Term
| Epidemiology of Valvular Heart Disease |
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Definition
Rheumatic disease
• Most common cause of valve disease worldwide
• Young age
• Estimated prevalence of 15.6 to 19.6 million.
Degenerative valve disease
• Most common cause in the developed countries (US)
• Older age
• Prevalence of 13% in age>75 years.
• Calcific aortic stenosis and structural mitral
regurgitation.
Emerging valve disease
• Functional regurgitations, endocarditis |
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Term
| MS mostly due to what type of valve disease |
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Definition
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Term
| AS, AR, MR mostly caused by what type of valve disease |
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Definition
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Term
| mitral stenosis etiologies |
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Definition
– Rheumatic heart disease (>90%) – Mitral annular calcification (3%) – Infective endocarditis (3%)
– Other etiologies (< 1%) |
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Term
| mitral stenosis epidemiology |
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Definition
– The most common cause of valvular heart disease in developing countries
– Female to male ratio 4:1
– Onset age 20-30 years of age |
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Term
| mitral stenosis pathophys |
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Definition
– Inflammation and scar
– Leaflet thickening
– Fusion of chordae
– Association with MR
– Multiple valves involved
[image] |
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Term
| mitral stenosis clinical manifestations |
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Definition
– Dyspnea
– Hemoptysis
– Right-sided heart failure
– Thromboembolism |
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Term
| mitral stenosis heart sounds |
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Definition
– Loud S1
– Opening snap
(closer to S2 as severity increases)
– Rumbling mid-diastolic murmur
– Pre-systolic murmur |
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Term
| mitral stenosis non-invasive testing |
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Definition
• ECG: Left atrial enlargement , Right ventricular hypertrophy
• CXR: LA, RV and RA enlargement, Interstitial edema |
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Term
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Definition
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Term
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Definition
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Term
| echocardiography for mitral stenosis |
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Definition
• Premier noninvasive diagnostic modality
– Accurate MV area calculation
– |
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Term
| mitral stenosis severity and echo measurements |
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Definition
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Term
| mitral stenosis medical treatment |
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Definition
– RF prophylaxis until at least age 25 (PCN)
– Meds for symptoms: • Diuretics
• Rate control (esp. with AF) – Anticoagulation |
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Term
| mitral stenosis surgical treatment |
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Definition
Surgical management (If symptomatic)
– Percutaneous Balloon Valvuloplasty
• Excellent results - prolonged benefits
• Contraindications:
– Heavy valve calcification
– Severe subvalvular calcification
– Greater than mild MR
– Mitral Valve Replacement |
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Term
| mitral regurgitation structural and functional etiologies |
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Definition
• Structural (leaflet related)
– Mitral valve prolapse
– Rheumatic heart disease – Endocarditis
• Functional
– Altered LV geometry
– Left ventricular dilation
– Ischemic heart disease with papillary muscle dysfunction |
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Term
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Definition
• Incidence 2.4%
• Myxomatous degeneration of mitral leaflets and chords
• Weakened valve together with cordal lengthening lead to prolapse into LA during systole |
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Term
| pathophysiology of mitral regurgitation steps |
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Definition
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Term
| mitral regurgitation clinical manifestations |
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Definition
– Weakness
– Dyspnea
– Left heart failure |
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Term
| mitral regurgitation heart sounds |
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Definition
– Blowing holosystolic murmur, immediately after S1 and continuing up to and sometime beyond and obscuring A2, heard best over the apex, radiating to the axilla.
