Valvular Heart Disease

Front 1

What is the name of the fibrous ring that supports and attaches to the leaflets of the valves?
Function of this?

Back 1

Annulus

Maintains proper shape of the valve

Front 2

Besides the annulus, what else are the leaflets of the mitral and tricuspid valves attached to?

Back 2

Chordae tendineae, which are attached to papillary muscles. This gives the valves added stability and integrity

Front 3

What are three types (descriptions) congenital valve disorders can be related to?

Back 3

Valve size

Malformed leaflets

Way leaflets are attached

Front 4

What is bicuspid aortic valve?

Back 4

Congenital disorder.
Aortic valve has 2 leaflets instead of 3. Without 3rd leaflet, may become stenotic or incompetent or have features of both (mixed valve disease).

Front 5

What is usually the treatment for bicuspid aortic valve?

Back 5

Often valve replacement surgery

Front 6

What percent of the population has a bicuspid aortic valve?

Back 6

2%

Front 7

What is papillary muscle dysfunction?

Back 7

Often affects mitral valve and can be the result of a heart attack.

Can result from papillary muscles becoming torn or stretched and losing their integrity (valve flops backward into ventricle). Flail leaflet.

Front 8

2 Infections of heart valves?

Back 8

Rheumatic heart disease

Endocarditis

Front 9

What is rheumatic heart disease caused by?

Back 9

Untreated strep infection in childhood. Antibodies to the strep cross react with the valves.

Valve is NOT infected with bacteria.

Front 10

Pathophys of rheumatic heart disease?

Back 10

Antibodies attack valves causing loss of valvular integrity via inflammation and scarring.

Valves can "stick"

Often affects mitral valve.

Manifestations may NOT be seen for 15-30+ years after acute illness.

Front 11

What is endocarditis?

Back 11

Significant and LIFE THREATENING infection of endocardium.

Front 12

Pathophys of endocarditis?

Back 12

Blood born pathogens (usually bacteria, but can also be fungus) attach to heart valves causing vegetations on surface of valve or cause holes or scarring on the valve.

Front 13

Organisms that most often cause endocarditis?

Back 13

Strep viridans
Staph aureus
Enterococci

In IV drug users, S. aureus is MCC. Usually affecting tricuspid valve.

Front 14

What patients are most at risk of developing endocarditis?

What can be done to help protect these pts?

Back 14

Pts w/ underlying structural or congenital disease (bicuspid aortic valve dz etc),
Prosthetic heart valves,
Hx of rheumatic heart dz

Sometimes abx prophylaxis is used

Front 15

Clinical presentation of endocarditis?

Back 15

Often non-specific:
Fever, fatigue, arthralgias, sometimes appear septic.

PE: subungual (under nail) petechiae, splinter hemorrhages, Osler Nodes, Janeway lesions.
Heart murmur

Front 16

What are septic emboli?

Back 16

Pieces of the vegetation on the valve in endocarditis can break off and get lodged in other places in the body. Can cause a TIA or renal emboli, etc.

Front 17

What are the 2 major criteria in Duke Criteria for Infective Endocarditis?

Back 17

Positive blood cultures (2 separate cultures) with an organisms consistent w/ endocarditis.

Endocardial involvement (pos echo showing a vegetation or mass on the valve or supporting apparatus)

Front 18

What are the 6 minor criteria in Duke Criteria for Infective Endocarditis?

Back 18

Fever > 100.4,
Predisposition,
Vascular phenomena (emboli, septic infarct, Janeway lesions),
Immunologic phenomena (Osler Nodes, + rheumatic factor),
Microbiologic evidence (pos cultures that don't meet major criteria),
Echo finding consistent w/ endocarditis but do not meet major criteria.

Front 19

What must patients have to meet Duke Criteria for Infective Endocarditis?

Back 19

2 major criteria OR
1 major and 3 minor OR
5 minor

Front 20

What are Osler nodes?

Back 20

Painful, red, raised lesions on hands and feet.
Deposition of immune complexes.

Front 21

What are Janeway Lesions?

Back 21

NON-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles

Caused by septic emboli

Front 22

Diagnostic tests when suspecting endocarditis?

Back 22

CBC

3 sets of blood cultures (before starting abx)

CXR

Echo to look for valve abnormalities or vegetations.

*EKG not helpful.

Front 23

Treatment of endocarditis?

Back 23

Often prolonged 4-6 week course of IV abx.
Surgical replacement of infected valve or valvular debridement may be needed.

Usually involves infectious disease consult. Tx starts with prevention!

Front 24

What is the deal with antibiotic prophylaxis for endocarditis?

Back 24

ONLY pts at risk of endocarditis benefit.

No longer mandated for GI and GU procedures like colonoscopy or cystoscopy.
Counsel patients regarding abx before dental procedures/ cleanings.

Front 25

Other causes of valvular heart disease to consider?

