CH8 Valvular Disease questions

What is mitral stenosis?

a form of valvular disease characterized by narrowing of the mitral valve orifice

What are the causes of mitral stenosis?

RHD, calcification of MV, infective endocarditis, and congenital stenosis

What is the most common cause of MS?

Rheumatic fever leading to RHD

What is rheumatic fever (ARF)?

Inflammatory condition that primarily affects the heart, skin, and connective tissue

What causes rheumatic fever?

group A beta-hemolitic streptococcus

What are cardiac symptoms of rheumatic fever?

tachycardia, impaired LV contractility, pericardial friction rub, transient heart murmurs

Involvement of the heart in Rheutmatic fever causes...

cross reactivity between bacterial and cardiac antigens leading to carditis

What is carditis?

inflammation of all 3 layers: pericardium, myocardium, endocardium

What is the treatment for rheumatic fever?

ASA (aspirin) and PCN (penicillin)

What is used to establish the diagnosis of ARF?

Jone's criteria

What fits the major criteria of ARF?

carditis, migratory arthritis, sydenham chorea, eythema marginatum, subcutaneous nodules

What fits the minor criteria of ARF?

arthralgia, fever, elevated acute-tase reactant, prolonged PRI

What is RHD?

A complication of ARF- permanent deformity and impairment of valves with symptoms of valvular dysfunction 10-30 years after ARF

RHD causes valvular inflammation, what are the outcomes?

thickening/calcification of leaflets, shortening of commissures, and thickening/shortening of chordae tendineae

What is the commissure?

The "line" where the valves meet as they close

Fibrous thickening and calcification of valvular leaflets

The valve is too "heavy" from Ca to fully open

Fusion of the commissures

stiffens or restricts the movement of the valve leaflets, causing the valve to narrow

Thickening and shortening of chordae tendineae

Doesn't allow the mitral valve leaflets to open as wide as they normally can

How does mitral valve stenosis lead to pulmonary edema and pulmonary HTN?

Very tight valve → pressure builds up in LA → pressure is pushed back into lungs → pulmonary congestion → pulmonary edema and pulmonary hypertension

What are the 2 distinct forms of PHTN?

passive in the initial phases of pressure gradient increase and relative which protects the Pv from high pressure but will eventually cause increase in RVp → dilatation of RV → Right-sided HF

Chronic pressure overload of LA will cause....

dilatation of the chamber, atrial fibrillation, and thrombus formation → thromboembolism → stroke!

What are the symptoms of mitral valve stenosis?

dyspnea, orthopnea and PND, hemoptysis, Ortner syndrome

What is PND?

paroxysmal nocturnal dyspnea

What is hemoptysis?

coughing up blood

What is Ortner syndrome?

hoarseness caused by compression of the laryngeal enlarged LA or PA

When examining a patient with MS, what are common observations?

Loud S1 due to calcification, opening snap after S2, diastolic rumble murmur

What does an EKG show for a patient with MS?

LAE, RVH, PHTN, Afib

What does a chest x-ray show for a patient with MS?

LAE, pulmonary redistribution, interstitial edema, Kerley B lines, RV enlargement, prominent pulmonary arteries

What does an echocardiogram show for a patient with MS?

-Thickened MV leaflets with abnormal fusion of their commissures and restricted separation during diastole

-LAE

-thrombus

-doppler evaluation to assess severity of MS and MVA

What is the normal MVA?

4-6cm2

What is the MVA in severe MS?

< 1.5cm2

What is the area of a very severe MS?

<1.0 cm2

What are treatments of MS?

salt intake restriction and diuretics, betablockers and Ca-channel blockers, and digoxin and anticoagulants

What is the purpose of reducing salt intake and diuretics for MS?

to improve symptoms of pulmonary congestion

What is the purpose of beta-blockers and Ca-channel blockers for MS?

to reduce heart rate and improve LV filling time

What is the purpose of digoxin and anticoagulants for MS?

to treat atrial fibrillation and prevent thromboembolism

What are interventional therapies to improve MS?

Percutaneous balloon mitral valvuloplasty, Open mitral valve commissurotomy, Mitral valve replacement

What is mitral regurgitation?

abnormal reversal of blood flow from LV into the lA through the MV

When does MR occur?

systole

What is primary MR?

disruption of structural integrity of any MV apparatus components - results in abnormal closure of valve during systole

What causes secondary or functional MR?

LV Dysfunction (MI, ischemic HD, cardiomyopathy) causes abnormal coaptation and closure of the leaflets

What causes acute MR?

result from sudden damage of MV apparatus: PM rupture due to infarction, sudden rupture of chordae tendineae, blunt trauma, degeneration of chordae, Marfan syndrome

What can cause chronic MR?

mitral valve prolapse, rheumatic HD, congenital valve defects, calcification of valve annulus (MAC)

What happens to left ventricular (LV) volume in acute MR?

It increases due to sudden volume overload from regurgitant flow into the left atrium.

Why does total stroke volume increase in acute MR?

Because it includes both forward stroke volume and the regurgitant volume leaking back into the LA.

Why is forward stroke volume decreased in acute MR?

A significant portion of LV output goes backward into the LA instead of forward into the aorta.

How does acute MR cause volume and pressure overload in the LA?

The sudden regurgitant flow from the LV rapidly increases LA volume and pressure.

What does increased left atrial pressure (LAP) lead to in acute MR?

Pulmonary venous congestion and acute pulmonary edema.

Why does acute pulmonary edema occur in acute MR?

