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165 Cards in this Set
- Front
- Back
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What is the range of clinical presentation of Valve dysfunction?
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-Insignificant
to -Severe and rapidly fatal |
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What is Stenosis?
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Failure of a valve to open completely
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What is Insufficiency?
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Failure of a valve to close completely
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What is secondary valve failure?
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The insufficiency of a valve due to abnormalities in a different structure.
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What does secondary valve failure result in?
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Functional regurgitation
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What are 2 causes of Functional regurgitation?
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-Ventricular dilation
-Aortic/pulmonic artery dilation |
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How does Ventricle dilation cause functional regurgitation?
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It pulls the papillary muscles down and out during systole so that the atrioventricular valves don't close all the way.
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How does Aortic or Pulmonary artery dilation cause functional regurgitation?
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It prevents full closure of the aortic or pulmonic valves.
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What is the most frequent cause of valve stenosis?
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Acquired
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What valves are defective in 2/3 of all valve diseases?
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-Aortic
-Mitral (left side of heart valves) |
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What structure is abnormal in stenosis?
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The cusp
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What is the typical onset of stenosis?
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Chronic
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What is the most common type of valve Insufficiency?
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Intrinsic (not acquired)
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If valve insufficiency is not intrinsic, what else could it be caused by?
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Distortion of support structures (functional regurgitation)
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What 2 conditions cause Calcific valve disease?
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1. Dystrophic calcification (most common)
2. Highly repetitive mechanical stress |
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How are valve problems generally identified?
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By hearing murmurs on the physical exam.
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What does secondary valve failure mean?
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The valve problem isn't intrinsic, but caused by abnormalities in the tissue around the valve.
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What are 2 causes of secondary valve failure? What is the result of each?
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-Dilation of the ventricle
-Dilation of the aortic or pulmonary artery -Both result in functional regurgitation. |
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How does dilation of the ventricle cause functional regurgitation?
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By pulling the papillary muscles away from the tricuspid or mitral valves which prevents them from closing all the way.
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How does dilation of the aortic or pulmonary artery cause functional regurtitation?
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By preventing full closure of the aortic or pulmonic valves.
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What is the most common and frequently seen type of valve disease?
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Acquired stenosis
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What are 2/3 of all valve disease comprised of?
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Either mitral or aortic valve stenosis
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What is the usual problem that causes acquired stenosis, and what type of onset is commonly seen?
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-Primary cusp abnormality - in the tissue itself
-Chronic process - not sudden death |
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What are the 2 primary ways that insufficiency can develop?
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-Primary intrinsic disease of the valve cusp
or -Distortion of the supporting structures (functional regurg) |
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What is calcific disease?
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Dystrophic calcification of the heart valves due to wear and tear
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How is calcific disease different from atherosclerosis?
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There is no significant lipid deposition or cell proliferation
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Why does calcific disease occur in valves?
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Due to the highly repetitive mechanical stress that valves are under.
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What will ausculatation show in calcific aortic stenosis?
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An ejection sound at the 2nd right IC border
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Why do we care about calcific aortic stenosis?
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Because it can result in congestive heart failure and is the most common type of valve disease of them all.
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What heart changes result from calcific aortic stenosis?
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Left ventricular hypertrophy
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What is a common symptom of patients with calcific aortic stenosis?
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Angina
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What do symptoms imply?
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Poor prognosis and the need for surgery
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What happens to patients with angina due to calcific aortic stenosis?
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50% die within 5 years
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What happens to the patients who develop CHF due to calcific aortic stenosis?
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50% die within 2 years
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What valve disease do we see in 1.4% of the population that is predisposed to degenerative calcification?
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Bicuspid aortic valve
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What may cause the Bicuspid aortic valve to become incompetent?
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-Aortic dilation
-cusp prolapse -infective endocarditis |
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Where do calcification deposits develop in MITRAL valve calcification?
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In the fibrous ring - annulus behind the leaflets
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What can mitral valve calcification lead to? (3 things)
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-Stenosis
-Regurgitation -Arrythmia/sudden death |
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What are 2 things that a mitral valve calcification puts a patient at risk for?
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-Thromboembolism
-Infective endocarditis |
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When does a calcified mitral valve lead to sudden death?
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When the calcification deposits penetrate deeply enough to compromise the AV conduction system.
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What is indicated by:
-Chest pain like angina/dyspnea -Fatigue -Depression/anxiety/panics -Mid-systolic click or holosystolic blowing? |
Mitral valve myxomatous degeneration
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What is mitral valve myxomatous degeneration?
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Prolapse
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What exactly happens in mitral valve prolapse?
