BOARD BASICS: valvular heart diseases

right sided hear murmurs increase in intensity during …

inspiration

… murmus increase in intensity with valsalva maneuver and on standing from a squatting position

HCM

… clicks move close to S1, and the murmr lengthens with valsalva and on standing from a squatting position

MVP

this sound occurs with RBBB, pulmonary valve stenosis, VSD, and ASD (both with left to right shunts)

fixed splitting

this sound split S2 with expiration

paradoxical splitting

this sound occurs with LBBB, HCM, and severe AS

paradoxical splitting

this murmur is mid systolic, located at the base of the heart, grade 1/6 to 2/6 without radiation, and associated with normal splitting of S2

innocent heart murmurs

signs of possible significant cardiac disease

S4, murmur grade ≥3/6 intensity, and diastolic murmur, continous murmurs, and abnormal splitting of S2

… is indicated in symptomatic patients, in those with systolic murmur grade ≥3/6 intensity, any diastolic murmur, continuous murmurs, and abnormal splitting of S2

TTE

an increased P2, an S3, and an early peaking systolic murmur over the upper left sternal border are normal findings during …

pregnancy

murmur is midsystolic, harsh, crescendo-decrescendo

location is RUSB

aortic stenosis

its murmur radiates to the right clavicle, carotid, apex

aortic stenosis

associated findings: enlarged, nondisplaced apical impulse, S4, bicuspid valve without calcification will have systolic ejection click followed by murmur

aortic stenosis

severe form findings may include decreased A2, high pitched late peaking murmur, diminished and delayed ccarotid upstroke, radiation of murmur to both clavicles and carotids

aortic stenosis

murmur is diastolic, decrescendo

located at LLSB (valvular) or RLSB (dilated aorta heard) best sitting and leaning forward

aortic regurgitation

associated findings include enlarged, displaced apical impulse, S3 or S4, increased pulse pressure, bounding carotid and peripheral pulses

aortic regurgitation

acute severe form murmur may be masked by tachycardia and short duration of murmur

severtiy in chronic form is difficult to assess by ascultation

aortic regurgitation

murmur is diastolic; low-pitched, rumble; decrescendo

heard at the apex and best in left lateral decubitus position

mitral stenosis

associated with loud S1, tapping apex beat, opening snap after S2 if leaflets mobile, irregular pulse if AF present

mitral stenosis

interval between S2 and opening snap is short in severe mitral stenosis

intensity of murmur correlates with transvalvular gradient

P2 may be loud if pulmonary hypertension present

mitral stenosis

murmur is systolic; holo-mid, or late systolic; blowing or muscial

best heard at apex

can radiate to axilla or back, occasionally anteriorly to precordium

mitral regurgitation

associated with systolic click in prolapse, S3; apical impulse hyperdynamic and may be displaced if dilated left ventricle

mitral regurgitation

in …, valsalva maneuver moves onset of clikc and murmur closer to S1; handgrip maneuver increases murmur intensity

MVP

acute severe form may have soft or no holosystolic murmur, mitral inflow rumble, or S3

mitral regurgitation

murmur is holosystolic

best heard at LLSB

can radiate to LUSB

tricuspid regurgitation

associated with merged and prominent c and v waves in jugular venous pulse; murmur increases during inspiration

tricuspid regurgitation

can have right ventricular impulse below sternum

pulsatile, enlarged liver with possible ascites

murmur may be high pitched if associated with severe pulmonary hypertension

tricuspid regurgitation

murmur is diastolic; low-pitched, decrescendo; increased intensity during inspiration

best heard at LLS

does not radiate

tricuspid stenosis

associated with elevated central venous pressure with prominent a wave, signs of venoug congestion (hepatomegaly, ascites, edema)

tricuspid stenosis

low pitched frequency may be difficult to auscultate, especially at higher heart rate

tricuspid stenosis

murmur is systolic; crescendo-decrescendo

best heard at LUSB

can radiate to the left clavicle

pulmonary valve stenosis

associated with pulmonic ejection click after S1 (diminishes with inspiration)

pulmonary valve stenosis

increased intensity of murmur with late peaking

pulmonary valve stenosis

murmur is diastolic decrescendo

best heard at LLSB

does not radiate

pulmonary valve regurgitation

associated with loud P2 if pulmonary hypertension present

pulmonary valve regurgitation

murmur may be minimal or absent if severe because of minimal difference in pulmonary artery and right ventricular diastolic pressures

pulmonary valve regurgitation

murmur is midsystolic, grade 1/6 or 2/6 in intensity

best heard at RUSB

does not radiate

innocent murmur

associated with normal intensity of A2, normal splitting of S2

innocent murmur

may be present in conditions with increased flow (eg, pregnancy, fever, anemia, hyperthyroidism)

innocent murmur

murmur is systolic crescendo-decrescendo

best heard at LLSB

does not radite

HOCM

associated with enlarged hyperdynamic apical impulse; bifid carotid impulse with delay; increased intensity during valsalva maneuver or with squatting to standing