– Louder when afterload increases (squatting, isometric hand grip, phenylephrine) or when left ventricular volume increases . |
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Term
| mitral valve prolapse heart sounds |
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Definition
– Mid Systolic Click
– Late Systolic Murmur
– Murmur earlier, longer and louder when left ventricular volume decreases or when afterload decreases. |
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Term
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Definition
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Term
| mitral regurgitaion diagnosis |
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Definition
• Echocardiography
– Extent of color regurgitation on 2D echo
– Estimation of effective regurgitant orifice (ERO) by Doppler
• Mitral regurgitation assessment of severity |
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Term
| mitral regurgitation severity and echo measurements |
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Definition
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Term
| mitral regurgitation medical management |
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Definition
– Treatment of congestion with diuretics
– Vasodilators for symptomatic patients to decrease afterload
– Periodic follow-up to assess for LV enlargement or reduced EF |
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Term
| mitral regurgitation surgical management |
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Definition
– Mitral valve repair
– Mitral valve replacement
• Timing of surgery
– When symptomatic
– EF <60%, ESD>40 mm |
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Term
| tricuspid stenosis general findings and symptoms |
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Definition
• General
– Uncommon
– Majority rheumatic associated with mitral stenosis
• Symptoms
– Fatigue and malaise due to reduction in cardiac output
– As right atrial pressure increases, venous congestion leads to JVD, hepatomegaly, ascites, and peripheral edema
– Right atrial wall thickens and chamber dilates |
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Term
| tricuspid stenosis heart sounds |
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Definition
– A mild diastolic murmur, rumbling character – Best heard over the left sternal border
– Tricuspid opening snap with wide-splitting S1 |
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Term
| tricuspid stenosis treatment |
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Definition
• Treatment typically not needed
• Repair of tricuspid stenosis is indicated for:
– Class 3-4 symptoms
• Ascites, hepatic congestion, peripheral edema • Refractory to medical treatment |
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Term
| tricuspid regurgitation etiologies |
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Definition
– Right ventricular dilatation (most common) • Pulmonary hypertension
• Left sided heart failure
• Mitral valve disease
– Bacterial endocarditis
– Congenital abnormalities – Trauma |
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Term
| tricuspid regurgitation physical exam findings |
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Definition
– Systolic murmur at LSB louder with inspiration
– Elevated JVP
– Large pulsatile liver
– LE edema
– Ascites |
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Term
| tricuspid regurgitation medical and surgical treatment |
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Definition
• Medical treatment
– Treat the underlying cause of pulmonary hypertension (CHF, sleep apnea,...)
– Diuretics
• Surgical treatment
– Tricuspid valve repair (ring annuloplasty) – Tricuspid valve replacement |
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Term
| pulmonary stenosis symptoms and most common etiology |
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Definition
• Congenital etiology is most common cause – Rheumatic cause uncommon
• Symptoms
– Angina, syncope |
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Term
| pulmonary stenosis physical exam diagnosis and treatment |
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Definition
• Physical exam
– Early systolic ejection click followed by systolic ejection
murmur with radiation to base of the heart
• Diagnosis
– Echocardiogram
• Treatment
– Balloon commissurotomy if increased gradient across
valve |
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Term
| aortic stenosis symptoms and normal valve area |
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Definition
• Normal Aortic Valve
Area: 3-4 cm2
• Symptoms: Occur when valve area is 1/4th of normal area. |
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Term
| 3 types of aortic stenosis |
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Definition
– Supravalvular
– Subvalvular
– Valvular |
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Term
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Definition
• Congenital
• Rheumatic (Acquired)
• Degenerative/Calcific (Acquired)
• Patients under 70: >50% have a congenital cause
• Patients over 70: 50% due to degenerative |
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Term
| pathophysiology of aortic stenosis |
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Definition
• A pressure gradient develops between the left ventricle and the aorta. (increased afterload)
• LV function initially maintained by compensatory pressure hypertrophy
• When compensatory mechanisms exhausted, LV function declines. |
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Term
| presentation of aortic stenosis |
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Definition
- Syncope: (exertional)
- Angina: (increased myocardial oxygen demand; demand/supply mismatch)
- Dyspnea: on exertion due to heart failure (systolic and diastolic)
- Sudden death |
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Term
| physical exam findings with aortic stenosis |
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Definition
• Slow rising carotid pulse (pulsus tardus) &
decreased pulse amplitude (pulsus parvus)
• Heart sounds- soft and split second heart
sound, S4 gallop due to LVH.
• Systolic ejection murmur- cresendo- decrescendo character.
– This peaks later as the severity of the stenosis increases.
