Cv 14: Valve Disease

Front 1

What are the systolic murmurs?

Back 1

- Aortic Stenosis
- Mitral Regurgitation

Front 2

What are the diastolic murmurs?

Back 2

- Aortic Regurgitation
- Mitral Stenosis

Front 3

What does Aortic Regurgitation hate?

Back 3

Bradycardia

Front 4

What does Mitral Stenosis hate?

Back 4

Tachycardia

Front 5

Which of the murmurs hate a slow HR or a fast HR?

Back 5

- Aortic Regurgitation hates Bradycardia
- Mitral Stenosis hates Tachycardia

Front 6

What is the most common cause of aortic stenosis?

Back 6

Calcific Degeneration:
- <65 yo: usually to bicuspid valve (if <30, almost always)
- >65 yo: probably tricuspid valve

Front 7

What is notable about the pressure vs time curve for a normally functioning aortic valve?

Back 7

All the pressure from the ventricle gets transferred to the aorta (no resistance to blood flow by aortic valve)

Front 8

What is notable about the pressure vs time curve for an aortic valve with stenosis?

Back 8

- Pressure in ventricle highly exceeds pressure in aorta
- This means that the aortic valve is limiting the transfer of pressure from LV to aorta

Front 9

Does aortic stenosis cause a pressure or volume overload state? What does this cause?

Back 9

Pressure overload → Hypertrophy (sarcomeres in parallel)

Front 10

What does the Pressure-Volume loop for an aortic valve with stenosis tell you?

Back 10

- Ventricle is squeezing, but volume is staying the same valve is stenosed
- Causes increase in pressure above normal
- Eventually pressure in ventricle exceeds pressure in aorta and some blood gets out
- There is a smaller stroke volume

Front 11

What physical exam features will you notice for aortic stenosis?

Back 11

- Sustained LV impulse
- No / little LV displacement
- Pulsus Parvus et Tardus (slow and delayed upstroke of carotid impulses)
- Absent A2 or paradoxically split A2
- Murmur is systolic crescendo decrescendo (later peaking is associated with worse stenosis)

Front 12

What valve pathology is associated with Pulsus Parvus et Tardus? What does this mean?

Back 12

- Aortic Stenosis
- Slow and delayed upstroke of carotid impulses

Front 13

What valve pathology is associated with a systolic crescendo-decrescendo murmur?

Back 13

Aortic Stenosis - late peaking indicates worse stenosis

Front 14

Describe the typical murmur for Aortic Stenosis.

Back 14

- Absent A2 or paradoxically split A2
- Systolic murmur with crescendo decrescendo

Front 15

Describe the typical chest x-ray for Aortic Stenosis.

Back 15

- Little cardiac enlargement due to LVH
- Post-stenotic dilation of the ascending aorta
- Ca2+ on aortic valve

Front 16

What is the mean survival for patients with the following symptoms from their Aortic Stenosis?
- Angina?
- Syncope?
- CHF?

Back 16

- Angina: 5 years
- Syncope: 3 years
- CHF: 2 years

Front 17

Should a patient without symptoms from their aortic stenosis be worried about dying?

Back 17

No, you don't have a shortened lifespan until you start getting symptoms:
- Angina: 5 years
- Syncope: 3 years
- CHF: 2 years

Front 18

What is the size of the valve opening for the different severities of aortic stenosis?

Back 18

- Mild: >1.5 cm2
- Moderate: 1-1.5 cm2
- SEVERE: <1 cm2

Front 19

When should you get an aortic valve replacement for Aortic Stenosis?

Back 19

** Symptomatic patients w/ severe AS (valve opening <1 cm2)
- Patients w/ severe AS undergoing CABG
- Patients w/ severe AS undergoing surgery on aorta or other heart valves
- Patients w/ severe AS and LV systolic dysfunction (ejection fraction < 50%)

Front 20

What life-prolonging treatment(s) are there for Aortic Stenosis?

Back 20

Only valve replacement

Front 21

Does mitral regurgitation cause a pressure or volume overload state? What does this cause?

Back 21

Volume overload
- Tolerated well until severe
- When severe regurgitation develops slowly enough, patients can often tolerate well for extended periods

Front 22

What is the most damaging to organ systems: rate of change or degree of change?

Back 22

Rate of change is the most important factor for organ damage

Front 23

What is notable about the pressure vs time curve for a mitral valve with regurgitation

Back 23

- Pressure transfer from LV to Aorta is normal
- The LA pressure increases more than it should d/t blood returning from LV → LA

Front 24

What does the Pressure-Volume loop for a mitral valve with regurgitation tell you?

Back 24

- There is no point in time when both mitral and aortic valves are completely shut
- Therefore, there are no iso-volumic parts of curve
- LV volume gets higher because more blood is staying in heart (original blood to get pumped into LV + blood that regurgitated back and is getting pumped back in)
- Leads to greater contraction (Frank-Starling mechanism) because it is stretched out more → increased SV

Front 25

Describe the typical murmur for Mitral Regurgitation.

