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105 Cards in this Set

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What is Aortic Stenosis?
obstruction of LV outflow

pressure gradient between LV and aorta

lumen less than 1.0cm2
leads to LVH (then possible dilatation)
In AS, What is Congenital bicuspid AV?
asymptomatic, until around 50yo (calcification, rigidity, narrowing)
In AS, explain rheumatic
“childhood febrile illness” usually only seen after mitral stenosis (commissural fusion, calcification, narrowed orifice)
What are the 4 NYHA Classification?
Etiology (congenital, acquired)
Anatomy (valvular, coronaries, muscle)
Physiology (arrhythmia, ischemia, CHF)
Functional limitation (degree of activity that elicits symptoms)
what is “Senile” Calcific in AS
elderly (fibrosis, heavy calcification, fusion of leaflets)
List 3 signs & symtoms for AS
Angina
Syncope
Dyspnea
List late findings of AS
Left ventricular failure

Severe pulmonary hypertension

Resultant right heart failure

15-20% sudden death
On physical exam, what are the findings for AS?
Lower B/P with narrowed pulse pressure

Delayed and diminished pulses

Prominent “a-wave” on jugular venous exam

Palpable S4 with non-displaced, sustained PMI

“thrill” at the base
Auscaltation for AS should may hear
Apical S4 (plus S3 if CHF present)

“diamond-shaped” murmur (crescendo-descrescendo)

Low pitch, rough, “rasping” murmur at the base radiating to the carotids

“parodoxical S2 split” from constant late A2
How will an AS chest xray present?
Post-stenotic dilation of the aorta

Calcification of aortic valve on x-ray or fluoroscopy

signs of congestion with LVH, dilatation of RV
What will you see on an ECG for an AS?
Possible Atrial Fibrillation

Left axis deviation
LBBB or intra-ventricular conduction delay (from diffuse myocardial fibrosis)
If LAE present, look for MV disease
An ECG/ Doppler may show?
LVH

Aortic Valve Calcified
Eccentricity, ? Bicuspid

Evaluate LV ejection fraction
Doppler interrogation allows calculation of AVA

additional valvular abnormalities (ie AI, MR, etc)
How can Cardia Catherization help in an AS?
Hemodynamics and presence/degree of pulmonary hypertension

Measure LV/Aortic gradient

Calculate valve area

Evaluate LV ejection fraction

Presence/absence of CAD
What is the best management for AS?
fix outflow obstruction

plan repair/replacement

Medical therapy

Endocarditis prophylaxis!!!!

CHF stabilization

Avoid pre-and after-load therapies

Balloon dilation in young bicuspid valve but not in senile calcific
Is valve replacement for AS patients necessary?
Yes, surgery is indicated for all symptomatic pts
What is used to valve replacement and how is it maintained?
Either tissue (porcine or human) or mechanical

Anticoagulation always necessary in mechanical

With INR 2.5-3.5 normal
Tissue valves “wear-out early”

Endocarditis prophylaxis always needed

Close monitoring for leaks, clot, infection
What is AORTIC INSUFFICIENCY Regurgitation
LV end-diastolic volume increases hemodynamic issue

The chamber thickens and dilates to accommodate the regurgitant volume until heart can weigh 4x normal (1000gms)

Eventually the LV fails causing pulmonary hypertension and resultant RV failure
what are the causes for AI?
Infectious (endocarditis, syphilitic)

Inflammatory (Rheumatic, ankylosing spondylitis, Lupus)

Congenital (bicuspid, prolapse associated with VSD, congenital fenestrations)

Degenerative
(Cystic medial necrosis, Marfan’s)
Traumatic
Historically how would an AI pt present?
Asymptomatic until middle age

May have history of murmur, bicuspid valve, RHD

signs of LV overload and failure (SOB, orthopnea, PND, etc)
what would you see on a physical exam for pt c AI?
Wide pulse pressure