Back 25

Ischemic heart disease (mitral regur following MI)

HTN

Aortic aneurysms

Connective tissue dz (marfans, lupus)

Fibro-calcific degeneration (often seen in aortic valve)

Front 26

What are the 2 general categories that valvular heart diseases fall into?

Back 26

Valvular stenosis: Stiff/ inflexible, narrowing of valve opening.

Valvular insufficiency (regurg or incompetent) - incomplete closure resulting in backward flow

Front 27

Most prevalent form of CV disease in western world after hypertension and coronary artery dz?

Back 27

Aortic stenosis

Front 28

What is the most common etiology of aortic stenosis in the world (less common in US)?

Back 28

Rheumatic heart disease

Front 29

What is aortic stenosis?

Back 29

Degenerative calcification of a trileaflet valve or progressive stenosis of a bicuspid valve.

PROGRESSIVE disease

Front 30

Risk factors for fibrocalcific aortic stenosis?

Back 30

Diabetes

HTN

Hyperliipidemia

Tobacco

*Same risk factors as CAD

Front 31

What is the an adaptive response to aortic stenosis?

Back 31

Left ventricular hypertrophy

Front 32

3 cardinal features of progressive aortic stenosis?

Back 32

Angina

Syncope

Heart failure / exertional dyspnea

Front 33

What is tx usually for aortic stenosis?

Prognosis?

Back 33

Surgery

Average survival: 2-3 years

Front 34

2 major physical findings in aortic stenosis?

Back 34

Crescendo- decrescendo systolic murmur along left sternal border radiating to the upper right chest and carotids.

Parvus et tardus: decreased intensity of arterial pulse in moderate to sever AS - delayed weak carotid impulse.

Front 35

3 diagnostic tests for aortic stenosis?

Back 35

Echo,
EKG,
Cardiac cath

Front 36

What is the imaging modality of choice for dx and determination of severity of aortic stenosis?

Back 36

Echo.

Can assess valve integrity, competence, and velocity of flow across valve and valve area.

Front 37

What would be seen on an EKG in aortic stenosis?

Back 37

Left ventricular hypertrophy.

Conduction abnormalities or A-fib may develop as well.

Front 38

At what point is cardiac cath used as dx of aortic stenosis?

Back 38

Usually used to identify assoc coronary dz and is advised before valve replacement surgery

Front 39

TX of aortic stenosis?

Back 39

If asymptomatic: follow to watch for progression.

If symptomatic: aortic valve replacement = tx of choice.
Mechanical valve
Bioprosthetic valve
Percutaneous balloon valvuloplasty - not a great option

Front 40

What is TAVI (transcatheter aortic valve implantation)?

Back 40

A new modality to treat aortic stenosis.

Replacement valve is inserted via femoral artery and placed in the area of the patient's own aortic valve.

Still under investigation. Would only be used in pts for whom valve replacement surgery is not an option.

Front 41

What causes aortic regurgitation?

Back 41

Failure (structure or function) of aortic leaflets. Can be due to congenital abnormalities, endocarditis, atherosclerotic degeneration, connective tissue disorder (Marfans) or various other diseases.

Front 42

What is the MCC of aortic regurg worldwide (less common in US)?

Back 42

Rheumatic heart disease

Front 43

What occurs as a result of aortic regurgitation?

Back 43

Left ventricular preload and afterload excess which results in volume overloading of the LV which leads to leads to LV dilation and LV dysfunction.

Can be assoc w/ sx of CHF (exertional dyspnea/ nocturnal dyspnea)

Front 44

Exam findings in aortic regurgitation?

Back 44

Increased SV and widened Pulse pressure (elevated systolic, low diastolic).

Periph pulses: water hammer

Murmur: high freq, blowing, decrescendo diastolic best heard after expiration.
Murmur decreases w/ maneuvers that lower bp (valsalva).

Front 45

Dx test of choice for aortic regurg?

Back 45

Cardiac ultrasound (echo)

Can be used to assess LV size, EF, morphology of aortic valve.

Front 46

What test is used prior to valve replacement to identify coronary disease?

Back 46

Cardiac cath

Front 47

Prognosis in aortic regurg?

Back 47

Asymptomatic w/ normal LV size and function: good prognosis.

Mod sx or evidence of LV enlargement are at higher risk and should be considered for surgery.

Front 48

Medical therapy for aortic regurg?

Back 48

Vasodilator therapy (hydralazine, nifedipine, ACEI).

Goal is to decrease systemic bp.

Avoid B-Blockers - resultant bradycardia could increase diastolic filling times and worsen AR.

Front 49

MCCs of mitral valve disease?

Back 49

Rhematic heart disease MCC of all mitral valve disease except for mitral valve prolapse.

Front 50

What is mitral valve stenosis?

Back 50

Mitral valve less flexible and more rigid - impedes flow between left atrium and left ventricle, causing dilation of left atrium

Front 51

Sx/ findings of mitral stenosis?