High LAP inhibits normal drainage from the lungs, causing fluid to back up into pulmonary capillaries.

How does chronic MR affect LV end-diastolic and systolic volumes?

Both increase due to ongoing regurgitant volume overload.

What effect does increased wall stress have on the LV over time?

It leads to LV dilation and progressive dysfunction.

How does LV dilation worsen MR?

Dilation stretches the mitral valve annulus, preventing proper leaflet closure.

How does LV dysfunction affect stroke volume in chronic MR?

It decreases both LV and forward stroke volume.

What happens to ejection fraction (EF) in chronic decompensated MR?

EF eventually decreases as LV contractility declines.

How does the left atrium adapt in chronic MR?

It dilates to accommodate excess regurgitant volume, initially keeping LAP lower.

What causes pulmonary congestion in chronic MR?

Elevated LAP from progressive LA dilation and volume overload.

What develops from long-standing pulmonary congestion?

Pulmonary hypertension and dyspnea.

What symptoms appear as chronic MR decompensates?

Dyspnea, fatigue, and other congestive heart failure (CHF) symptoms.

Why are symptoms delayed in chronic MR compared to acute MR?

The LA and LV gradually adapt through dilation, temporarily compensating for regurgitation.

What are the symptoms for acute MR?

pulmonary edema

What are the symptoms for Chronic MR

fatigue and weakness during exertion; in severe MR: dyspnea, orthopnea, PND, peripheral edema

What is found on a physical examination for a patient with chronic MR?

Apical holosystolic murmur radiating to the axilla, S3 present, Apical impulse displacement toward the axilla

What is found on a physical examination for a patient with Acute MR?

Apical early decrescendo systolic murmur and Signs of pulmonary congestion

What is found on a chest x-ray for acute MR?

pulmonary edema

What is found on a chest x-ray for chronic MR?

LA and LV enlargement

What is found on an EKG for a patient with MR?

LAE and LVH

What is found on an echo for a patient with MR?

structural cause for MR and assesses severity of MR

What does a cardiac cath identify in a patient with MR?

accompanying coronary disease, left ventriculography, severity of MR

What does acute severe MR require?

corrective surgery and treatment to stabilize the patient

What is the treatment for primary chronic MR?

treatment of HF and surgical repair/replacement of MV (balloon valvopathy and TMVR)

What is the treatment for secondary chronic MR?

heart failure medication

What is mitral valve prolapse?

abnormal billowing of the MV leaflets into the LA during systole

What typically accompanies MVP?

MR

What is the clinical presentation for MVP?

Frequently asymptomatic or presenting chest pain and palpations, common in women

What is heard in an auscultation for MVP?

mid-systolic click and late systolic murmur

Confirmation of diagnosis of MVP

echocardiography and course is benign

What is Aortic stenosis?

the narrowing of the AV opening restricting the blood flow of the systemic circulation into the Ao

What are the causes of Aortic stenosis?

degenerative (calcification), rheumatic valve disease, bicuspid aortic valve

What is the primary structural problem in aortic stenosis?

A progressive decrease in the area of the aortic valve opening.

What happens to antegrade (forward) velocity when the aortic valve area decreases by half?

It decreases significantly, reducing forward blood flow.

How does the left ventricle initially adapt to aortic stenosis?

By developing concentric hypertrophy to overcome increased afterload.

What type of dysfunction is seen in the early changes of aortic stenosis?

Diastolic dysfunction.

What causes diastolic dysfunction in early aortic stenosis?

Decreased compliance of the thickened LV wall leading to increased LV diastolic pressure.

During early aortic stenosis, how is contractility and stroke volume affected?

Contractility remains normal, and stroke volume is maintained (unchanged contractility).

What are the possible complications of diastolic dysfunction in early AS?

Atrial fibrillation, mitral regurgitation, and eventually heart failure.

What type of dysfunction occurs in the late changes of aortic stenosis?

Systolic dysfunction.

What structural or metabolic problems contribute to systolic dysfunction in late AS?

Myocardial ischemia, myocardial fibrosis, and abnormal wall motion.

How does systolic dysfunction affect contractility and stroke volume?

It causes decreased contractility and decreased stroke volume.

What is the ultimate outcome if aortic stenosis progresses without intervention?

Heart failure due to combined diastolic and systolic dysfunction.

Why is concentric hypertrophy initially beneficial but eventually harmful in aortic stenosis?

It maintains cardiac output early but later leads to stiffness, ischemia, and reduced compliance.

What are the 3 symptoms of aortic stenosis?

Angina, Syncope, Dyspnea

What causes angina in AS?

due to imbalance between oxygen supply and demand

What causes syncope in AS?

due to reduced CO during exertion

What causes dyspnea in AS?

due to LV non-compliance leading to ↑LA pressure and PWP, causes HF

What are found during a clinical exam evaluating AS?

late systolic ejection murmur radiating to carotid, diminished/absent S2, S4 present (due to noncompliant LV), tardus parvus pulse

What does an EKG show for a patient with AS?

LVH

What does an echo show for a patient with AS?

LVH, abnormal anatomy and reduced excursion of AV, doppler evaluates severity of stenosis via pressure gradient and AVA

What does a cardiac cath show for a patient with AS?

confirms severity of stenosis and coronary involvement

What are treatments of aortic stenosis?

aortic valve replacement, percutaneous ballon valvuloplasty, transcatheter aortic valve replacement

When should a patient get an AVR?

when they become symptomatic and the criteria for intervention with 60% rise in survival rate