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87 Cards in this Set

  • Front
  • Back
Severity of valve dysfunction depends on...
valve orifice size.

A perfect valve causes no obstruction to forward flow and allows no backward flow, and unfortunately doesn’t exist.
The severity of stenotic lesions relates to...
degree of diminution in valve area during forward flow
The severity of regurgitant lesions relates to...
size of orifice through which backward (regurgitant flow) occurs
How does the pump adapt to valvular dysfunction with stenotic lesions?
stenotic lessions
--> PRESSURE overload
--> Severe myocardial hypertrophy
= Concentric Hypertrophy
How does the pump adapt to valvular dysfunction with regurgitant lesions?
Regurgitant flow
--> VOLUME overload
--> chamber dilation
--> moderate myocardial hypertrophy
= Eccentric Hypertrophy
How do you distinguish between concentric and eccentric hypertrophy?
ratio of wall thickness to chamber volume...
volume is increased in eccenetric hypertrophy
What happens when there are factors that limit the pump's ability to adapt to valvular dysfunction?
Severe hemodynamic derangement
Symptoms
(Acute aortic regurgitation, Mitral regurgitation)
What history do you need to predict a valve lesion?
- Age
- Gender
- Socioeconomic background
- Age and circumstances of onset of symptoms
- Concomitant medical problems:
- rheumatic fever (mitral stenosis)
- hypertension (coarctation and bicuspid aortic valve)
- ischemic heart disease
What are causes of right sided valvular disease in an adult?
Right sided endocarditis associated with:
- chronic IV drug use
- chronic IV access (i.e. in dialysis pts)

tricuspid valve lesions
How can you distinguish a right sided lesion from a lift sided lesion with auscultation?
right sided lesions have significant respiratory variation with the murmur...

whereas left sided lesions do not vary with breathing
What are the most common causes of valvular disease in US?
- senile calcific degeneration (AS)
- annulo-aortic ectasia (AR)
- myxomatous degeneration (MR)

Note: no longer Rheumatic heart disease.
What is the primary test for valvular dysfunction?
ECHOCARDIOGRAPHY
for screening, definitive diagnosis and follow up
What is the primary treatment for valvular dysfunction?
Surgery
Normal Anatomy of Aortic Valve
Tricuspid
- Right Coronary cusp
- Left Coronary cusp
- Non-coronary cusp
What types of valvular dysfunction develop from bicuspid aortic valves?
Aortic stenosis or aortic regurgitation
Bicuspid Aortic Valves
- 1-2% of the population
- Frequent cause of symptomatic aortic stenosis in young patients
- Associated with other congenital abnormalities (especially coarctation) in 20% of cases
What percentage of people with coarctation have BAV?
80%
What are the 4 types of Aortic Stenosis?
1. 3 leaflets of equal size and good shape (most common form, >60 y/o)
2. 3 leaflets, but one is smaller (>60 y/o)
3. 2 leaflets (present in midlife)
4. 1 leaflet (presents btwn 8 and 20 y/o; congenital w/ severe sxs)
Stenosis causes a murmur when the valve should be -----.

Diastole vs Systole for all 4 valves?
OPEN = stenOsis

Systolic murmur for aortic and pulmonic
Diastolic murmur for tricuspid and mitral
Regurgitant flow causes a murmur when the valve should be ----.

Diastole vs Systole for all 4 valves?
CLOSER = regurgitant flow

Systolic murmur for tricuspid and mitral.
Diastolic murmur for aoritc and pulmonic.
Systolic aortic valve gradient
In normal heart physiology, the LV pressure suring systole is equivalent to the aortic pressure.

When the LV pressure exceeds the Aortic pressure, the difference is the systolic aortic valve gradient

... Indicative of Aortic Stenosis
Etiology of Aortic Stenosis in young patients
THINK CONGENITAL
- Bicuspid (2% of pop, 3 males:1 female, suspect co-existing coarctation)

Rarely:
- unicuspid valve
- sub-aortic stenosis (discrete or diffuse)
Etiology of Aortic Stenosis in middle aged patients
(4th and 5th decades)

Bicuspid Aortic Valve
Rheumatic Disease
Etiology of Aortic Stenosis in old patients
(6th, 7th and 8th decades)

THINK DEGENERATION... this is the most common cause of aortic stenosis
Symptoms of Aortic Stenosis
TRIAD OF SYMPTOMS
1. Angina
- reduced coronary flow reserve
- increased demand - high afterload
2. Syncope
3. Heart Failure
- diastolic and systolic dysfunction

