Mitral Valve Stenosis 

Etiology

Mitral Valve Stenosis

Pathophysiology

If the mitral valve does not open sufficiently.

Blood backs up will go and eventually cause congestion in the lungs.

Mitral Valve Stenosis

Symptoms

• Exertional dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea secondary to pulmonary congestion

Mitral Valve Stenosis

PE Findings

• Opening snap following S2
• Low pitched murmur at the apex
• Tachycardia possible
• Rales secondary to pulmonary congestion

Mitral Valve Stenosis

Treatment

• If pt. is in Afib then treat the Afib – cardiovert, warfarin
• Pulmonary congestion – diuretics and vasodilators
• Percutaneous balloon valvuloplasty
• Valve replacement

Mitral Valve Regurgitation

Pathophysiology

When the left ventricle contracts blood leaks back into the the left atrium.  This causes na increase in  preload resulting in an increase ejection fraction.  Eventually this wears on the heart and you get an enlarged left ventricle and a decreased ejection fraction. Eventually leads to pulmonary congestion.  

***Mitral regurge is the most common valvular issue in the United states.

Mitral Regurgitation

Etiology

• Mitral valve prolapse is the most common cause (thin females are most common for mitral valve prolapse)
• Myocardial infarction
• endocarditis (regurge will also put a patient at increased risk of endocarditis)
• Ruptured chordae tendineae  (caused by MI or endocarditis most likely)

Mitral Regurgitation

Symptoms

• Asymptomatic
• Exertional dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea secondary to pulmonary congestion

Mitral Regurgitation

PE Findings

• Pansystolic blowing murmur at the apex and radiating to the axilla
• Loud S3
• Mitral valve prolapse has a midsystolic click
• Brisk carotid upstroke
• Rales secondary to pulmonary congestion

Mitral Regurgitation

Treatment

• If pt has Afib, treat Afib – cardiovert, warfarin
• Pulmonary congestion – diuretics and vasodilators
• Surgical
  • Valve repair for prolapse
  • Valve replacement

Aortic Stenosis

Pathophysiology & Etiology

Aortic stenosis is believed to be similar to atherosclerosis. Build up of calcifications on aortic valve

• A congential biscuspid or unicuspid valve.  The aortic valve is normally a tricuspid valve.  Symptoms usually occur in middle aged person.
• Degenerative or calcific aortic stenosis. Upwards of 25% of patients over 65 have some degree of aortic stenosis.

Aortic Stenosis

Symptoms

• Asymptomatic
• Exertional dyspnea
• Syncope
• Angina – secondary to poor perfusion of coronary arteries

Aortic Stenosis 

PE Findings

• Harsh systolic murmur along left sternal border and it may radiate to the neck
• ECG – left ventricular hypertrophy
• Chest x-ray – Calcified aortic valve
• Echo with Doppler is diagnostic

Aortic Stenosis

Treatment

• Aortic Valve replacement  (#1 treatment)
  • prosthetic – last longer but require anticoagulation
  • Pericardial and porcine valves do not require anticoagulation but have a shorter lifespan
• Ross procedure – replacement of aortic valve with patient’s own pulmonary valve and a cadaver valve replaces the pulmonary valve.
• Balloon valvuloplasty not effective long term

Aortic Regurgitation

• Rheumatic fever is historically relevant, but is now less common due to widespread antibiotic use.
• Congential bisuspid aortic valve
• Endocarditis
• HTN
• Marfan syndrome

Aortic Regurgitation

Symptoms

• Routine medical exam – asymptomatic until middle aged
• Exertional dyspnea
• Angina
• Paroxysmal nocturnal dyspnea

Aortic Regurgitaiton

PE Findings

• Wide arterial pulse pressures
• Chest x-ray – left ventricular hypertrophy
• ECG – left ventricular hypertrophy
• Echo with Doppler is diagnostic
• Cardiac cath can be used for more information

Tricuspid Regurgitation

Causes

• Right ventricular hypertrophy (tricuspid regurg also causes right ventricular hypertrophy)
• Pulmonary hypertension often caused by left sided heart failure
• Ebstein’s anomaly
• Tricuspid prolapse
• Endocarditis

Tricuspid Regurgitation

Symptoms

• Exertional dyspnea
• Chest pain
• Swelling of feet and ankles

Tricuspid Regurgitation

PE Findings

• Murmur is along the lower left sternal border.  It is holosystolic blowing and radiates to the right sternum and xiphoid.
• Jugular venous distention
• ECG may show abnormal p wave due to enlarged right atrium
• Chest X-ray – enlarged right atrium
• Echo with Doppler can assess severity
• Cardiac cath can be used for more information

Tricuspid Regurgitation

Treatment

• Diuretics to decrease fluid volume
• Salt restrictions to decrease fluid volume
• Surgical valve repair
• Valve replacement
• If pulmonary hypertension is a problem treat it with arterial vasodilators

Pulmonary regurgitation

Causes

• High pressure cause
  
  • Pulmonary HTN
• Low pressure causes
  • Endocarditis
  • Rheumatic heart disease
  • MI
  • Plaque
  • Iatrogenic

Pulmonary Regurgitation

Symptoms

• mild cases are well tolerated and have few or no symptoms
• Severe cases may have right ventricular hypertrophy
• severe cases may have right heart failure

Pulmonary Regurgitation

PE Findings

• Widely split S2
• ECG may show right ventricular hypertrophy
• Echo with doppler will show extent of regurgitation
• Cardiac cath may be used to gain more information