Back 51

A-Fib,
Fatigue,
Dyspnea (secondary to pulm congestion that results from increased left atrial pressure),
Hemoptysis (secondary to increased pulm venous pressure),
Embolic event.

Front 52

Findings on PE of mitral stenosis?

Back 52

Accentuated S1 S2 followed by an opening snap.

Diastolic "rumble"

Apical low pitched diastolic murmur.

Front 53

Modality of choice to assess pts w/ mitral stenosis?

Back 53

Echo.

Doppler flow provides info about severity of stenosis.
Also assesses degree of pulm htn.

Front 54

What would you see on CXR in mitral stenosis?

Back 54

Left atrial enlargement

Front 55

What would you see on EKG in mitral stenosis?

Back 55

Left atrial enlargement.

Also screen for A fib.

Front 56

Tx of mitral stenosis?

Back 56

Asymptomatic: follow annually.

Symptomatic or those w/ pulm htn: consider balloon valvuloplasty or surgical replacement.

Give anti-coags to those w/ Afib.
If MS caused by rheumatic heart dz, give abx prophylaxis.

Front 57

Leading cause of mitral regurg worldwide?

In US?

Other cause?

Back 57

Worldwide: Rheumatic heart dz

US: degeneration of valve (myxomatous disease.)

Also, functional MR from MI or dilation of mitral valve annulus.

Front 58

What is the heart's compensation for mitral regurgitation?

Back 58

Left ventricle adapts to volume overload by dilating and enlarging. May remain compensated and asymptomatic for years.

Can eventually lead to HF.

Front 59

Findings on exam of mitral regurg?

Back 59

Mild may not have any findings.

Severe: signs/ sx of HF.

Murmur: Medium to high pitched apical systolic murmur.

Front 60

Findings on CXR in mitral regurg?

Back 60

Cardiomegally due to LV and LA enlargement is common w/ chronic MR but is not diagnostic.

Front 61

Findings on EKG in mitral regurg?

Back 61

Left atrial enlargement and AFib often. Not diagnostic.

Front 62

Most common dx modality ofr mitral regurg?

Back 62

Echo

Front 63

Only curative approach in severe mitral regurg?

Back 63

Surgery (valve repair or replacement).

Timing of surgery depends on sx, degree of MR, LV size and LV function.

Front 64

What is Mitral Valve Prolapse AKA?

Back 64

Click murmur syndrome

Front 65

What occurs in mitral valve prolapse?

Back 65

Mitral leaflets essentially become stretched so as the ventricles contract, the mitral vavle blows back into left atrium.

Front 66

Is mitral regurgitation always a finding in mitral valve prolapse?

Back 66

No

Front 67

Mitral valve prolapse found more in males or females?

Back 67

Females

Front 68

Sx in Mitral valve prolapse?

Back 68

Asymptomatic sometimes.
Severity of sx doesn't always correlate to severity of MVP.

Palpations,
Decreased stamina,
Dyspnea,
Anxiety

Front 69

Dx of mitral valve prolapse?

Back 69

PE: click systolic murmur heard.
Echo.
Radionuclide scans,
Cath.
*Echo often sufficient

Front 70

Tx of mitral valve prolapse?

Back 70

May require endocarditis abx prophylaxis prior to dental cleaning.

Yearly eval w/ ultrasound.

Pt education to recognize sx of valve disease.

Front 71

Aortic/ mitral valve dz
OR
Tricuspid valve dz
MC?

Back 71

Aortic/ mitral valve dz is more common.

Front 72

Causes of tricuspid valve disease?

Back 72

Infection (Rheumatic heart dz or endocarditis). - if RHD, often assoc w/ mitral or aortic dz.

Pulm HTN (increased pressure through valve)

Congenital defects

Carcinoid heart disease

Front 73

Sx of tricuspid valve disease?

Back 73

Arrhythmia (atrial arrhythmias/ fib),

Decreased stamina,

CHF (dyspnea, edema, etc)

Front 74

Dx of tricuspid valve disease?

Back 74

Murmur,

Echo,

Cath

Front 75

Tx of tricuspid valve disease?

Back 75

Surgical repair - annuloplasty ring

Front 76

In valve replacement, what things are taken into consideration to decide whether to use a mechanical valve vs a bioprosthetic valve?

Back 76

Pt age,

Overall health,

Lifestyle,

Anti-coagulation considerations

Front 77

Pro and Con of mechanical valve?

Back 77

Pro: more durable than bioprosthetic

Con: More thrombogenic and commit pt to anti-coagulation therapy forever.

Front 78

For whom is a bioprosthetic valve usually a better choice?
For whom not a better choice?

Back 78

Bioprosthetic usually better choice in older patients.

May not be best in younger pts due to "wear and tear" and need for a replacement.

Front 79

Follow up for patients after valve replacement?

Back 79

Monitor anti-coag w/ mechanical valves. - with bioprosthetic valve - should be on aspirin.

Prophylactic dental care w/ approp abx to prevent endocarditis.

Annual echo.