- Dyspnea on exertion and at rest
- Impaired exercise tolerance
- GI bledding from AVMs (may be associated with destruction of vWF by valves)
Aortic Stenosis
What is the estimated survival based on specific symptoms?
- Angina (if untreated): 5 year survival

- Syncope: 3 years survival

- Heart Failure: 2 year survival
What depicts the severity of aortic stenosis?
SYMPTOMS
not the intensity of physical findings
Aortic Stenosis

Ausculation
- “Diamond” shaped, harsh, systolic crescendo-decrescendo

- Decreased, delay & prolongation of pulse amplitude
- Paradoxical S2
- S4 (with left ventricular hypertrophy b/c of stiffness)
- S3 (with left ventricular failure)
Aortic Stenosis

Physical Exam
- Described as a systolic “ejection murmur” (along with pulmonic stenosis)
- Associated with delayed carotid upstrokes
- Carotid pulsations characterized by delayed and weakened upstroke (the pulsus parvus et tardus)
- Usually heard best at RightUpperSternalBorder and radiates to carotids
- Aortic stenosis can also radiate to the apex and mimic mitral regurgitation (the Gallavardin phenomenon)
What is the gallavardin phenomenon?
when aortic stenosis murmur radiates to the apex amd mimic mitral regurgitation
What is pulsus parvus et tardus?
- small, late pulse considered typical of severe aortic stenosis
- Carotid pulsations characterized by delayed and weakened upstroke
How do we classify the severity of Aortic stenosis?
Based on the amount of functional tissue in the valve:
- Normal aortic valve area: 2-3 cm2
- Mild AS >1.5 cm2
- Moderate AS 1.0-1.5 cm2
- Severe AS <1.0 cm2; mean gradients >50 mmHg
Treatment of Patients with Asymptomatic Aortic Stenosis
—follow expectantly
- Endocarditis prophalaxis
- Annual Survey with echo in patients with severe AS or when symptoms change
- Patient education regarding symptoms
When is surgery indicated in patients with aortic stenosis?
- in patients with Severe Symptomatic aortic stenosis

- in patients with severe or moderate AS who need heart surgery for a different reason
Valvular Causes of Aortic Regurgitation (aortic insufficiency)
1. Bicuspid aortic valves, especially when associated with aortic root dilitation
2. Infective endocarditis
3. Rheumatic heart disease
4. Radiation
5. Subvalvular (with supracrystal or subpulmonary VSD that decrease competance of valve)
Chronic Aortic Regurgitation Etiologies
1. Rheumatic heart disease (stenosis results in regurg)
2. Congenital bicuspid valve
3. Myxomatous disease
4. Marfan’s
5. Other connective tissue disorders
6. Chronic aortitis (syphilitic)
Acute Aortic Regurgitation Etiologies
THESE ARE FATAL

1. Aortic dissection (suspect with HTN)

2. Infective endocarditis (bacteria eat through leaflet)

3. Traumatic (decompression injuries associated with MVAs where steering wheel impacts chest wall)
Myxomatous Disease and Aortic Regurgitation
1.Heriatble disorder, but can occur spontaneously.

2. Leaflet tissue is redundant and elongated, which allows leaking. The cords are also elongated.

3. Present in 3-8% of women. Fair skinned with hyper-extendable joints.
What is an Austin Flint Murmur?
Aortic Regurgitation Murmur ... most common with severe AR

- mid to late diastolic apical rumble
What is found during chest exam for patients with Aortic Regurgitation?
- Apical impulse diffuse, hyperdynamic, displaced laterally and inferiorly variable thrill over the base, suprasternal notch, over carotids, carotid shudder S1 is soft, A2 is soft or absent, S3 (3rd heart sound) and S4 (4th heart sound gallops
- Early diastolic decrescendo murmur, high frequency, begins immediately after A2 best heard by the diaphragm, radiates to the apex
- Severity of AR correlates with duration of the murmur
- Murmur best heard along right sternal border
What are the clinical Manifestations of Chronic Aortic Regurgitation?
- may be asymptomatic
- symptoms develop after considerable cardiomegaly and myocardial dysfunction