Physical findings of Marfan’s

Displaced PMI w/palpable S3 and S4

Possible pulmonary congestion

Diastolic “blowing” murmur along LSB

Ejection click at aortic valve w/systolic murmur

Rumbling apical diastolic “Austin-Flint” murmur of early MV closure
What causes Peripheral Manifestations of AI? and list the signs
Result from large stroke volume with rapid diastolic runoff:
DeMusset’s sign
Corrigan’s pulse
Quincke’s sign
Duroziez’ murmur
Muller’s sign
Hill’s sign
what is DeMusset's sign?
Bobbing head
What is Corrigan’s pulse?
Water-hammer pulse, rapidly rising and falling
What is Quincke’s sign?
Arterial pulsations of the nailbeds
What is Duroziez’ murmur?
Systolic and diastolic murmur over femoral artery
What is Muller’s sign?
Rhythmic pulsation of uvula
What is Hill’s sign?
A disproportionate elevation in FA pressure
How will an AI present on chest xray?
Enlarged heart if chronic with signs of pulmonary congestion

Possible Calcified AV

Enlarged aorta in connective tissue disorders
What would you see on a pt c AI ECG?
LVH

ST depression and T wave inversions

Left axis deviation

Widened QRS (from patch fibrosis – bad sign!)
What will and ECG/Doppler show on an AI pt?
Expanded systolic excursion free wall of LV

“supernormal” velocity of wall motion

Rapid, high frequency fluttering of anterior leaflet MV (Austin Flint murmur)

Dilated LV, LA, Aortic Root

regurgitant flow from aorta into LV during diastole
What is cardia catherization used for in a pt c AI?
presence and severity of AI
Assess LV function
R/O Coronary artery disease
How can Radionuclide Studies help in AI pt?
evaluate LV function at rest and with exercise

A decreased EF w/exercise suggests myocardial impairment
What Medical Treatment are used for pt c AI?
Vasodilators
ACE-I
B-blockers in Marfans
diuretics, salt restriction
digoxin
Manage arrhythmias
SBE prophylaxis
Penicillin for syphilitic
?anticoagulation
What do ACE-I do for AI pts?
Reduces regurge
List Vasodialators for AI pts?
Hydralazine, nifedipine, ACE-I
How does diuretics, salt restriction assist pt c AI?
Reduce pre-load
What is digoxin used for in AI pt?
Improve inotropy
When is Surgical Treatment needed for AI pt?
Symptomatic pt EF < 55% or LV end-systolic dimension > 5.0 cm on M-mode Echo

Surgery on aortic root for diameter >5.5 cm (or 5.0 in Marfans)
When is it Considerable mortality for AI pt?
if LV severely decompensated
“time to operate” sometimes difficult to determine
What is a main characteristic of pt c AI?
High pitched "decrescendo diastolic murmur"
Accentuated by sitting up/ leaning forward

Austin Flint murmur:
Apical low pitched diastolic rumble

LVH
What are the Features of the Mitral Valve? (MR)
bileaflet (anter and poster)

complex support structure (chordae tendinea,papillary muscles, annulus, wall of LV)

on “high pressure” left ventricular contraction
plays an active role
What are the signs for Chronic MR?
Degenerative
Infectious
Structural
Explain the degenerative features of a chronic MR pt?
myxomatous degeneration, annular calcification, Marfan Syndrome
Explain the Infectious features of a chronic MR pt?
Infective endocarditis
Explain the structural signs for a chronic MR pt?
ruptured chordae tendineae, papillary muscle dysfunction, increased annulus as result of LV dilatation, prosthetic valve leak
Explain the degenerative features of an acute MR pt?
Myxomatous degeneration with chordal rupture
Is the feature of an acute and a chronic MR pt the same in the infectious sign?
Yes the same Infective endocarditis
Explain the Structural features of an acute MR pt?
rupture of papillary muscle secondary to ischemia, malfunction of prosthetic valve, trauma
What is the process in chronic MR pt?
gradual dilatation of LV and LA with the LA accommodating the volume.
Little in the way of transmitted pressure to the lungs till late, then pul HTN and right heart failure
What is the process in acute MR pt?
instantaneous transmission right thru the normal sized LA into the pulmonary venous system with severely elevated pressures, pulmonary edema and acute right heart strain
What finding in pt history increases MR?
inciting event

Well tolerated chronically until evidence of left heart failure

Findings of Right heart failure
What are the inciting events in a MR pt history?
childhood rheumatic fever, febrile illness after dental procedure, CHF
What are the signs for left heart failure in a MR pt?
DOE, orthopnea
What are the findings of Right heart failure in a MR pt?
peripheral edema, increased JVD, hepatomegaly
What are the findings on a Physical Examination of Chronic MR pt?
Increased “a” wave