– Loudness does NOT tell you anything about severity |
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Term
| natural history/progression of aortic stenosis |
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Definition
• Mild AS to Severe AS: – 8% in 10 years
– 22% in 22 years
– 38% in 25 years
• The onset of symptoms is a poor prognostic indicator. |
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Term
| evaluation of aortic stenosis |
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Definition
• Echocardiography is the most valuable test for diagnosis, quantification and follow-up of patients with AS.
• Two measurements obtained are:
a) Left ventricular size and function: LVH, Dilation, and EF
b) Doppler derived gradient and valve area (AVA) |
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Term
| aortic stenosis severity based on echo measurements |
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Definition
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Term
| treatments/management of aortic stenosis |
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Definition
• Medical
– Limited role since AS is a mechanical problem. Vasodilators are relatively contraindicated in severe AS
• Aortic Balloon Valvotomy – Shows little benefit.
• Surgical Replacement – Definitive treatment |
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Term
| echo surveillance times for aortic stenosis |
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Definition
• Mild: Every 5 years
• Moderate: Every 2 years
• Severe: Every 6 months to 1 year |
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Term
| indications for surgery w aortic stenosis |
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Definition
• Any symptomatic patient with severe AS (includes symptoms with exercise)
• Any patient with decreasing EF
• Any patient undergoing CABG with moderate or severe AS |
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Term
| aortic regurgitation definition |
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Definition
| – Leakage of blood into LV during diastole due to ineffective coming together of the aortic cusps |
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Term
| 2 etiologies for acute aortic regurgitation |
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Definition
• Endocarditis
• Aortic Dissection |
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Term
| physical exam findings for acute aortic regurgitation |
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Definition
– Wide pulse pressure
– Diastolic murmur
– Florid pulmonary edema |
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Term
| treatment of acute aortic regurgitation |
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Definition
• True Surgical Emergency:
– Positive inotrope
• Dopamine, dobutamine
– Vasodilators
• Nitroprusside)
– Avoid beta-blockers
– Do not even consider a balloon pump |
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Term
| 3 etiologies for chronic aortic regurgitation |
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Definition
• Bicuspid aortic valve
• Rheumatic
• Infective endocarditis |
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Term
| pathophysiology of chronic aortic regurgitation |
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Definition
• Combined pressure AND volume overload
• Compensatory Mechanisms
– LV dilation, LVH
– Progressive dilation leads to heart failure |
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Term
| natural history/progression of chronic aortic regurgitation |
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Definition
• Asymptomatic until 4th or 5th decade
• Rate of Progression: 4-6% per year
• Progressive Symptoms include:
- Dyspnea: exertional, orthopnea, and paroxsymal nocturnal dyspnea
- Nocturnal angina: due to slowing of heart rate and reduction of diastolic blood pressure
- Palpitations: due to increased force of contraction |
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Term
| physical exam finding for chronic aortic regurgitation |
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Definition
• Wide pulse pressure: most sensitive
• Hyperdynamic and displaced apical impulse
• Auscultation-
– Diastolic blowing murmur at the left sternal border
– Austin flint murmur (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate
• Low-pitched mid-diastolic rumble
– Systolic ejection murmur: due to increased flow across the aortic valve |
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Term
| 3 ways to evaluate chronic aortic regurgitation |
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Definition
• CXR
– Enlarged cardiac silhouette and aortic root enlargement
• ECHO
– Evaluation of the AV and aortic root with measurements of LV dimensions and function (cornerstone for decision making and follow up evaluation)
• Aortography
– Used to confirm the severity of disease |
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Term
| severity of aortic regurgitation based on echo findings |
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Definition
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Term
| management of chronic aortic regurgitation |
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Definition
-Medical: Vasodilators (ACEI’s), Nifedipine improve stroke volume and reduce regurgitation only if patient symptomatic or hypertension.
-Serial Echocardiograms: Monitor progression.
-Surgical Treatment: Definitive treatment |
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Term
| indications for aortic valve replacement in aortic regurgitation |
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Definition
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Term
| indications for surgical treatment in aortic regurgitation |
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Definition
• ANY Symptoms at rest or exercise
• Asymptomatic treatment if:
– Ejection fraction drops below 50% or LV becomes dilated |
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