- exertional dyspnea, otheropnea, PND
- an uncomfortable awareness of the heart beat especially on lying down
- syncope is rare and angina is less common then in AS
Traube’s sign
refers to booming systolic and diastolic sounds over the femoral artery
Durozierz’s sign
consists of systolic and diastolic murmur over the femoral artery
Quinke’s sign
capillary pulsations seen in fingertips
Hill’s signs
popliteal systolic pressure exceeding brachial artery systolic pressure by 50-60 mmHg, etc.
What are the clinical Manifestations of Chronic Aortic Regurgitation?
- may be asymptomatic
- symptoms develop after considerable cardiomegaly and myocardial dysfunction

- exertional dyspnea, otheropnea, PND
- an uncomfortable awareness of the heart beat especially on lying down
- syncope is rare and angina is less common then in AS
Traube’s sign
refers to booming systolic and diastolic sounds over the femoral artery
Durozierz’s sign
consists of systolic and diastolic murmur over the femoral artery
Quinke’s sign
capillary pulsations seen in fingertips
Hill’s signs
popliteal systolic pressure exceeding brachial artery systolic pressure by 50-60 mmHg, etc.
de Mossert’s sign
Bobbing of the head with every heart beat, waterhammer or collapsing type pulses
Physical Exam (not chest exam) in patients with aortic regurgitation
1. Bobbing of the head (DE MOSSERT'S SIGN), with every heart beat, waterhammer or collapsing type pulses
2. TRAUBE'S SIGN refers to booming systolic and diastolic sounds over the femoral artery
3. DUROZIERZ'S SIGN consists of systolic and diastolic murmur over the femoral artery
4. QUINKE'S SIGN: capillary pulsations seen in fingertips
5. HILL'S SIGNS: popliteal systolic pressure exceeding brachial artery systolic pressure by 50-60 mmHg, etc.
Lab Tests for Aortic Reguritation
1. X-ray
2. Echocardiogram
3. Cardiac catheterization
Why do you want a X-ray on someone with Aortic regurgitation?
LV enlargement which can be massive (cor bovinum), dilation of ascending aorta, egg-shell calcification of ascending aorta seen in luetic AR, valve calcification uncommon
Why do you want an Echo on someone with Aortic regurgitation?
- Detailed AV and aortic root anatomy, LV dilation, aortic root dilation, LV performance, diastolic flutter of MV, degree of AR by Doppler and color flow Doppler studies.
- Echocardiogram can detect etiologies of AR and to assess how well the LV is handling the volume overload.
- The ideal study for following a patient serially
Why do you want a cardiac catheterization on someone with Aortic regurgitation?
- Aortic root injection for severity of AR
- LV gram for size and function of LV, regurgitant fraction.
When do patients with Aortic Regurgitation have the best prognosis after surgery?
If they have the surgery BEFORE there are symptoms and especiall BEFORE LV dysfunction.
Indication for Valve Replacement in Aortic Regurgitation

ACC/AHA Class I
- Symptomatic patients with preserved LVF (LVEF >50%)

- Asymptomatic patients with mild to moderate LV dysfunction (EF 25-49%)

- Patients undergoing CABG, aortic or other valvular surgery
Indication for Valve Replacement in Aortic Regurgitation

ACC/AHA Class II a
Asymptomatic patients with preserved LVEF but severe LV dilatation (EDD>75 mm or ESD > 55mm)
Indication for Valve Replacement in Aortic Regurgitation

ACC/AHA Class II b
- Patients with severe LV dysfunction (EF < 25%)

- Asymptomatic patients with normal systolic fxn at rest (EF >0.50) and progressive LV dilatation when the degree of dilatation is moderately severe (EDD 70 to 75 mm, ESD 50 to 55 mm).
Indication for Valve Replacement in Aortic Regurgitation

ACC/AHA Class III
Asymptomatic patients with normal systolic function at rest (EF >0.50) and LV dilatation when the degree of dilatation is not severe (EDD <70 mm, ESD <50 mm).
When do you not NEED to operate with aortic regurgitation?
- Normal systolic function
- LV chamber size is normal
- no symptoms despite severe aortic insufficiency

* when contraction starts to decrease and the dilation becomes too high then it is time to operate
Mitral Stenosis
Etiology
- Primarily a result of rheumatic fever (~ 99% of MV’s @ surgery show rheumatic damage )
- Scarring & fusion of valve apparatus
- Rarely congenital
- Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease
- Two-thirds of all patients with MS are female.
Mitral Stenosis Pathophysiology
Obstruction of LA emptying
--> increase LA pressure
--> decrease CO (from inadequeate LV filling)

* with excessive LA stretching there can be SA node interference... Palpitations
How does Rheumatic Heart Disease lead to Mitral Stenosis?
Rheumatic Heart Disease
--> inflammation of the valve and chordae tendinea
--> stiffer valve (leafelts are fibrotic, calcified and thicker)
What is the outcome of mitral stenosis?
1. The reduced ventricular filling (decreased preload) can result in reduced ventricular stroke volume.

