Valvular Heart Disease

biological valve replacement

bovine pericardium, does not require long term anticoagulation unless concurrent condition

higher risk for endocarditis, requires antibiotic prophylaxis for IE

risk for structural valve degeneration

mechanical valve replacement

durable and lasts longer

requires long term anticoagulation

require antibiotic prophylaxis for IE

mitral valve stenosis general info

obstruction of blood flow from LA to LV

increased LA pressure and decreased CO

thickening of valve leaflets, calcification, fusion of mitral commissures, thickening and fusion of chordae

• fish mouth appearance

mitral stenosis etiology

rheumatic heart disease

mitral annular calcification or congenital disease with fusion of chordae or malposition of papillary muscles

atrial myxoma

mitral stenosis sx

asx until afib develops or pregnancy occurs

left heart failure

dyspnea on exertion

orthopnea

PND

hemoptysis

loud first heart sound

RV lift, elevated JVP, ascites, edema

50-80% pts can develop paroxysmal or chronic afib

opening snap followed by apical rumbling diastolic murmur

• accentuated by left lateral decubitus position using bell of steth

mitral stenosis dx

ECG: LA abnormality, afib

echo: TTE

obtain accurate valve area, RV fx

determine suitability for balloon mitral valvotomy

mitral stenosis tx

intervention indicated for sx, afib, or pulmonary HTN

mitral balloon valvuloplasty

mitral valve replacement or repair

mitral stenosis moderate to severe tx

condition corrected prior to becoming pregnant if possible

mitral valve stenosis afib tx

warfarin or else pt will have systemic embolization

when to refer to mitral stenosis

all pts with mitral stenosis

monitor with yearly exams and echoes

cardiologist will determine how often to follow up

acute mitral regurgitation general info

pt is gravely ill, emergency

ischemic cause: papillary muscle ruptured due to MI or trauma

non-ischemic cause: ruptured mitral chordae tendinae due to mitral valve prolapse

chronic mitral regurgitation etiology

infective endo

mitral valve prolapse

rheumatic fever

MR can be primary to mitral valve apparatus or cardiac disorder (CHD/MI)

chronic MR etiology

volume overload on heart leads to LVH

LA enlarges to accommodate = compensated MR

prolonged volume overload = impaired LV fx, decreased EF, pulmonary congestion = decompensated MR

acute MR sx

cardiac emergency with sudden onset and rapid progression of pulmonary edema, hypotension, shock

chronic MR sx

exertional dyspnea and fatigue

general MR sx

paroxysmal or persistent afib

can cause left HF

pansystolic murmur apex radiate to axilla

displacement of LV impulse

soft first heart sound and widely split second heart sound

• if severe S3

mitral regurg dx

EKG: LA abnormality or afib, LVH

TTE confirms dx, TEE if TTE is suboptimal

acute mitral regurgitation tx

medical/surgical emergency

chronic mitral regurgitation tx

surgical intervention based on sx, severity of MR, LVEF, LVESD

mitral valve repair/replacement

when to refer MR

more than mild MR

mitral valve repair should be done early to improve mortality and morbidity

mitral valve prolapse general info

most common cause of mitral regurg

young women

collagen abnormalities such as Marfans

mitral valve prolapse etiology

floppy or myxomatous mitral valve, degenerative mitral valve disease

varying portions of one or both leaflets protrude or extend abnormally above mitral annulus into the left atrium

mitral valve prolapse sx

asx or nonspecific hest pain, dyspnea, fatigue or palpitations

mid systolic click early when you sit or stand versus when you squat

pectus excavatum or scoliosis

systolic murmur of MR

mitral valve prolapse dx

TTE

mitral valve prolapse tx

beta blocker for palpitations

mitral valve repair favored over replacement

when to refer for mitral valve prolapse

all pts

audible MR

periodic echo to assess LV size and EF

aortic stenosis etiology

narrowing of aortic valve

congenital: unicuspid or bicuspid aortic valve, sx when 50-65

degenerative: calcific aortic stenosis

aortic stenosis sx

asymptomatic

dyspnea on exertion

exertional dizziness or syncope

angina

HF

systolic ejection murmur radiates to neck carotids

second heart sound diminished as worsens

palpable LV heave or thrill in late disease

aortic stenosis dx

ECG: LVH

CXR: enlarged cardiac silhouette, calcification of aortic valve, dilation of aorta

