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31 Cards in this Set

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How are Stenotic and Regurgitant Lesions assessed?
Stenosis: assessed by valve area and pressure gradient

Regurgitation:assessed by volume of leak
What is the Law of LaPlace in Pressure Load?
As pressure increases, tension increases
The heart responds to increased tension
If the pressure increases, then the thickness must increase to normalize tension, no effect on radius
What is the Law of LaPlace in Volume Load?
As volume (radius) increases, tension increases

The heart responds to increased tension

If the volume increases, then the thickness must increase to normalize tension
How does the Diastolic Pressure/Volume Relation change in Concentric and Eccentric Hypertrophy?
Concentric - up and left

Eccentric - down and right
LV Diastolic Pressure/Volume Relation in Eccentric Hypertrophy
Low filling pressures despite elevated diastolic volume

Later, systolic dysfunction

Elevated filling pressures with systolic dysfunction-->
Increased work of breathing
--> Dyspnea
LV Diastolic Pressure/Volume Relation in Concentric Hypertrophy
High left atrial filling pressure--> High pulmonary venous pressure--> Increased lung water--> Increased work of breathing --> Dyspnea
Diastolic Pressure/Volume Relation in Aortic Regurgitation
No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion--> Dyspnea or Pulmonary Edema
Aortic Stenosis - Etiology
- Congenital bicuspid valve
- Degenerative calcific aortic stenosis
- Rheumatic, not in isolation, but associated mitral disease
Aortic Stenosis Pathophysiology
Concentric LVH, poor LV filling, usually normal systolic function

CHF (dyspnea, exercise intolerance), from elevated diastolic pressure

Angina from decreased coronary perfusion pressure and increased myocardial oxygen demand

Syncope usually from ventricular arrhythmias
Aortic Stenosis:
Physical Exam
Post PVC beat

Forceful apical impulse, not usually displaced

Atrial filling wave and S4

Harsh midsystolic murmur and thrill at right upper sternal border, radiating to carotid

Parvus et tardus carotid impulse
Aortic Stenosis:
Diagnostic Tests
ECG: LVH, with large QRS complexes, and also LAE

CXR: not remarkable

Echocardiogram: dense, thick, poorly mobile aortic valve, LVH and LAE

Doppler: estimate valve area and mean gradient

Cardiac Catheterization: valve area, pressures, flows, coronary anatomy
Aortic Regurgitation:
Etiology
-Congenital bicuspid valve

-Rheumatic aortic disease

-Infective endocarditis

-Inherited connective tissue diseases (Marfan’s)

-Inflammatory connective tissue diseases (Ankylosing spondylitis, rheumatoid arthritis)
Aortic Regurgitation:
Pathophysiology and Symptoms
LV volume load
Acute: acute pulmonary congestion, pulmonary edema
Chronic: eccentric hypertrophy

Eccentric LVH is well tolerated for decades, until the LV systolic function finally begins to deteriorate, then symptoms of CHF appear (dyspnea, fatigue, weakness)

Occasional angina: supply/demand imbalance
Aortic Regurgitation:
Diastolic Pressure/Volume Relation
Acute aortic regurgitation-->
No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion--> Dyspnea or Pulmonary Edema
Aortic Regurgitation:
Physical Examination
High systolic pressure, low diastolic, high pulse pressure, Corrigan’s pulse

Apex beat displaced caudal and leftward

Dynamic early filling with early filling apex wave and S3

Diastolic decrescendo hi-pitched murmur, may be holodiastolic
Aortic Regurgitation: Diagnostic Tests
-ECG: LVH, frequently without LA enlargement

-Chest X-ray: cardiac enlargement, often dilated ascending aorta

-Echocardiogram: confirms eccentric LVH, morphologic valve abnormalities

-Doppler: severity of flow abnormality

-Catheterization: severity of regurgitation, pressure and flow consequences
Mitral Stenosis:
Pathophys and Symptoms
-Normal mitral valve area 4.0-5.0 cm2, and critical is less than 1.0-1.5 cm2

-Dyspnea on exertion
-->increased heart rate means proportionately shorter time in diastole
--> increased cardiac output means higher transmitral flow
--> LA pressure >25mmHg