2. Decreased Cardiac Output (CO).

3. If SV falls significantly, the reduced CO may result in a reduction in aortic pressure.
Clinical Symptoms of Mitral Stenosis
- pulmonary congestion and edema (increased in LA pressure --> increase in pulmonary capillary hydrostatic pressure)

- dyspnea, PND, orthopnea, palpitations, fatigue, exercise intolerance
When does moderate mitral stenosis cause problems?
- pregnancy
- thyroid disease
- sepsis
What is the normal valve area of the mitral valve?
4-6 cm^2

... in severe mitral stenosis, it is <1 cm^2
Etiology of Chronic Mitral Regurgitation
1. Myxomatous disease (prolapse - elongated valve and chordae tendinae)
2. Rheumatic heart disease
3. Annulo-aortic ectasia
4. Other connective tissue disorders
5. Dilated cardiomyopathy (annular dilation)
6. Ischemia (papillary muscle dysfunction)
Etiology of Acute Mitral Regurgitation
1. Infective endocarditis
2. Myxomatous disease (choral rupture, flail mitral valve)
3. Ischemic heart disease (post-infarction papillary muscle rupture ... can occur 7 day s/p MI)
Acute Mitral Regurgitation
(Pathophysiology, Etiology, SXS, PE, Course)
Pathophysiology: Acute LV Volume Load
Etiology: Rupture (spontaneous, infection, infarction)
SXS: dyspnea
PE: Pulmonary congestion (with rales), Sys Murmur (high pitch), S-4
Course: RAPID
Chronic Mitral Regurgitation
(Pathophysiology and Compensation)
Pathophysiology:
Leak into Left Atrium causes
increase LV Volume Load
Compensation:
- LV Dilates & Hypertrophies
- Increase stroke volume
- Left Atrium Dilates
What is the Course of Chronic Mitral Regurgitation?
- Tolerated well
- Long Asymtomatic (or minimal Sxs)–10 years or More
- Mild MR may have Normal life span
- But: If Irreversible LV Dysfunction --> MVR cannot be helped
Physical Exam of Mitral Regurgitation
- JVD and Carotids will be normal until late in disease process
Auscultation and Mitral Regurgitation
- Apex Impulse – Laterally Displaced and Hyperdynamic

S-1: Normal or decreased
S-2: May be wide split (A2 early)
S-3: Palpable
S-4: Rare in severe chronic MR (dilated LA, AF)

- Pansystolic murmur in apex, axilla right precordium or back
Mitral Valve Prolapse
- Thickened or myxomatous mitral leaflets
- Systolic displacement of the mitral leaflet into the left atrium of at least 3 mm or more beyond the mitral annulus in the parasternal or apical long-axis view
- Mitral regurgitation
Normal, Physiologic Valvular Regurgitation with the Mitral Valve
- Always trivial or at most mild
- Usually central
- Valve anatomically normal appearing
When do you do surgery with Mitral Valve Regurgitation?
Give annual echos and send the patient to surgery when the contractility deceases (decrease in EF) and dilation becomes too high

(this is the same as with aortic regurgitation)
What information does an echo provide?
- Chamber size, wall thickness, function
- Pressure, flow (Doppler)
- Vessel anatomy
- Valvular anatomy and function
- Congenital anomalies
- Intracardiac masses
- Pericardial function
What are the advantages of an echo?
- Risk free
- Wealth of information
- Moderate cost
What are the disadvantages of an echo?
- Variable quality of data, depends on patient habitus
- Operator dependent
What information does a cardiac catheterization provide?
- Coronary anatomy
- Chamber and vessel pressure, flow
- Chamber motion
- Shunts, malformations
What are the advantages of cardiac catheterization?
Often definitive, gold standard
What are the disadvantages of cardiac catheterization?
- Risk to life, limb, kidneys
- Ionizing radiation
- Expense
Prosthetic Valve Disease
- Increase mean valve gradient
- Valvular regurgitation (usually trivial)
- Fallibility: strut fracture, occluder liberation, etc.
- Need for anticoagulation (1%/year hemorrhage)
What are the complications associated with prosthetic valve disease?
- Obstruction: thrombus, pannus
- Regurgitation
- Thromboembolism
- Endocarditis
- Ring abscess