7. Valvular Heart Disease, Pericarditis, Pericardial Effusion

What makes a murmur audible?

Turbulent blood flow through heart

Diastolic valvular conditions (4)

- Aortic regurgitation

- Pulmonic regurgitation

- Mitral stenosis

- Tricuspid stenosis

Systolic valvular conditions (4)

- Aortic stenosis

- Pulmonic stenosis

- Mitral regurgitation

- Tricuspid regurgitation

Pathophys of aortic stenosis

Degenerative calcification of aortic cusps (similar to vascular atherosclerosis)

Risk factors of aortic stenosis

- Male

- Hyperlipidema

- Genetic

- Congenital bicuspid aortic valve

Common risk factor between all valvular stenoses

Rheumatic heart disease

MC valvular heart dysfunction

Aortic stenosis

MCC aortic stenosis

Age-related progressive degeneration/calcification

Aortic stenosis + HF (what occurs/prognosis)

- Increased pressure in LV → hypertrophy

- 2-year mortality (if not replaced)

S/S of aortic stenosis

Extertional (presents first):

- Syncope

- Angina/dyspnea (impaired coronary perfusion during distole)

- A-fib w/ severe stenosis (stretching of LA)

Heart sound of aortic stenosis

Harsh cresendo-decrescendo systolic, radiating to the neck

Diagnostic testing for ALL valvular disorders

Echocardiogram

Classification of severe aortic stenosis

Valve area <1 cm^2 (normal is 3-4)

Diagnostic workup of aortic stenosis

- Echo w/ doppler

+/- EKG with LVH

+/- CXR with cardiomegaly/calcification

Indication for cardiac cath with workup of aortic stenosis

Discrepany of symptom severity and echo findings

Indications for intervention of aortic stenosis

- Symptomatic, severe ALWAYS

- Asymptomatic, severe with 1 of following: CABG (sx), signs of HF (decreased LV efficiency)

Management of aortic stenosis

Surgical aortic valve replacement OR transcatheter aortic valve implantation

Recommendation for SAVR for aortic stenosis

<65 yo OR life expectancy >20 years

Types of valves for surgical aortic valve replacement (SAVR)

- Bioprosthetic (porcine/bovine)

- Mechanical valve

Bioprosthetic (porcine/bovine) vs. mechanical valve for AS

Bioprosthetic (porcine/bovine): Decreased thromboembolism risk; anticoag then lifelong ASA

Mechanical: Last longer BUT high thromboembolism rate → lifelong warfarin

Recommendation for TAVR for aortic stenosis

>80 yo

Transcatheter aortic valve implantation (TAVR/TAVI)

- Similar effectiveness to SAVR

- Can use "valve-in-valve" with biopresthetic AVR dysfunction

- Initial dual antiplatelet + lifelong ASA

MCC of pulmonic stenosis

Congenital - fibrosis of valve and leaflet thickening

S/S of pulmonic stenosis

- RHF failure symptoms

- Sx on exertion

- Cyanosis

RHF failure symptoms (3)

- Peripheral edema

- Hepatomegaly

- JVD

Heart sound of pulmonic stenosis

Cresendo-decrescendo systolic with widely split S2

Diagnostic workup of pulmonic stenosis

- Echo w/ doppler

+/- EKG with RVH

+/- CXR with cardiomegaly

Indications for intervention with pulmonic stenosis

- Symptomatic

- Cyanotic/exercise intolerance

Management of pulmonic stenosis

Surgical repair/replacement

General cause (pathyphys) of mitral regurgitation

Blood leaks into LA during systole

Pathophys of chronic mitral regurgitation

- Progressive worsening w/ heart adaptation

- Increased pressure in LA → backup in pulm veins (and adaptive LV changes) → Pulm HTN

Pathophys of acute mitral regurgitation

Insufficient time for compensatory LA enlargement and LV dilation → acute HF presentation & acute pulmonary edema

Main causes of mitral regurgitation (3)

Primary/organic: Factors that inhibit full closure of valve/leaflets

Functional/secondary ischemia: Acute MI association

Functional/secondary nonischemia: Distortion of LV → papillary displacement

S/S of mitral regurgitation

- Palpitations

- Dilated LA → Afib

Acute MR → cardiogenic shock/acute HF

Heart sounds with mitral regurgitation

Holosystolic, radiating to axilla +/- S3

Diagnostic workup of mitral regurgitation

- Echo w/ doppler (TEE can give better view than TTE)

If surgery:

- Cardiac cath to assess CAD (and will address both in surgery)

Indications for intervention with (chronic) mitral regurgitation

- Symptomatic

- Undergoing CABG already

Management of mitral regurgitation

Surgical repair — NO anticoag requirement, preserves native valve

Surgical replacement

Management of (acute) mitral regurgitation

Awaiting emergent surgery:

Vasodilators: decrease aortic pressure

Temporary intra-aortic balloon pump

Management of chronic mitral regurgitation w/o criteria for surgery

Yearly echo

Transcatheter mitral valve repair (Mitraclip)

Clips perpendicular to leaflets to manage mitral regurgitation

Pathophys of mitral valve prolapse

- Abnormal thick mitral valve leaflet displaced superiorly into LA (generally benign)

- Severe prolapse can cause regurgitation

Risk factors for mitral valve prolapse

Autosomal dominant

Heart sounds with mitral valve prolapse

Mid-systolic click at apex

Management of mitral valve prolapse

- Monitor with echo

- BB, avoid stimulants

Risk factors of tricuspid regurgitation

Elderly (commonly with structurally normal valve)

