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Valvular Heart Disease
Terms in this set (42)
What is the normal function of a valve?
Maintains forward flow and prevents reversal of flow; Valves open and close in response to pressure differences (gradients) between cardiac chambers
What is a valve stenosis?
Obstruction to valve flow during that phase of the cardiac cycle when the valve is normally open.
Aortic stenosis would occur during (systole/diastole).
Systole. Mitral stenosis happens during diastole!
How do we calculate valve area during valve stenosis?
Proportional to: Flow/ (square root of pressure gradient)
Valve regurgitation is also known as:
Insufficiency or incompetence. Results from inadequate valve closure which produces back leakage
T/F: A single valve can be both stenotic and regurgitant.
TRUE but both lesions cannot be severe! (can not open fully OR close fully).
What kinds of disease states can cause mitral stenosis?
Rheumatic heart disease--99.9%
; Congenital; Prosthetic valve stenosis; Mitral annular calcification; Left Atrial Myxoma
What kinds of disease states can cause acute mitral regurgitation?
Infective endocarditis; Ischemic heart disease (papillary muscle rupture); Mitral valve prolapse (chordal rupture); Chest trauma
What kinds of disease states can cause chronic mitral regurgitation?
Ischemic heart disease (papillary muscle dysfunction; Inferior and posterior MI); Mitral valve prolapse; Infective endocarditis; Rheumatic; Prosthetic; Mitral annular calcification; Cardiomyopathy (LV dilatation; Hypertrophic cardiomyopathy--HOCM)
Rheumatic Heart disease can cause what type of stenosis most commonly?
What is the most common type of mitral valve concern found?
Chronic mitral regurgitation
What is the pathophys of mitral regurgitation?
MR leakage of blood into LA during systole; Primary abnormality-->A percentage of the LV stroke volume goes BACKWARDS into the LA-->LV volume overload (LVVO); Compensatory mechanisms: increase in SV (and EF); LV (and LA) dilatation via eccentric hypertrophy
What are some symptoms of chronic mitral regurgitation?
Left Ventricular volume overload (LV dilatation, eccentric hypertrophy); Increased LA pressure; Dyspnea; Pulmonary HTN; Atrial arrhythmias; Low output state
What are the physical findings of mitral regurgitation?
Hyperdynamic LV: brisk carotid upstrokes; Hyperdynamic displaced LV apical impulse; RV heave
What are the auscultatory findings of mitral regurgitation?
S1 (soft or normal); Increased P2; Holosystolic blowing murmur at apex (MVP: mid-systolic click; IHSS--murmur increases with Valsalva; Acute MR--ejection or decrescendo systolic murmur); End stage-->S3 Gallop and diastolic flow rumble
LV enlarges with eccentric hypertrophy; Maintains EF until fairly late; Pulmonary wedge pressure remains normal until enter severe case. What am I?
Mitral stenosis pathophysiology
Restriction of blood flow from LA to LV during diastole (should be no gradient between LA or LV but here see higher LA pressure); Normal MVA 4-6 cm^2, but severe MS see <1 cm^2
Define mitral valve flow via equation
Cardiac output/diastolic filling period
T/F: As HR increases in Mitral stenosis, diastole shortens disproportionately and MV gradient increases.
What are some symptoms of mitral stenosis?
Dyspnea, orthopnea, PND, severe experience dyspnea at rest
What are the physical findings of mitral stenosis?
Body habitus: thin, asthenic, female; Low BP; RV heave and apical tap
What are the auscultatory findings of mitral stenosis?
S1 (Variable intensity, increased early, progressively decreases); OS (opening snap, variable intensity); A2-OS interval (Varies inversely with severity of MS; shortens as MVA diminishes); Low-pitched diastolic rumble at apex (duration of murmur correlates with severity of MS; Pre-systolic accentuation); Increased P2
How do you treat mitral stenosis?
