of MS: “shorter the interval, greater would be the severity of the disease”
  • ii) Auscultation of the lungs:
    • Reveals bilateral rales (crackles) because of elevated pulmonary capillary pressure that results in accumulation of intra-alveolar fluid


Why is Atrial fibrillation (AF) is common in MS:

  • Abnormal enlargement leads to loss of organized contraction of the left atrium and hence AF
  • Thrombus in the left atrium is observed due to stasis in LA (20% of patients with MS)
  • Embolic events lead to neurologic symptoms such as transient numbness/weakness of the extremities, sudden loss of vision or stroke.