Back 25

Throughout all of systole you have fluid going from LV to LA at constant rate = Holosystolic Murmur

Front 26

What symptoms are noted with chronic Mitral Regurgitation?

Back 26

- Exertional symptoms are most common
- Heart can change without symptoms (well-tolerated until severe)

Front 27

What are some causes of primary (organic) mitral valve pathology?

Back 27

- Myxomatous disease - degenerative
- Rheumatic valve disease
- Endocarditis
- Congenital (cleft leaflet)

Front 28

What are some causes of secondary (functional) mitral valve pathology?

Back 28

- Ischemic Cardiomyopathy
- Dilated Cardiomyopathy
- Hypertrophic Cardiomyopathy

Front 29

How should you manage mitral regurgitation?

Back 29

Management based on:
- Development of symptoms
- Loss of LV systolic function

Front 30

What is the most common cause of Mitral Stenosis?

Back 30

Rheumatic Fever / immune disease

Front 31

What happens to the pressures when there is Mitral Stenosis?

Back 31

- Pressure increases in LA to push blood into LV
- This can increase the pressure in the lungs → pulmonary edema

Front 32

What is the normal size opening to the Mitral Valve? What is the size with mitral stenosis?

Back 32

- Normal: 3-4 cm2
- MS: < 2 cm2
- Severe MS: < 1 cm2

Front 33

When do you get symptoms of pulmonary congestion with Mitral Stenosis?

Back 33

- At smaller valve size openings, the pressure increases to try to maintain flow across mitral valve
- Once you exceed a certain level of pressure (for any valve size) you will get pulmonary congestion
- It is easy to exceed this threshold when the valve size is severely limited (possibly even at rest)

Front 34

What are the symptoms of Mitral Stenosis?

Back 34

- Predominantly exertional
- Atrial fibrillation evolves
- Severe pulmonary hypertension w/ RH failure eventually (because RH has to push really hard to get blood to go into LH which has increased pressure)

Front 35

Describe the typical murmur for Mitral Stenosis.

Back 35

- Early: opening snap and diastolic murmur
- Late: opening snap and diastolic murmur w/ RV lift

- Snap is high pitched
- Murmur is low pitched = diastolic rumble

Front 36

How do you confirm the diagnosis of Mitral Stenosis?

Back 36

- Echo Lab
- Cardiac Catheterization Lab

Severe MS:
- MVA (mitral valve area) ≤ 1 cm2
- MVG (mean valve gradient) ≥ 10 mmHg

Front 37

What do you seen on EKG of Mitral Stenosis?

Back 37

Hockey stick shape in mitral valve

Front 38

How do you treat Mitral Stenosis?

Back 38

- Balloon Valvuloplasty
- Valve Replacement

Front 39

What can cause Aortic Regurgitation?

Back 39

- Endocarditis
- Trauma
- Dissection of aorta

Front 40

What happens to the heart with chronic aortic regurgitation?

Back 40

Heart gets REALLY BIG (largest dilation of heart) = "Cor Bovinum"

Front 41

What valve pathology is associated with "Cor Bovinum" = cow heart?

Back 41

Aortic Regurgitation

Front 42

What does the Pressure-Volume loop for an aortic valve with regurgitation tell you?

Back 42

- No isovolumic phase because there is never a time when both valves are closed
- Increased LV pressure (compared to mitral regurgitation)

Front 43

What are the symptoms / tolerance of Aortic Regurgitation?

Back 43

- When progression to severe is slow, chronic severe aortic regurgitation is very well tolerated
- When symptoms evolve, they are usually exertional
- Sometimes there is loss of systolic function while patient remains asymptomatic

Front 44

What will you notice on physical examination of Aortic Regurgitation?

Back 44

- Widened pulse pressures
- Diffuse and displaced Point of Maximal Impulse (PMI)
- Diastolic murmur (diastolic decrescendo murmur as they lean forward and exhale)

- De Musset's sign: head bobbing
- Muller's sign: bobbing uvula
- Quinicke's sign: blanching nail beds

Front 45

What are the peripheral signs of aortic regurgitation?

Back 45

- De Musset's sign: head bobbing
- Muller's sign: bobbing uvula
- Quinicke's sign: blanching nail beds

Front 46

Describe the typical murmur for Aortic Regurgitation.

Back 46

Diastolic Decrescendo murmur best heard as they lean forward and exhale

Front 47

What are they signs indicative of?
- De Musset's sign: head bobbing
- Muller's sign: bobbing uvula
- Quinicke's sign: blanching nail beds

Back 47

Aortic Regurgitation

Front 48

How do you treat Aortic Regurgitation?

Back 48

Valve replacement