Medical Rx for early stages (Class I/II): HR control with Dig and beta blockers,
Anticoagulation (Afib, prior embolic event, visible LA thrombus)
; Surgical Rx for late stages (Class III/IV): Balloon mitral valvuloplasty (if commissural fusion, pliable noncalcified leaflets, No MR or LA thrombus) or Mitral valve surgery (open commissurotomy or MV replacement)
Treatment of Chronic mitral regurgitation
Medical Rx for mild to mod MR with vasodilators, diuretics, anticoagulation; Surgical Rx: ideally before LV systolic function declines (MV replacement; MV ring and CABG; MR repair: associated with improved long-term LV function; MVP, ruptured chords, infective endocarditis, pap ms rupture)
When replace a mitral valve after chronic mitral regurgitation, what happens to afterload?
Increases! Decrease ejection fraction by 10%! Need a higher ejection fraction to make sure you don't drop below 40% after the procedure
What diseases can cause aortic stenosis?
Degenerative calcific (senile); Congenital (uni or bicuspid); Rheumatic; Prosthetic
What diseases can cause acute aortic insufficiency?
Infective endocarditis; Acute aortic dissection (Marfan's Syndrome; Chest trauma)
What diseases can cause chronic aortic insufficiency?
Aortic leaflet disease (infective endocarditis, rheumatic, bicuspid aortic valve, prolapse and congenital VSD, prosthetic); Aortic root disease (Aortic aneurysm/dissection, Marfan's syndrome, CT disorders, syphillis, HTN, annulo-aortic ectasia)
Normal aortic valve area is 2.5-3 cm^2, whereas critical Aortic Stenosis is:
<0.7 cm^2. Severe AS is <1cm^2
Thickened (stiff and noncompliant) LV with a normal cavity in aortic stenosis results in:
Increased LVEDP and Increased LV mass (increased MVO2), but this is well-tolerated for decades. When LV fails, get CHF.
What are the clinical symptoms of aortic stenosis?
Typically asymptomatic for many years. Symptoms develop when valve is critically narrowed and LV function deteriorates (Bicuspid AV: 50s-60s; Senile AS: 70s-80s);
Classically: Syncope 2-3 years, Angina pectoris 5 years, Dyspnea (secondary to CHF) 1-2 years life expectancy.
What is the symptom triad of aortic stenosis? What is the mnemonic?
Syncope 2-3 years, Angina pectoris 5 years, Dyspnea (secondary to CHF) 1-2 years life expectancy.
What are some physical findings of severe aortic stenosis?
Parvus et tardus (late and weak carotid pulse); Heaving and sustained LV apical impulse
What are some auscultation findings of severe aortic stenosis?
S4 gallop; no systolic ejection click (only found in mild or moderate AS); Late systole with obliteration of S2 (SEM, peaking); S2 is single, paradoxical or Absent
What are the physical findings of chronic aortic regurgitation?
Widened pulse pressure
>70 mmHg (e.g. 170/60); Low diastolic pressure (<60 mmHG); Hyperdynamic LV: DeMusset's sign (bobbing head), Correigan's pulse, Quincke's pulsations (in figners), Durozier's murmur
What are the auscultation findings of chronic aortic regurgitation?
Diminished A2; Systolic ejection murmur from increased flow during systole; Decrescendo diastolic blowing murmer at LSB; Austin-Flint murmur--diastolic flow rumble at apex (due to interference with trans-mitral filling by impingement from aortic regurgitant jet; DDx--mitral stenosis (increases intensity with amyl nitrite)
Austin-flint murmur. What do I have?
Chronic aortic regurgitatioin
How do we treat aortic stenosis?
Medical Rx: HR and BP control with beta blockers, cardioversion for A fib, CHF--diuretics; Surgical Rx: AVR--for symptomatic pts with severe or critical AS (operate before LV dysfunction, CABG for CAD), Ross Procedure; Interventional procedure (Trans-aortic valve replacement--TAVR)
How do we treat aortic insufficiency?
Meds: vasodilator; Surgical (Acute AI=emergently; Chronic AI with symptoms of CHF; Asymptomatic AI before LV dysfunction)
Which has a longer durability, Mechanical or biological prosthetic valves for aortic stenosis?
Trans-aortic valve replacement; Indications: inoperable patient with severe AS, high risk for AVR, limited lifespan, refuses surgery
What is the ross procedure?
For aortic valve surgery. Autotransplant of pulmonic valve to the aortic position, reimplantation of the coronary aa; Homograft (cadaver) valve in the pulmonic position. Indications: younger patients, no anticoagulation, requires similar sized aortic and pulmonic roots.
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