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one or both of the mitral valve leaflets balloons back into the atrium during systole.
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What % of the population has some form of mitral valve prolapse?
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3%
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So what features are seen on the mitral leaflets in myxomatous degeneration?
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-Interchordal ballooning - hooding
-Thick and rubbery leaflets |
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What is a MAJOR characteristic of mitral valve myxomatous degeneration?
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Annular dilation of the mitral valve
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What happens to the chordae tendinae frequently in mitral valve prolapse?
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They elongate, become thinner, and occasionally rupture
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What is seen histologically in mitral valve myxomatous prolapse?
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-Decreased collagen
-Marked thickening by myxomatous material |
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What is seen histologically in the chordae tendinae in mitral prolapse?
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Decreased collagen
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What is thought to be the cause of Mitral valve prolapse?
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Defects in structural proteins which predispose the valve to damage by longstanding hemodynamic stress.
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In what syndrome is mitral valve prolapse frequently seen?
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Marfan's
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What % of patients with MV prolapse develop serious complications?
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3%
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What are 4 serious complications that people with MV prolapse can develop?
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1. Infective endocarditis
2. Stroke/infarct 3. Surgical requirement 4. Arrythmia |
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Why are patients with MV prolapse more prone to stroke or infarct?
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Because of thrombi that deposit on the leaflet, which can embolize to other parts of the body and cause damage.
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What are 3 long-term causes of needing surgery for MV prolapse?
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-Leaflet deformity
-annulus dilation -Cords lengthening |
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What is a rapid onset requirement for surgical repair of MV prolapse?
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Cordal rupture
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Why do patients with MV prolape sometimes develop arrythmias and sudden death?
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Possibly because of the snapping of the cords and valve leaflets on the ventricle and atria - disrupts the conducting system.
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What is Rheumatic Fever caused by?
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Strep A pharyngitis
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When after strep A pharyngitis does Rheumatic fever occur?
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2-3 weeks later
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What exactly causes Rheumatic fever symptoms?
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An autoantibody to Group A strep antigens that cross-reacts with tissue antigens.
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What can rheumatic fever progress to?
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Chronic rheumatic heart disease
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What type of heart defect is seen in chronic rheumatic heart disease?
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Valve deformities - of the mitral valve
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What type of stenosis is the MV stenosis seen in rheumatic heart disease?
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Fibrotic fusion of the leaflets
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What has happened to the incidence of rheumatic heart disease? Why?
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It has decreased - due to:
-better socioeconomics -Better/more rapid treatment and diagnosis -Decreased Group A strep virulence |
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What are Jones criteria?
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Criteria for establishing whether a person has rheumatic fever.
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What are the Jones criteria?
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1. Evidence of a preceding Group A Strep infection
2. Two major manifestations or 1 major and 2 minor |
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What is evidence of a preceding group A Strep infection?
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Serum antibodies to 1 or more strep enzymes.
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What are the 5 major manifestations of Rheumatic fever?
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1. Migratory polyarthritis
2. Erythema marginatum 3. Carditis 4. Sydenham chorea 5. Subcutaneous nodules |
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What is Sydenham chorea?
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A neurologic disorder with involuntary purposeless rapid movements
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What are the minor criteria for Rheumatic fever diagnosis?
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-Fever
-Arthralgia (aches) -Elevated acute phase reactants |
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What is the most common age of onset of acute rheumatic fever?
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5-15 yrs old
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What are 4 symptoms of acute carditis?
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-Pericardial friction rub
-Weak heart sounds -Tachycardia -Arrythmia |
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What is another name for Pericardial friction rub? Why?
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Bread and butter rub - because there is a sort of sticking of the pericardium to the heart which causes the rub.
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What do patients feel as a result of the pericarditis and how do they compensate?
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Pain from the rubbing - leaning forward takes some of the pressure off and helps ease the pain.
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What heart problems does myocarditis lead to in Acute rheumatic fever?
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-Dilation
-Functional MV insufficiency -Heart failure |
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What finding is more common in adults with acute rheumatic fever?
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Migratory polyarthritis of the large joints
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What is the hallmark finding within the heart in patients with acute rheumatic fever?
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Aschoff bodies
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What are Aschoff bodies?
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Granulomas due to the cross-reaction of Auto-Ab with tissue surface antigens in the heart - stimulate inflammation
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What is found in the pericardium of patients with acute rheumatic fever?
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Fibrinous pericarditis
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What is found on the valves or chordae tendinae in patients with ARF?
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Small vegetations
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What are 2 complications of aschoff's bodies?
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-Fibrosis later on
-AV conduction disturbances |
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What is the prognosis of people with acute rheumatic fever?