Carotids with early sharp upstroke, then normal

Laterally and inferiorly displaced PMI with palpable
S3 and S4

Holosystolic (Pansystolic) diastolic murmur at apex radiating to axillae

Pulmonary Ejection sound from pul HTN

Left atrial lift late systole behind RV, “rocking motion
What will chest xray show for a Chronic MR pt?
left atrial, left ventricular and right ventricular enlargement
What will chest xray show for an Acute MR pt?
pulmonary edema without chamber enlargement
What are the secondary findings on ECG to the chamber's of a MR pt?
Increased voltage of LA and LV in chronic MR

Atrial arrhythmias

LAD until right heart failure then may shift rightwards
What shows on Echocardiography of a MR pt?
Assessment of MV leaflet motion and directional doppler flow helps with mechanism of the MR

TEE allows precise MV detail

Chamber size of LA, LV and RV

Ejection fraction of LV always “over-estimation” as unloading into low pressure LA makes the LV “look good”…
Why is Cardiac Catheterization used in Mr pt?
Hemodynamics with degree of pulmonary HTN measured and PCWP

LV angiogram to assess EF, LVEDP and quantitate degree of regurgitation (1+ mild to 4+ severe)

LA size

Presence of coronary artery disease
Why do MR pt undergo Exercise Testing?
assessing severity of MR and timing of surgery

May have echo for transplant candidates
What are the Medical Treatment to prevent LV failure and delay need for MV surgery for pt c MR?
Relieve LV wall stress

ACE inhibitors

B/P control

Prevent or treat ischemia

Maintain sinus rhythm, treat arrhythmias

Consider anticoagulation
What are ACE inhibitors used for in MR pt?
first line therapy to allow easier LV emptying and reduce regurgitant volume, especially when LV dysfunction present
In MR pt at what level should Bp control?
to levels of <139 sys and <89 diastolic
In relieving LV wall stress we are really preventing _ in MR pt?
prevention of adverse remodeling
When should Surgical Intervention be considered for MR pt?
Symptomatic pt

EF <60% or marked LV dilation

Repair vs replacement
When is surgery considered for an acute MR?
endocarditis, MI, rupture chordae usually emergency surg
In a pt c MR when will you consider repair vs replacement?
Try to repair if at all possible, but if replace try to use patients own annular papillary structure
What are the causes of Mitral Stenosis MS and what are some of the signs?
DOE, Orthopnea, PND, hemoptysis (rupture of pul-bronch venous)
Causes:
Rheumatic Fever
Congenital disease
What other symptoms may precipitate signs of MR?
Sx precipitated by Afib, pregnancy
What are the 2 syndromes for a MR pt?
Moderate: pulm edema
Severe: pulm HTN, low CO
How does a MR sound?
Prominent mitral 1st sound, opening snap, apical diastolic rumble
Which bacteria found in Rheumatic Fever?
Found in what age group?
strep pharyngitis (Group A)

age 5-15yrs
How does the body react to Rheumatic fever, to develop MR?
Antibodies form in response to the strep antigen
These antibodies mistakenly attack host tissues!

Special propensity for connective tissue, like valve collagen

Inflammation occurs and repeated attacks with intermittent attempts at healing create fibrous thickening, adhesion of valve commissures
What step may be taken to Prevent RF?
Treat strep pharyngitis aggressively!!!
Penicillin G or Penicillin V
Oral sulfadiazine
Oral erythromycin
azithromycin
What are the dosages for the prevention of RF?
IM injection of 1.2 million units of Penicillin G once a month or Penicillin V 250 mg BID (less effective)

