Comprehensive Study Guide on Valvular Heart Disease for Exam 3

ECHO

definitive diagnostic tool for valvular heart disease

valve gradient

difference in pressure on each side of a valve; determined by ECHO

intensity, pitch, quality, timing, shape, location, radiation

how to describe a cardiac murmur

grade I

faint murmur, heart only after a few seconds of auscultation

grade II

moderately loud murmur, heard immediately

grade III

loud murmur, not associated with a thrill

grade IV

loud murmur associated with a thrill

grade V

very loud murmur, can be heard if only the edge of stethoscope is in contact with the skin

grade VI

loudest murmur possible, can be heard with stethoscope just removed from the chest and not touching the skin

diastolic murmurs

end in the ventricle; aortic regurg, mitral stenosis, pulmonic regurg, tricuspid stenosis

systolic murmurs

begin in the ventricle; aortic stenosis, mitral regurg, tricuspid regurg, pulmonic stenosis, VSD, hypertrophic cardiomyopathy

atrial contraction, systole, closure of tricuspid valve, maximal right atrial filling, emptying of right atrium

JVP waveform (ASK ME)

mitral stenosis

thickening of mitral valve leaflets, commissures fuse, calcium deposits on the valve, and chordae tendineae thicken and shorten

rheumatic heart disease

mitral stenosis is most commonly due to this disease

mitral stenosis

presents with dyspnea on exertion, palpitations & afib, hemoptysis, hoarseness, cough, orthopnea, chest pain, thromboembolism; murmur is diastolic rumbling with opening snap loudest at apex, best heard in left lateral decubitus position

mitral stenosis

-EKG: afib, left atrial enlargement, right axis deviation, right ventricular hypertrophy

-ECHO: measures mitral orifice size (severe if <1.0 cm2), measures size of left atrium

diuretics, beta blockers, warfarin

medical treatment for mitral stenosis

percutaneous mitral balloon commissurotomy

non-invasive treatment for mitral stenosis

mitral valve replacement

surgical treatment for mitral stenosis

tissue valves

last 10-15 years, bovine or porcine, daily ASA 81 mg

mechanical valves

last 1000 years, made of titanium or pyrolytic carbon, require warfarin anticoagulation

mitral regurgitation

-mitral insufficiency; incompetent mitral valve allows regurgitation of blood back into left atrium during systole

-causes: mitral valve prolapse, ischemia/infarction, cardiomyopathies, acute rheumatic heart disease, calcification

mitral regurgitation

-ECG: LAE, arrhythmia

-CXR: LA, LV enlargement

-ECHO: regurgitant volume, LVEF, LA size, LV size, PA pressure, RV function

mitral valve prolapse

-improper closure of the mitral valve; floppy, degenerative, or myxomatous, seen in up to 10% of healthy young women

-often asymptomatic or nonspecific CP, dyspnea, fatigue, palpitations, mid-systolic click +/- systolic murmur

mitral regurgitation

exertional dyspnea, fatigue, pulmonary edema, palpitations, pansystolic murmur (high-pitched, blowing) radiates to left axilla, possible S3

diuretics, BB, vasodilators, anticoagulation

medical treatment for mitral regurgitation

surgery

emergent treatment for acute mitral regurg, elective treatment for chronic mitral regurg

aortic stenosis

-narrowing of aortic valve; may be congenital or due to calcification/degeneration

-presentation: syncope, angina, dyspnea, chest discomfort, exercise intolerance

-systolic crescendo-decrescendo harsh ejection murmur with ejection click that radiates towards carotids, soft and single S2, possible S4, thrill along LSB

aortic stenosis

-delayed carotid pulse upstroke

-normal CXR

-EKG: LVH, LAE

-ECHO: valve area <1.0 cm2, jet velocity >4.0 m/sec, mean transvalvular gradient >40mmHg

diuretics, BB

medical treatment for aortic stenosis

aortic valve replacement, balloon valvuloplasty, transcatheter aortic valve replacement (TAVR)

surgical treatments for aortic stenosis

aortic regurgitation

-increased SV due to backwards flow of blood from aorta into LV; can be caused by biscupsid valve disease, Marfan, calcified valve disease, RHD, aortic dissection, blunt chest trauma, endocarditis

-chronic: exertional dyspnea, fatigue, atypical chest pain, eventual LV failure

-acute: cardiogenic shock, flash pulmonary edema, chest pain

-murmur: high-pitched/decrescendo diastolic murmur at apex, no opening snap, radiates to apex, better heard with sitting and leaning forward

-widened pulse pressure, water hammer pulse, de Musset's sign, Quinke's sign, Austin Flint murmur

aortic regurgitation

-ECG: LVH

-ECHO: regurgitant volume, dilated LV or aorta

diuretics, BB, nifedipine, ACEi

medical treatment for mild aortic regurgitation

aortic valve replacement

surgical treatment for severe aortic regurgitation

TEE, heart cath

additional workup included for aortic regurgitation

tricuspid stenosis

-etiology: rheumatic, carcinoid syndrome, fen-phen

-right heart failure, giant A wave on JVP, diastolic rumble murmur increases with aspiration along LLSB

-RA enlargement on ECG, cardiomegaly and dilated SVC on CXR

diuretics, valve replacement

treatments for tricuspid stenosis

tricuspid regurgitation

-occurs whenever there is RV dilation from any cause: pulm valve stenosis, pulm HTN, cardiomyopathy, RCA myocardial infarction, HF, pacemaker lead valvular injury, endocarditis

-right HF, X wave on JVP becomes obliterated, systolic murmur increases with inspiration

-RA enlargement on ECG

diuretics, tricuspid annuloplasty, valve replacement

treatments for tricuspid regurgitation

pulmonary valve stenosis

-rare, usually congenital

-DOE, chest pain, eventual RV failure, palpable parasternal lift, loud harsh systolic murmur +/- thrill that increases with inspiration, ejection click preceding murmur

-ECG shows RAD and RVH

percutaneous balloon valvuloplasty, surgical commissurotomy, valve replacement

treatments for symptomatic pulmonary valve stenosis

pulmonary valve regurgitation

-most cases due to pulmonary HTN, also caused by abnormal valve, carcinoid disease, post-surgical repair of Tetralogy of Fallot repair

-most asymptomatic

-RV heave & lift, widely split S2, diastolic murmur increases with inspiration

diuretics, valve replacement

treatment for pulmonary valve regurgitation

inspiration

increases right sided murmurs

expiration

increases left sided murmurs

acute mitral regurgitation, acute aortic regurgitation, aortic stenosis causing syncope

3 emergent valvular conditions