Causes of tricuspid regurgitation

Functional (most): Dilation of RV

Structurally abnormality: Rheumatic fever, endocarditis

** Most mild

S/S of tricuspid regurgitation

- RHF symptoms

- Asymptomatic (esp. w/o pulm HTN)

Heart sounds with tricuspid regurgitation

Holosystolic at left sternal border, w/o radiation

Diagnostic workup of tricuspid regurgitation

Echo w/ doppler

Management of tricuspid regurgitation

- Loop diueretics

- Low Na diet

- Surgery only if symptomatic + primary issue

Pathophys of aortic regurgitation

Backflow of blood from aorta to LV during diastole

Causes of aortic regurgitation

- Aortic root dilation (MC idiopathic)

- Bicuscpid aortic valve (15%)

Risk factors of aortic regurgitation

- Marfans (CT disorder)

- Lupus

- Endocarditis

S/S of aortic regurgitation

LHF

Heart sounds with aortic regurgitation

Early diastolic, blowing, decrescendo at RSB and along LSB

PE findings with aortic regurgitation

- Austin flint murmur

- Corrigan/water hammer pulse

- Traube's sign

Austin flint murmur

- Severe aortic regurgitation

- Soft mid-diastolic rumble at apical area

Corrigan/water hammer pulse

Rapid rise and collapse of carotid artery

Traube's sign

Pistol-shot systolic sound over femoral artery

Diagnostic workup of aortic regurgitation

- Echo w/ doppler

- Cardiac cath: Determines aortic root involvement

Management of aortic regurgitation

- Reduce afterload w/ HTN (ACEI/ARB, nifedipine)

- Acute → surgery

- Chronic & EF <50% → surgery; open if aortic root involved

Pathophys of pulmonic regurgitation

Blood back into RV from pulmonary arteries during diastole

MCC of pulmonic regurgitation

Pulmonary HTN

S/S of pulmonic regurgitation

RHF symptoms

Heart sounds with pulmonic regurgitation

Early diastolic, decrescendo

Management of pulmonic regurgitation

Address underlying

Pathophys of mitral stenosis

Reduced valve area obstructs flow from LA to LV during diastole

Normal area of mitral valve

4 to 6cm^2

Causes of mitral stenosis

Rheumatic heart disease

MC valvular condition that presents during pregnancy

Mitral stenosis

S/S of mitral stenosis

- Increased LA pressure → pulm congestion → RHF

- Afib

- Rales

Heart sounds with mitral stenosis

High-pitched, opening snap, diastolic rumble with loud S1

Lifestyle management of mitral stenosis

- Avoid strenuous

- Low Na diet (avoid fluid retention)

Afib → rate/rhythm + anticoag warfarin

Indications of interventions with mitral stenosis

- Symptomatic

- Asymptomatic with severe (<1 cm^2)

- Pulm HTN

Management of mitral stenosis

- Percutaneous balloon mitral commissurotomy (most)

- Replacement (severe)

Cause of tricuspid stenosis

Rheumatic fever

S/S of tricuspid stenosis

- RHF

- Afib (RA enlargement)

Heart sounds with tricuspid stenosis

Opening snap, diastolic rumble that increases with respiration

Management of tricuspid stenosis

- Diuretics

- Replacement (severe)

MC disorder of pericardium

Acute pericarditis

Causes of acute pericarditis

- Viral

- Autoimmune: response to recent MI/trauma (Dressler's syndrome)

- Hypothyroid, ovarian hyperstim

Pericarditis can occur with...

Myocarditis

S/S of acute pericarditis

- Sharp, pleuritic, worse supine

- Improved sitting up/leaning forward

Diagnosis of acute pericarditis

Clinical based on H&P

EKG findings with acute pericarditis

Diffuse ST elevations and PR depression

Diagnostic workup of acute pericarditis

Echo: May show pericardial effusion

Effusion → CXR: Cardiomegaly/water bottle heart

Treatment of acute pericarditis

- High dose anti-inflammatory meds + activity restriction

- Avoid strenuous until sx resolve

Medication regiment for acute pericarditis

- ASA OR Ibuprofen for 1-2 weeks, taper

- PPI to protect stomach

- Colchocine (w/o contraindications; liver disease/dose reduction w/ renal disease)

Post-MI treatment for acute pericarditis

ASA instead of ibuprofen

Pericardial effusion

Abnormal accumulation of fluid in pericardial sac

Cause of pericardial effusion

- CHF/MI

Exudative: Infection

Hemorrhagic: trauma/aortic dissection

S/S of pericardial effusion

- Muffled heart sounds

- Similar to acute pericarditis

Diagnostic workup of pericardial effusion

Echo: Size of effusion

CXR: Water bottle heart

EKG findings with pericardial effusion

- Low voltage QRS complexes (5mm or less in the 6 limb leads) with electrical alternans

Electrical alternans is associated with...

Pericardial effusion

Treatment of pericardial effusion

Treat underlying

+/- pericardiocentesis for diagnostic/therapeutic

Cardiac tamponade

Accumulation of fluid putting pressure on heart reducing ventricular filling and hemodynamic compromise

** MEDICAL EMERGENCY

S/S of cardiac tamponade

MC: Chest pain, dyspnea, tachypnea

- Beck's triad

- Pulsus paradoxus

Beck's triad

- Hypotension

- JVD

- Muffled heart sounds