Oral sulfadiazine 1 g daily for penicillin allergic patients

Oral erythromycin 250 mg BID or azithromycin for both penicillin and sulfadiazine allergic patients
What are the Major Jones Criteria in MS pt?
Migratory arthritis
Carditis
Sub-cutaneous nodules
Erythema marginatum
Sydenham’s chorea
What are the Minor Jones Criteria in Ms pt?
Fever
Elevated sedimentation rate/C-reactive protein
Arthralgias
Increased PR interval
Prior RF or RHD
What are the Criteria Needed for RF?
Two major
One major, two minor
Which valves are affected in Rheumatic Heart Disease?
Mitral>aortic>tricuspid (almost never involves pulmonic)
What happens to the valves in Rheumatic Heart Disease?
Stenosis, regurgitation or combination of the two
When does the diagnosis of “RF” (where there is a “pancarditis”, arthritis, etc) change to “RHD”?
when there is residual evidence of cardiac impairment characteristic of this disease long after the acute illness has passed:
20 yrs after the acute illness (4th decade)
what is the time frame for Acute rheumatic fever?
typically begins as polyarthritis 2-6 weeks after streptococcal pharyngitis
The Acute rheumatic fever disease involves what parts?
heart, joints, central nervous system (CNS), skin, and subcutaneous tissues
What might you expect on Mitral Stenosis Physical Exam?
Large “a” waves on JVP

Normal to Low blood pressure

? Palpable S1

Possible RV lift

Diastolic “thrill” left apex in left lateral decubitus position
Auscultation
S1 “snapping” and accentuated
Increased P2 with Ejection Click
“Opening snap” of MV after S2
“diastolic rumble”, low-pitched at apex in LLD position, accentuates towards end
Severity gauged by the closeness of “OS” to S2 and the duration of the murmur
What else may be Associated findings on auscultation of MS pt?
Aortic stenosis/regurgitation
Tricuspid stenosis/regurg
Mitral regurgitation
Graham-Steell murmur of Pulmonic Insufficiency secondary to severe pulmonary hypertension
What may be seen on chest Xray of MS pt?
Small LV

Straightened left heart border

Prominent PA

Dilatation of pulmonary veins upper lobes

Kerly “B” lines of congested interlobular septa and lymphatics

Esophagus displaced posteriorly secondary to LAE
Electrocardiogram will show in a MS pt?
LAE
With pulmonary hypertension: RAE, RVH, Right axis deviation
Atrial Fibrillation
Echocardiogram will show in a MS pt?
Ant and poster leaflets of mitral valve do not separate fully

Decreased E-F slope

Calcifications and thickening with shortening of the chords

Decreased MV orifice
LAE
What may a Cardiac Catheterization advise in MS pt?
measure pressure
Calculate MVA
Assess hemodynamics, severity of pulmonary hypertension
Presence of MR
Evaluate LV ejection fraction
Evaluate for CAD
Cardiac catherization approach is?
trans-septal approach to enter LA
What are the Treatments for asymptomatic patients c MS?
SBE prophylaxis

Limit strenuous physical activity

MAINTAIN SINUS RHYTHM!!!
Convert A-fib
What are the SBE prophylaxis for asymptomatic MS pt?
Penicillin for prophylaxis of Beta-hemolytic strep
What are the Treatment for symptomaic patients c MS?
Limit Na+, use diuretics

Digoxin , beta-blocker

Detect and treat anemia

Consider anticoagulation

Bedrest if hemoptysis present

MAINTAIN SINUS RHYTHM!!!
Digoxin is used for?
Beta-blocker used for?
for Afib
to control rate
When is Surgery needed for MS pt?
MVA <1.0cm2 and symptoms

If concurrent MS & MR
Balloon valvuolplasty for lesser calcified MS without regurgitation

Valve repair may be possible

Ultimately replacement
Which procedure not done much anymore in pt c MS?
Intra-operative “valvotomy”
When will replacement valves needed in MS pt?
first procedure in presence of heavy calcification or regurgitation
What kind of Post-surgical Care needed for MS pt?
Anticoagulation
maintain NSR
SBE prophylaxis
Good valve surveillance
What is the most common cause of Mitral Stenosis?
Rheumatic Fever from Group A Beta-Hemolytic Strep
Where is Mitral Stenosis heard?
heard best at the apex in the left lateral decubitus position
Low pitched diastolic rumble best accentuated by which movements in Ms pt?
squatting (valsalva) or expiration
What other informative occurences may not be strep?
Occasional pts have hoarseness due to recurrent laryngeal nerve compression b/t aorta and pulmonary artery
What sounds upon auscultation
for pt c MS?
Loud (Crisp) S1 , Increased P2