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UNMC Valvular Disease

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Causes of Acute Aortic Regurgitation
1. *Infectious Endocarditis* - leaflet perforation, prolaps, aortic root abscess.
2. *Aortic Root Dissection* - Connective tissue dx, Ascending Ao aneurysm, Iatrogenic, Trauma.
Physical findings of Acute Aortic Regurgitation
1. Wide pulse pressures - 100/40
2. Pulmonary Edema - LV pressure/volume pushes fluid into LA and lungs.
Managment of Acute Aortic Regurgitation
1. True Surgical Emergency - Replace the Valve.
2. DO NOT give beta-blocker, this is basically acute heart failure, and they will prolong diastole, which prolongs regurgitation.
3. Do NOT use balloon pumping, it will increase pressure and push more blood back into LV.
Causes of Chronic Aortic Regurgitation
*Any condition resulting in incompetent aortic leaflets*
1.*Congenital* = Bicuspid valve.
2.*Aortopathy* - collagen disorders(marfan, ehlers danlos)
3.*Acquired* - Rheumatic heart dx, Dilated aorta(HTN), degenerative, Rheumatoid arthritis, Syphilis!
What is Marfan Syndrome
1.Marfan syndrome is caused by mutations in the FBN1 gene on chromosome 15, which encodes the glycoprotein fibrillin-1, a component of the extracellular matrix.
2.Fibrillin-1 protein is essential for the proper formation of the extracellular matrix, including the biogenesis and maintenance of elastic fibers.
3. Elastin fibers are found throughout the body, but are particularly abundant in the aorta, ligaments and the ciliary zonules of the eye; consequently, these areas are among the worst affected.
Ehlers Danlos
1. is a group of inherited connective tissue disorders, caused by a defect in the synthesis of collagen (Type I or III).
2. Type III collagen - is a group of inherited connective tissue disorders, caused by a defect in the synthesis of collagen (Type I or III).
3. Associated with aortic aneurysm.
What type of problem is Aortic regurgitation - LV pressure or volume overload?
1. Both. Increased volume, and increased pressure to push through aortic stenosis.
2. Whole heart dilates, and hypertrophy too.
3. Increased Pressure, Increased radius, may or may not have increased wall thickness.
Why is there a LOUD S3 in Aortic Regurgitation?
1. In diastole, after the ventricle relaxes blood begins pouring in to the LV from the Aorta! This makes a very loud S3.
Aortic regurgitation symptoms, when do they develop?
1. Rate of progression depends on the etiology of the stenosis. Sometimes can be asymptomatic for 4-5 decades. 2. Usually eventually causes *CHF*.
CHF from Aortic regurgitation - signs and symptoms
1. Dyspnea on exertion.
2. Orthopnea - dyspnea when supine.
3. PND - Paroxysmal Nocturnal Dyspnea.
Why do you get Nocturnal Angina with Aortic regurgitation?
1. Bradycardia →↑regurgitation time(diastole)→↑ LVEDP & ↓DBP at night→ Decreased DBP leads to decreased diastolic coronary perfusion pressure. = Angina.
2. Can get daytime angina too if DBP < 40mmHg.
How does Aortic regurgitation present on Physical Exam?
1. Widened pulse presssure, bifid pulse - Pressure wave, then volume wave.
2. Large hyperdynamic, apical impulse.
What kind of murmur is heard in Aortic regurgitation?
1.Decrescendo pandiastolic murmur, best heard in expiration(increased thoracic pressure, pushes more blood retrograde into LV during diastole.)
2. Probably a systolic ejection murmur from the large volume.
Austin Flint murmur
1. is a low-pitched rumbling heart murmur which is best heard at the cardiac apex.
2.Classically, it is described as being the result of mitral valve leaftlet displacement and turbulent mixing of antegrade mitral flow and retrograde aortic flow
Corrigan Pulse
High Amplitude, abruptly collapsing pulse.
Quincke Pulse
1. Exaggerated reddening and blanching of nail beds.
Prognosis of in AR is determined by degree of CHF
- yup
TX for Aortic Regurgitation -
1. Surgery *BEFORE* LV dysfunction.
2. Symptoms = replace valve.
3. LVEF < 50% replace valve.
4. End systolic ventrical size ≥55mm
Why does CHF in Aortic regurg improve with tachycardia?
1. It is a form of regurgitation, shorter diastole means less regurgitation time.
What medications should be used and which should be avoided in Chronic Aortic regurg and why?
1. Use peripheral vasodialtors eg nifedipine, and replace the valve.
2. Do not use beta blockers, or non-dihydropyridine CCB, as these will cause bradycardia and increase diastole. They can precipitate acute heart failure
Summary of aortic regurgitation
1. Multiple etiologies for AR involving Ao valve/& or root.
2. Pressure and Volume overload → eccentric and concentric hypertrophy(mostly eccentric).
3. Bradycardia makes the CHF Worse! (↑Diastolic filling time →↑Regurgitation)
4. Decreased Diastolic pressure decreases coronary blood flow. → can cause nocturnal Angina!
5. Austin Flint Murmur is associated with moderate to severe aortic regurgitation = low ptiched Apical mid-diastolic rumble.
6. Physical finding: soft S1, Aortic Ejection murmur, loud S3, single S2.
Rheumatic heart dx, what causes it?
Group A βhemolytic strep, ie Strep pyogenes.
Histo - Aschoff bodies.
Aschoff bodies
*Histologic sign of Rheumatic heart dx*
Aschoff bodies are nodules found in the hearts of individuals with rheumatic fever.
An area of focal fibrinoid necrosis surrounded by inflammatory cell, including lymphocytes, and macrophages, that later resolve to form a fibrinous scar.
How what is used to diagnose Rheumatic heart dx?
The Jones Criteria!
#1 Must have hx of strep infection or currently have it.
Common symptoms of Acute RF include:
-Chills, fever, fatigue, migratory arthralgias.
Major Cirteria:
-*Carditis*
-*Polyarthritis*
-*Sydenham Chorea* (involuntary dance like movements)
-*Erythema marginatum (non pruritic, rash red margin white center).
-*subcutaneous nodules on spine, scapula, elbow, knees*


- Antistreptolysin O antibodies = evidence of strep infection.
Tx is high does aspirin and Penicillin.
Rhumatic heart dx acute vs long term affect on vlaves?
Acute can have mitral regurgitaiton.
Long term it can turn into mitral stenosis.
Infective Endocarditis(caused by infection) what are common causes?
1. Staph Aureus (catalse +, Coagulase+)
2. Strep Viridans - αhemolytic strep(turns agar green), optochin resistant(differentiates it from s. pneumo)
3. Strep Bovis.
What else is Strep Bovis associated with?
*Infective endocarditis, and Colon cancer = Strep bovis*
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