-Fatigue, attributed to low cardiac output

-Atrial fibrillation
--> sudden pulmonary congestion/edema
--> cardioembolic event
Mitral Stenosis
Physical Examination Si/Sx
-Faint apical impulse
-Loud S1
-Opening Snap, 0.06-0.10 sec after A2 (aortic component of S2)
-Diastolic rumbling murmur
localized to apex (left lateral decubitus position)
presystolic accentuation
-Loud P2 (pulmonary component of S2) indicates pulmonary hypertension
Mitral Stenosis
Diagnostic Tests
-ECG: normal, or LA enlargement, or Afib

-Chest X-ray: left atrial enlargement with elevation of left mainstem bronchus, and pulmonary venous congestion

-Echocardiogram: thickened doming mitral leaflets,
-Doppler shows high velocity flow across the stenosis

-Catheterization frequently unnecessary for diagnosis
-Treadmill: often useful for objective tolerance
Mitral Regurgitation
Etiology
-Myxomatous degeneration, or MV prolapse

-Infective endocarditis

-LV dilation from any cause

-Rheumatic heart disease
Mitral Regurgitation
Pathophys and Symptoms
Volume load: LV and LA
--> Acute: dramatic inc in LA pressure, acute pulmonary congestion edema, shock
--> Chronic: enhanced LV systolic ejection (into low pressure LA), LA and LV enlargement

Chronic LAE may lead to A fib
--> not as bad for circulation as mitral stenosis
--> risk of cardioembolism

-Loss of LV systolic performance - CHF: FATIGUE
DYSPNEA
Mitral Regurgitation
Physical Examination Si/Sx
Apical impulse:
--> displaced caudally and leftward
--> Hyperdynamic early filling wave
--> S3

-Soft S1

-Holosystolic murmur, best at apex

-Acute regurgitation: pulmonary edema w/ rales
Acute Mitral Regurg
Diastolic Pressure/Volume Relation
Acute mitral Regurg--> No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion --> Dyspnea or Pulmonary Edema
Mitral Regurgitation
Diagnostic Tests
- ECG: LVH and LA enlargement
- Chest X-ray: cardiomegaly
- Echocardiogram: LV enlargement, morphology of MR, Doppler can estimate severity of leak
- Catheterization: severity of regurgitation, effects on pressure and flow
- Radionuclide angiography (MUGA): ejection fraction
Tricuspid Disease
Etiology
- Tricuspid stenosis is rheumatic, rarely carcinoid

- Tricuspid regurgitation is usually due to RV dilation or endocarditis, not rarely a significant complicating factor in left heart disease
Pulmonic Disease
Etiology
- Pulmonary stenosis is congenital, can balloon

-Pulmonary regurgitation is rarely significant
IE: Inflammation of endocardial surface
-Etiology
-Target
-Risk Factors
MC ethos: infectious, usually bacterial

MC affected target: valve leaflet

Risk factors: degenerative valve disease and mitral valve prolapse, also VSD, bicuspid aortic valve, PDA, coarctation, and tetralogy

IV drug use: right-sided valvular lesions

Indwelling catheters: prosthetic valves
Bacterial Endocarditis - Which bacterial types are most commonly found in native valves, valves of IV drug users, prosethic valves?
- Native valves: most commonly streptococci (alpha-hemolytic, Streptococcus bovis, Enterococcus facealis), then Staph aureus

-IV Drug users: most commonly Staph aureus, also streptococcus

-Prosthetic valve endocarditis: Staph aureus, many others, and later alpha-hemolytic streptococcus
Rheumatic Fever:
-Definition
-Major and minor symptoms - Prevention of primary and secondary RF
Definition: An inflammatory disease, delayed nonsuppurative sequel to group A streptococcal infection

Major: migratory polyarthritis, Sydenham’s chorea, subcutaneous nodules, erythema marginatum, and carditis

Minor: arthralgia, fever, inc. sed rate, CRP, PR interval, acute phase reactant

Positive throat culture or rapid streptococcal antigen test, or elevated or rising ASO (streptococcal antibody) titer

Prevention of rheumatic fever: penicillin therapy of streptococcal pharyngitis (primary), and penicillin therapy to prevent recurrences (secondary)
Color Doppler used for?
View diastolic flow in aortic regurgitation
Use of Color Doppler in Tricuspid reguargitation to view___?
Tricuspid Regurg:
Use Color Doppler to view turbulant flow and large chambers:

In Systolic frame note the large RV, LV, and RA