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Pretty good! Only 1% die from fulminant rheumatic fever.
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What are patients that have had an initial attack of acute rheumatic fever at increased risk for?
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Subsequent pharyngeal infections leading to cumulative damage.
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What is the cause of 99% of mitral valve stenosis (noncalcific)?
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Rheumatic heart disease
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What is Rheumatic heart disease?
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The chronic complication and sequelae of acute rheumatic fever.
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What do 65-70% of patients with rheumatic heart disease have problems with?
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The mitral valve alone
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What do 25% of patients with rheumatic heart disease have problems with?
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The mitral AND aortic valves
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What does the type of valve involvement determine?
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What secondary heart changes will be seen.
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What are the secondary heart changes seen when only mitral valve stenosis is seen?
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-Left atrial dilation
-Pulmonary vascular changes -Right ventricular hypertrophy |
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What is the risk when there is Left atrial dilation?
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Mural thrombus and later thromboembolism.
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What is the timeframe in which chronic rheumatic carditis will manifest itself?
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Years to decades after acute rheumatic fever.
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What additional manifestation can be seen when the Aortic valve is included in chronic rheumatic heart disesae?
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Left ventricular hypertrophy
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What has to be considered when patients develop symptoms from the valve stenosis caused by chronic rheumatic carditis?
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Surgical repair
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What 4 cardiac changes are seen in chronic rheumatic heart disease?
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1. Fibrotic replacement of Aschoff bodies (organization)
2. Fibrotic leaflet thickening 3. Commisural fusion 4. Chordae tendineae shortening thickening and fusion |
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What is the commisural fusion in chronic rheumatic heart disease also sometimes called?
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Fishmouth deformity
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-32 yo chronic IV drug abuser
-Fever, mental status changes -Positive blood cultures -Heart murmur -Multiple infarcts in organs |
Infective endocarditis
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What is infective endocarditis?
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Colonization and invasion of the heart valves or endocardium by a microbe
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What type of microbe is usually the culprit in endocarditis?
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Bacteria
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What is generally seen in infective endocarditis?
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Bulky, friable vegetations involving one or more of the heart valves.
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How do fungal vegetations compare to the bacterial ones?
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Larger
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What is the major risk in infective endocarditis? Why would it happen?
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-Systemic embolism causing septic infarcts
-Caused by high organism load |
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What valves are most commonly involved in infective endocarditis?
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MV and AV (left heart)
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What valve is most commonly involved in IV drug abusers?
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The right heart valves!
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Why are the right heart valves more commonly infected in endocarditis of IV drug abusers?
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Because organisms circulating in the bloodsteam are injected into the veins and they lodge in the right side of the heart.
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Why are the left heart valves the more common site of infection in normal people?
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Because these valves are exposed to higher pressures and stress and so small organisms are more likely to lodge there.
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What are the 2 flavors of infective endocarditis?
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-Acute
-Subacute |
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What is the onset of acute infective endocarditis?
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Rapid
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What is the onset of Subacute infective endocarditis?
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Protracted - over weeks to months
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What is the valve like prior to
Acute infective endocarditis? Subacute infective endocarditis? |
Acute: previously normal
Subacute: previously abnormal |
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What type of organism is usually responsible for causing
Acute infective endocarditis? Subacute infective endocarditis? |
Acute: highly virulent
Subacute: low virulence |
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Which type of endocarditis has a higher death rate despite surgery and antibiotics?
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Acute
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What microscopic findings will be seen in infective endocarditis?
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-Fibrin
-Inflammatory debris -Microorganisms |
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What additional finding can be seen in subacute endocarditis at the base of the vegetation? Why?
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Granulation tissue - because this is a chronic process that involves healing.
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What type of infectious endocarditis is more likely to involve ulcerative/necrotizing vegetations?
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Acute
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What is the danger of ulcerative/necrotizing vegetations?
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They can erode into the underlying myocardium
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What is it called when vegetations erode into the underlying myocardium?
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Ring abscesses.
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What is the first step in the pathogenesis of infective endocarditis?
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Seeding of the bloodstream with the microorganism - bacteremia
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What are the 3 common portals of entry for bacteria causing bacteremia?
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-Dental/surgical procedures
-Infections anywhere in the body -Injections with contaminated needles |
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What is a general predisposing condition to infective endocarditis?
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Any valve abnormality
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So what are the 5 valvular abnormalities that are predisposing conditions to developing infective endocarditis?
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-Myxomatous MV prolapse
-Degenerative calcific stenosis -Bicuspid aortic valve (with or without calcification) -Artificial prosthetic valves -Rheumatic heart disease |
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What are 2 predisposing conditions to infective endocarditis that are NOT related to valve abnormalities?
