Y2B2B Cs- Aortic Valvular Disease

Front 1

wear and tear problem seen in older population that radiates to the carotids. dx

Back 1

aortic stenosis

Front 2

what are the etiologies associated with aortic stenosis? which one is the most common?

Back 2

1) Rheumatic - MC
2) calcific/ degenerative- years of wear and tear esp in HTN
3) congenital- bicuspid (mc type of congenital)--> functions normally for decades until turbulence induces calcification
4) post endocarditis--> only if they heal w/ calcification

Front 3

what is a clinical correlate for high LV filling pressure?

Back 3

s4

Front 4

what is the pathophysiology of aortic stenosis? (8 steps)

Back 4

1) calcification due yo turbulence or wear and tear
2) high outflow resistance causes concentric LVH
3) LVH causes high LV filling pressure --> stiffening of the heart during diastole (S4)
4) LV filling pressure is reflected to atrium then to the lungs
5) systolic fxn preserved until late
6) as gradient increases (pressure on either side of the valve), peak ejection is delayed later in systole
7) pulse volume decreases
8) V hypertrophy + high filling pressures lead to subendocardial ischemia

Front 5

what is the Triad of sxsassociated with aortic stenosis? why do you get these sxs?

Back 5

Triad of sxs:
1) chest pain- choking muscle
2) exertional syncope or near syncope- CO cannot increase so whatever blood can get out goes to the dilated pool of vessels --> your muscles and sacrifices your brain
3) dyspnea/ orthopnea: CHF

Front 6

what effect does aortic stenosis have on the pulse? why?

Back 6

other sx:
1) squishy delayed pulse because it takes awhile for the ventricles to empty

Front 7

what can you hear on auscultation in a pt w/ aortic stenosis?

Back 7

late peaking crescendo/decrescendo systolic mumur.
also hear a soft or absent S2
a S4 at apex
a paradoxic split S2

Front 8

which clinical presentation of aortic stenosis is the best marker of severity?

Back 8

Soft or absent S2

Front 9

what is the single clue between hypertrophic cardiomyopathy and aortic stenosis?

Back 9

upon standing, in AS the murmur will get softer, in HCM it will get louder

Front 10

what happens to the late peaking crescendo/decrescendo murmur in aortic stenosis when the pt is standing?

Back 10

Murmur may decrease with standing-> loudness of the murmur depends on how much blood flow it needs to pump.

Front 11

in aortic stenosis, why would you hear a soft or absent S2?

Back 11

d/t the valves not opening very well making closing that much more difficult

Front 12

in aortic stenosis, why would you hear a paradoxal split s2

Back 12

normally splits during inspiration, w/ critical aortic stenosis, it occurs when you are not inspiring and when you do inspire there is no split. Outflow is obstructive.. The aortic component is going to fall after the pulmonary component. At rest there is a split, but when you inspire you delay the pulmonic component and you get a single sound at S2

Front 13

in aortic stenosis, why would you hear a S4 at apex?

Back 13

d/t atria contraction on a stiff ventricle

Front 14

In aortic stenosis, what does the apical impulse feel like?

Back 14

hyperdynamic!!

Front 15

what is the rare association of aortic stenosis with?

Back 15

colonic angiodysplasia and lower GI bleed

Front 16

what does the heart of a pt w/ aortic stenosis look like on....
CXR:
ECG:

Back 16

CXR: normal to slightly enlarged LV
ECG: LVH

Front 17

what will a 2D echo and doppler tell you in a pt w/ aortic stenosis? which one is the most diagnostic?

Back 17

2D echo: structure and mobility of valve leaflets thickness and function of ventricular walls
doppler: quantify gradient and calculate valve area.*** most diagnostic

Front 18

In a pt w/ angina....
1) from onset of syncope, mortality in_____ yrs
2) from onset of angina, mortality in ____ yrs
3) from onset of CHF, mortality in _____ months

Back 18

1) 3
2) 5
3) 18 months

Front 19

what is the most appropriate intervention for aortic stenosis? what is the critical valve area for intervention?

Back 19

surgery---- 0.75 cm (fix whether or not symptomatic)

Front 20

what is the problem w/ balloon valvuloplasty in txing aortic stenosis?

Back 20

restenosis is rapid and profound, most w/n 6 months--> valve will heal and come back the way it was before.

Front 21

what is the surgical risk of aortic stenosis?

Back 21

4-6%

Front 22

what is transcutaneous valvular surgery? when would you use this?

Back 22

just like angioplasty w/ a coronary artery, you put a metal mesh w/ a catheter and inside the metal mesh is a pig valve. Placement of an expandable trileaflet valve w/n a stent into the stenotic aortic orifice.
use this for pts who can't have surgery for some reason. (still not all that great)

Front 23

what are the etiologies of aortic regurgitation?

Back 23

endocarditis
RF
calcific degeneration
trauma
aortic root dz

Front 24

what are the examples of aortic root dz?

Back 24

1) cystic medial necrosis
2) marfan's syndrome
3) annulo-ectasia
4) aortic aneurysm/ dissection
5) syphylitic aortitis
6) seronegative arthropathies- psoriatic arthritis and ankylosing spondylitis

Front 25

what is the pathophysiology of aortic regurgitation?

Back 25

1) high pressure leak increases LV filling volume, raising LVEDP, causes dilation and LV hypertrophy (dev cor bovinum- large thick walled heavy hearts)
2) heart keeps pumping for years (20 to 30 yrs) before breaking down.

Front 26

The unique combination of what two things keeps the heart of a pt w/ aortic regurgitation normal?

Back 26

LVH and dilation

Front 27

what would you expect to feel w/ a pt w/ aortic regurgitation? (5)

Back 27

1) bounding central pulses (corrigan's or water hammer)
2) laterally displaced PMI w/ hyperdynamia and enlargment
3) anterior heave
4) wide pulse pressure
5) quincke's pulses

Front 28

what would you expect to hear on auscultation w/ a pt w/ aortic regurgitation?

Back 28

1) diastolic decrescendo murmur at 2nd interspace right, radiating to apex heard best in expiration.
2) austin flint murmur
3) durozeiz's sign- to and fro murmur over the femoral artery
4) pulsus bisferiens- split pulse w/ two upstrokes

Front 29

what are quincke's pulses and what are they indicative of?

Back 29

they are nailbed capillary pulsations. They are indicative of aortic regurgitation.

Front 30

what is an austin flint murmur? what is it indicative of?

Back 30

it is a jet of regurgitation hitting the mitral valve during regurgitation. It is indicative of aortic insufficiency/ regurg.

Front 31

what 7 things would you do to evalute aortic regurgitation on a pt?

Back 31

hx
PE
2D echo
doppler
left heart catheterization
CXR
ECG

Front 32

what can you see on CXR and ECG of a pt w/ aortic regurgitation?

Back 32

CXR: cardiomegaly prominent
ECG: LVH

Front 33

when does the heart of a pt w/ aortic regurgitation finally break down?

Back 33

when dilation exceeds metabolic accommodation

Front 34

when do sxs of aortic regurgitation usually occur?

Back 34

after development of irreversible LV dysfunction

Front 35

what are the therapy measures used to tx aortic regurgitation?

Back 35

afterload reduction, inotropes, preload reduction (in presence of PEdema), strenuous exercise limitation, maintain sinus rhythm, antibiotic prophylaxis and possibly surgery

Front 36

when is surgery indicated?

Back 36

onset of sxs or if functional capacity falls. OR when the LV end systolic dimension 5 cm or diastolic dimension 7 cm