HOCM

murmur is systolic, crescendo-decrescendo

best heard at RUSB

does not radiate

ASD

associated with fixed split S2, right ventricular heave; rarely, tricuspid inflow murmur

ASD

may be associated with pulmonary hypertension with increased intensity of P2, pulmonary valve regurgitation

ASD

murmur is holosystolic,

best heard at LLSB

does not radiate

VSD

associated with palpable thrill; murmur increases with handgrip maneuver

VSD

murmur intensity and duration decrease as pulmonary hypertension develops (Eisenmenger syndrome)

Cyanosis if Eisenmenger syndrome develops

VSD

most common cause of … is progressive degenerative of a normal trileaflet valve that is usually diagnosed in patients aged ≥60 years. patients with congenital bicusspid valve usually present at young age (40-60 years)

aortic stenosis

cardinal symptoms of AS are …

dyspnea, angina, and syncope

echo may significantly understimate the transvalvular gradient in patient with severe LV dysfunction

aortic stenosis

do not select exercise stress testing for symptomatic patients with …

aortic stenosis

indications of aortic valve replacement in severe

aortic stenosis are …

• symptoms of dyspnea, angina, pre syncope, syncope, or HF

• ejection fraction <50% in an asymptomatic patient

• a concomitant cardiac surgocal procedure for other indications

TAVI is preferred to SAVR for symptomatic patients with severe AS with …

• aged >80 years

• younger patients with <10 years ife expectancy

• any age with a high prohibitive surgical risk

in …, medical therapy does not stall progression of disease but is indicated for patients with symptoms of LV dysfunction or HTN who are awaiting valve repair or replacement. treatment them with guideline-directed medical therapy

aortic stenosis

do not select … as a definitive treatment for AS in adults

ballon valvuloplasty

it is the most common congenital heart abnormality

Bicuspid aortic valve

first degree relatives of patients with a … and aortopathy should be screened with echocardiography

Bicuspid aortic valve

treatment for stenotic

Bicuspid aortic valve

surgical valve replacement is first line therapy. recommendations regarding when to intervene are the same as for tricuspid valves

treatment for regurgitant

Bicuspid aortic valve

valve replacement is the treatment of choice when it is clinically significant, manifesting as symptomatic HF or asymptomatic LVEF <50%

indications of aortic repar in

Bicuspid aortic valve

• severe AS or regurgitation replacement and aortic diameter >4.5cm

• aortic root diameter >5cm with an additional risk factor for dissection

  • aortic root diameter >5.5cm without risk factors

in Bicuspid aortic valve, the ascending aortic diameter should be assessed at least annually by echocardiography if the aortic root or ascending aorta dimension is >… cm

4.5

most common causes of acute severe AR

IE or aortic dissection

most common causes of chronic severe AR

dilated ascending aorta from HTN or primary aortic disease, calcification stenosis, bicuspid valve, or rheumatic disease

findings of chronic severe AR include …

• angina, orthopnea, exertional dyspnea

• widened pulse pressure

• left axis deviation and LVH on ECG

• cardiomegaly and aortic root dilatation and calcification on CXR

acute … is associated with a short, soft, and sometines inaudible diastolic murmur and normal heart size and pulse pressure

aortic regurgitation

treatment for

aortic regurgitation

schedule immediate valve replacement for patients with acute form. bridging medical therapy includes sodium nitroprusside and IV diuretics

indication for open surigcal valve replacement in

aortic regurgitation

• symptoms (dyspnea, angina)

• left ventricular EF ≤55%

• undergoing other cardiac surgeyr

do not select BB or intra-aortic balloon pumps for patients with acute …, because both may worsen the condition

aortic regurgitation

usually presents 20 to 40 years after an episode of RF

mitral stenosis

most common symptoms are fatigue, orthopnea, and paroxysmal nocturnal dyspnea

mitral stenosis

patients may have a history of AF or systemic thromboembolism

mitral stenosis

CXR shows an enlarged pulmonary artery, left atrium, right ventricle, and right atrium

mitral stenosis

ECG shows RV hypertrophy and notched P-wave duration >0.12 in lead II (P mitrale)

mitral stenosis

treatment of

mitral stenosis

percutaneous balloon mitral commissurotomy is first line therapy for symptomatic patients and for asymptomatic patients with severe stenosis or moderate stenosis associated with PH

acute … most often occurs in patients with chordae tendineae rupture

mitral valave regurgitation

acute … characteristic findings include the abrupt onset of dyspnea, pulmonary edema, or cardiogenic shock

mitral valave regurgitation

when to interrupt anticoagulation in patietns with prosthetic heart valve?

before noncardiac or dental surgery, but not cataract surgery

target INR for an aortic prostehtic valve without thromboembolism risk factors

2.5

target INR for ball-in-cage aortic prosthetic valve wtih thromembolism rsikf factor

3.0

target INR for any mitral valve prosthesis

3.0