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-Indwelling vascular catheters
-Host factors |
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What are 4 host factors that are predisposing conditions to infective endocarditis?
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-Malignancy
-Immune suppression -Alcohol/IV drug abuse -Diabetes mellitus |
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What is the most common organism that causes subacute infective endocarditis?
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Strep viridans
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What does Strep viridans tend to infect?
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Previously damaged valves
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What is the most common organism that causes acute infective endocarditis?
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Staph aureus
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What does Staph aureus tend to infect?
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Either normal OR previously damaged valves
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What organism is the most common cause of prosthetic valve endocarditis?
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Staph epidermidis
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What is the HACEK group?
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The oral bacteria
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What other strep can cause infective endocarditis?
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Enterococcus
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Is a bacteria always found in endocarditis?
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No; sometimes it can't be cultured due to antibiotic treatment, or it's just difficult to isolate.
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What is the most consistent sign of infective endocarditis?
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Fever
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What type of infective endocarditis will have a stormy onset with rapidly developing fever, chills, weakness and lassitude?
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Acute infective endocarditis
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How does the onset of subacute infective endocarditis differ?
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-Fever may be only slight/absent
-May just have nonspecific flu like symptoms |
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What can be found in 90% of patients with infective endocarditis?
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A left heart murmur
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What 5 weird findings are less common in infective endocarditis?
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JORPS
-Janeway lesions -Osler nodes -Roth spots -Petechiae -Subungual hemorrhages |
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What are Roth spots?
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Retinal hemorrhages
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What are Janeway lesions?
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Lesions on the palms and soles
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What are Osler nodes?
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Digit nodules
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What are the embolic complications of left-sided vegetations?
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Infarcts and abscesses in the brain, heart, spleen, or kidney
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What are the embolic complications of right-sided vegetations?
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Infarcts/abscesses in the lungs, or pneumonia
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What can result from the Ag-Ab complexes in circulation?
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Glomerulonephritis
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How is infective endocarditis prevented?
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Prophylactic use of antibiotics
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What are the valve leaflet deposits in NONbacterial thrombotic endocarditis like, in comparison to those in infective endocarditis?
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Much bigger
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What are the valve leaflet deposits in NBTE composed of?
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-Fibrin
-Platelets -Blood products |
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What patients are prone to NBTE?
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Patients with a predisposition to a clotting problem
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Why are NBTE cases dangerous, if there is no organism and the deposits are sterile?
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They can still embolize and cause the same complications as seen in IE.
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What is not generally seen in NBTE that may be seen in acute IE?
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No erosion or the myocardium
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What 2 conditions are NBTE cases associated with?
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-Deep vein thrombosis
-Pulmonary embolism |
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And What is generally the cause of NBTE?
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A hypercoagulable state
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What is Libman-Sacks disease?
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Endocarditis of Lupus
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What is the cause of endocarditis in lupus?
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Circulating antiphospholipid antibodies cause sterile vegetations in the MV and TV
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What malignancies are especially prone to causing hypercoagulable states? Why?
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Mucinous adenocarcinoma of the pancreas - bcuase of increased circulating mucin which is procoagulant.
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Going back to Libman-Sacks disease...
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yes?
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What is the hallmark finding in Libman sacks disease (SLE) vegetations?
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They are on the UNDERsurfaces of the Mitral / Tricuspid valves
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What can happen to the vegetations in libman sacks disease?
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They can cause necrosis
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Why is it bad when necrosis occurs in Libman-Sacks disease?
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It may be difficult to distinguish it from IE or NBTE.
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What are the 2 main types of artificial heart valves?
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1. Mechanical Prosthetics
2. Bioprosthetics |
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What are bioprosthetic heart valves made from?
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Animal tissue mounted on a prosthetic frame
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Which type of prosthetic heart valve generally works better? Why?
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Bioprosthetics - because they are more flexible; non physiologic valves are more rigid.
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Which type of prosthetic heart valve generally lasts longer?
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Mechanical
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What is the main complication of artificial valves?
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60% develop problems in 10 years
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What complications are generally seen in Mechanical prosthetic valves?
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-Local thrombotic obstructions
-Distant embolization |
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What do patients with mechanical heart valves require?
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Long term anticoagulation
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What is a side-effect of the anticoagulation therapy?
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Over-anticoagulation can cause hemorrhages
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What are 4 complications that can occur in either type of prosthetic heart valve?
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-Infective endocarditis
-Hemolysis -Structural deteriorations -Inadequete OR exuberant healing |
