S2: Ch1 Cv 2-4

Front 1

373. Mitral Stenosis general characteristics?

Back 1

a. Almost all cases are due to rheumatic heart disease. (Pt may not recall a hx of rheumatic fever).

Front 2

374. Pathophys of Mitral Stenosis?

Back 2

a. Immune-mediate damage of the mitral valve (due to rheumatic fever) leads to scarring and narrowing of the mitral valve orifice.
b. Mitral stenosis results in elevated left atrial and pulmonary venous pressures leading to pulmonary congestion.
c. Anything that increases flow across the mitral valve (exercise, tachycardia, etc) exacerbates the pulmonary venous HTN and assoc. sx.

Front 3

375. What can long standing mitral stenosis lead to?

Back 3

a. Pulmonary HTN and ultimately can result in right ventricular failure (RVF).
b. Long-standing mitral stenosis can also lead to Afib.
376. When do pts w/Mitral Stenosis usually start experiencing symptoms?
a. Usually asymptomatic until mitral valve area is reduced to approximately 1.5cm^2 (normal valve area is 4-5cm2.

Front 4

377. Symptoms of mitral stenosis?

Back 4

a. Exertional dyspnea, orthopnea, PND
b. Palpitations, chest pain.
c. Hemoptysis- as the elevated LA pressure ruptures anastomoses of small bronchial veins.
d. Thromboembolism
e. If RVF occurs, ascites and oedema may develop.

Front 5

378. Mitral Stenosis murmur?

Back 5

a. The opening snap is followed by a low-pitched diastolic rumble and presystolic accentuation. This murmur increases in length as the disease worsens.
b. Heard best w/bell of stethoscope in left lateral decubitus position.
c. S2 is followed by an opening snap.

Front 6

379. What is the murmur of mitral stenosis followed by?

Back 6

a. A loud S1. A loud S1 may be the most prominent physical finding.

Front 7

380. What on the murmur of mitral stenosis can give an indication regarding its severity?

Back 7

a. The distance between S2 and the opening snap can give an indication of the severity of the stenosis.

Front 8

381. What will be found on physical exam in long-standing mitral stenosis?

Back 8

a. Signs of RVF (right ventricular heave, JVD, hepatomegaly, ascites) and/or pulmonary HTN (loud P2).
b. All signs and symptoms will increase w/exercise and during pregnancy.

Front 9

382. Diagnosis of Mitral Stenosis?

Back 9

a. CXR: Left atrial enlargement (early)
b. Echo- Most important test in confirming diagnosis:
1. Left Atrial enlargement
2. Thick, calcified mitral valve
3. Narrow, “fish-mouth”-shaped orifice
4. Signs of RVF if advanced disease.

Front 10

383. Tx of Mitral stenosis?

Back 10

a. Medical: Diuretics, infective endocarditis prophylaxis, chronic anticoagulation w/warfarin is indicated (esp if pt has Afib)
b. Surgical (for severe disease)

Front 11

384. Surgical tx of mitral stenosis (severe disease only)?

Back 11

a. Percutaneous balloon valvuloplasty usually produces excellent results.
b. Open commissurotomy and mitral valve replacement are other options if valvotomy is contraindicated.

Front 12

385. Management of Valvular Heart Disease?

Back 12

a. No therapy is required in asymptomatic pts.
b. Diuretics can be used if the pt has mild symptoms.
c. If symptoms are more severe, surgical treatment is recommended.
d. If AFib develops at any time, treat accordingly (see discussion on AFib).

Front 13

386. Pathophys of Aortic Stenosis?

Back 13

a. Causes obstruction to LV outflow, which results in left ventricular hypertrophy (LVH).
b. When the aortic valve area falls below 0.7 cm, cardiac output fails to increase w/exertion, causing angina (but may be normal at rest).

Front 14

387. What affect does longstanding AS have on the heart?

Back 14

a. The LV dilates, causing progressive LV dysfunction.
b. With severe AS, LV dilatation pulls the mitral valve annulus apart, causing mitral regurg.

Front 15

388. Causes of Aortic Stenosis?

Back 15

a. Calcification of bicuspid aortic valve
b. Calcification of tricuspid aortic valve in elderly
c. Congenital uni-leaflet valve
d. Rheumatic fever.

Front 16

389. Course of AS?

Back 16

a. Pts are often asymptomatic for years (until middle or old age) despite severe obstruction.
b. Development of angina, syncope, or heart failure is a sign of poor prognosis.
c. Survival is similar to that of the normal population before the development of these 3 classic symptoms (angina, syncope, heart failure).

Front 17

390. Note: All together, only one 4th of pts w/symptomatic AS survive 3 yrs in the absence of aortic valve replacement (i.e., the 3-yr mortality rate is 75% w/out surgery).

Back 17

390. Note: All together, only one 4th of pts w/symptomatic AS survive 3 yrs in the absence of aortic valve replacement (i.e., the 3-yr mortality rate is 75% w/out surgery).

Front 18

391. 3 Clinical symptoms of AS?

Back 18

a. Angina
b. Syncope- usually exertional
c. Heart failure symptoms, such as dyspnea on exertion, orthopnea, or PND.

Front 19

392. Murmur of AS?

Back 19

1. Harsh crescendo-decrescendo systolic murmur
2. Heard in second right intercostal space.
3. Radiates
b. S4
c. Parvus et tardus- diminished and delayed carotid upstrokes
d. Sustained PMI
e. Precordial thrill

Front 20

393. Diagnosis of AS?

Back 20

a. CXR: Calcific aortic valve, enlarged LV/LA (late)
b. ECG: LVH, LA abnormality.
c. Echo: Diagnostic in most cases. Findings include LVH: thickened immobile cardiac valve; and dilated aortic root.
d. Cardiac cath:
1. Definitive diagnostic test
2. Can measure valve gradient and calculate valve area <0.8 cm indicates severe stenosis; normal aortic valve 3-4 cm.
3. Useful in symptomatic pts before surgery.