TTE: calcification, leaflet opening, severeity of LV wall thickness, overall ventricular fx

aortic stenosis tx

transcath aortic valve replacement

surgical aortic valve repair

young adolescents: percutaneous balloon angioplasty

when to refer for aortic stenosis

pts with echo evidence or sx of aortic stenosis

what is aortic regurgitation

inadequate closure of aortic valves in diastole, blood leaks back into LV = LVH

increased SV

widens pulse pressure

aortic regurgitation etiology

HTN, marfan, rheumatic etiology, congenitally bicuspid valves, infective endo

aortic regurgitation sx

asx until middle age

early: decreased functional capacity/fatigue

later: L sided HF wiith fatigue, PND, PE, exertional dyspnea, orthopnea

angina pectoris

apical impulse laterally displaced

diastolic blowing murmur

corrigan/water hammer pulse

quincke pulse

duroziez sign

musset sign

hill sign

austin flint murmur

pulse has rapid rise and fall with elevated systolic and low diastolic pressure

corrigan/water hammer pulse

nailbed capillary pulsations

quincke pulses

to and fro murmur over partially compressed femoral peripheral artery

duroziez sign

head bob with each pulse

musset sign

peripheral bed is larger in leg than arm, in severe systolic BP in leg > 20mmHg compared to arm

hill sign

mid or late diastolic low pitched mitral murmur in advanced AR due to partial closure of mitral valve by rapidly rising LV diastolic pressure due to AR

austin flint murmur

aortic regurgitation dx

ECG: LVH

CXR: cardiomegaly with LV prominence, dilated aorta

TTE

aortic regurgitation tx

surgery once sx occur

pharmacologic therapy to reduce afterload w pts systolic BP > 140

aortic regurgitation refer

audible aortic regurg

dilated aorta

tricuspid stenosis general info

causes systemic venous congestion

blood flow across valve increases with inspiration and decreases with expiration

tricuspid stenosis etiology

prosthetic valve degeneration or carcinoid disease

rheumatic heart disease

pacemaker = fibrosis

tricuspid stenosis sx

R HF, hepatomegaly

ascites

a wave seen in elevated JVP

diastolic rumble along increases with inspiration

tricuspid stenosis dx

ECG: right atrial enlargement

CXR: cardiomegaly normal PA, dilated SVC

TTE: tricuspid valve thickened

tricuspid stenosis tx

valve replacement

treat RHF if present

tricuspid stenosis when to refer

tricuspid stenosis on echo

what is tricuspid regurgitation

backflow of blood into RA

can lead to RHF

tricuspid regurgitation etiology

secondary to RV dilation due to LHF, pulmonary HTN

not due to primary tricuspid valve disease

ebsteins anomaly: congenital abnormality affecting tricuspid valve and RV

tricuspid regurgitation sx

RV failure sx

elevated JVP

dilated RV causes RV heave

holosystolic murmur

hepatomegaly

PAD

Rivero-Carvallho sign: murmur becomes louder and longer w inspiration

S3 or S4

tricuspid regurgitation dx

ECG: aflutter/afib

CXR: large RA or dilated azygous vein

TTE

mild tricuspid regurgitation tx

diuretics

treat underlying cause of RV dysfunction

if inherent defect of tricuspid regurgitation cannot be repaired

bioprosthetic valve replacement

moderate to severe tricuspid regurgitation tx

refer

follow ups with cardiologist

pulmonary regurgitation general info

high pressure: strain and RV failure caused by pulmonary HTN

low pressure: RV adapts, asx for years

pulmonary regurgitation high pressure murmur

graham steell: loud high pitched diastolic murmur increases with inspiration

S3/S4 gallop, split S2, pulmonary systolic click

fatigue

pulmonary regurgitation dx

Echo: RV enlargement, abnormal RV wall, RV volume overload

Cardiac MRI and CT gold standard

ECG/CXR: RBBB, RVH

pulmonary regurgitation tx

treat underlying cause

valve replacement if RV dysfunction

refer