Clin Med 1 ( Valvular Diseases)

¬Aortic Stenosis

¬loud crescendo-decrescendo systolic ejection murmor in right 2nd intercostal space

¬Mitral Regurgitation

¬high pitched holosystolic loudest at apex radiating to axilla

¬Tricuspid Regurgitation

¬soft holosystolic at left sternal border

¬Mitral Prolapse

¬crisp midsystolic click and a delayed or late systolic regurgitation murmur.

¬murmur located at apex

¬Aortic Regurgitation

¬high pitched blowing early diastolic decrescendo murmor at left sternal border

¬Mitral Stenosis

¬rumbling mid-diastolic murmor with ccenuated S1. S2, best heard on expiration or when the patient is squating or excercising because venous return is increase

EtiologyTricuspid Insufficiency (Regurg)

•Relatively Common

•Congenital

•Endocarditis

•Connective tissue disorder

•Rheumatic Fever

•Chest trauma

•Endocarditis

Clinical history Tricuspid Insufficiency (Regurg)

•Most often asymptomatic

•Pulsation sensation in the neck

•Hepatomegaly•

Ascites

•Edema

Physical examTricuspid Insufficiency (Regurg)

•Edema

•JVD

•Hepatomegaly

•+/- pulsatile liver

•Soft, holosystolic, blowing, high-pitched murmur at the left mid sternal border

•Increased murmur intensity with inspiration

TRICUSPID INSUFFICIENCY"The Murmur"

Type of murmur : Holosystolic blowing high pitch

Mumurm location : Subxiphoid ,left mid sternal border

Radiation : None

Hearing : Increase , sqauting full inspiration( Carvallo;s sign)

Diseases associated with Tricuspid Regurgitation (Insufficiency)

¬Heart failure

¬Pulmonary HTN

¬Some cardiomyopathies

¬Infections

¬Infective endocarditis

¬Rheumatic fever

¬Congenital heart disease

¬Ebstein anomaly

¬Carcinoid syndrome

¬Marfan syndrome

¬Injury from implantable device wires

¬

¬Past use of the diet pill Fen-Phen

Workup Tricuspid Insufficiency (Regurg)

¬Echocardiogram

¬CXR

¬EKG

¬Cardiac Cath

¬

Clinical managementTricuspid Insufficiency (Regurg)

Medical:

¬Diuretics

¬ACE-I

¬Aldosterone antagonists

¬Aldactone

¬Spironolactone

Surgical:

¬Severe TR refractory to medical tx

¬Repair favored over replacement

Definition Tricuspid Stenosis

Narrowing through the valve

EtiologyTricuspid Stenosis

•Uncommon disorder

•MC etiology Rheumatic disorder or connective tissue problem

Also can :

•Congenital

•Endocarditis

•Tumor Obstruction

Clinical history Tricuspid Stenosis

Fatigue

dyspnea

fluttering sensation of the heart

Abnominal pain

R side HF

Physical exam Tricuspid Stenosis

•Similar to Mitral Stenosis

•Often coexists with Mitral Stenosis

•JVD

•Hepatomegaly

•Ascites

•Edema

TRICUSPID STENOSIS"The Murmur"

:Type of Murmur: Mid-diastolic

Opening snap

(occurs later than opening snap of mitral stenosis

Murmur Location : Lower left sternal border (LLSB) (Xiphoid Border)

L 4th ICS

Radiation: None

Hearing Aid:

Increases

Full Inspiration

Squatting

Lying supine

Leg raise

Decreases

Valsalva

Standing

Expiration

Diseases associated with Tricuspid Stenosis

¬Rheumatic heart disease

¬Carcinoid syndrome

¬Infective endocarditis

¬Congenital heart disease

¬Pulmonary HTN

¬Almost always due to rheumatic fever

Workup Tricuspid Stenosis

¬Echocardiogram

¬CXR

¬EKG

¬Cardiac Cath

¬

Clinical managementTricuspid Stenosis

Medical intervention:

¬Monitor Sx

¬Diuretics

¬Sodium restriction

Surgical intervention: ¬Valve Repair ® commissurotomy

¬Valve Replacement

Complications of surgical replacement Tricuspid Stenosis

Surgical replacement : Mechanical valve , bioprothetic valve

Requires post surgical anticoagulation

Can cause hemolysis due to shering force : Shistocytes seen on peripheral smear

Elevated LDH, decreased haptoglobin and mild hyperkalemia

Pulmonary regurgitation

Retrograde from pulmonary artery valve into the R ventricle.

Etiology Pulmonic Insufficiency (Regurg)

¬Most commonly congenital

Tetralogy of Fallot

¬Endocarditis

¬Pulmonary HTN

¬May be seen with lung disease/s such as COPD or others

¬Retrograde blood flow from pulmonary artery into RV ® R-side volume overload

Clinical history Pulmonic Insufficiency (Regur)

•Asymptomatic in most cases

•Decreased exercise tolerance

•Fatigue

Clinical presentation Pulmonic Insufficiency (Regurg)

•Kussmaul's Sign

•S3 gallop is associated with an extremely dilated RV

•Pansystolic murmur

•Ascites

•Cachexia and jaundice

•Atrial fibrillation

•Peripheral edema

•Right ventricular heave

PULMONIC INSUFFICIENCY" The Murmur"

Type of Murmur :

1) Graham-Steell Murmur

Brief

Early diastolic murmur DUE TO PULMONARY HTN

2) Pansystolic

Rough, Low pitched

NOT DUE TO PULMONARY HTN

Murmur Location:

1)Left Upper Sternal border at the 2nd L ICS

2) Parasternal 4th ICS

Hearing Aid:

1)Increases

Full inspiration

Sitting Upright

Squatting

Decreases

Valsalva

Standing

Expiration

2)Increased by

Inspiration, exercise, leg raising

Decreased by

Standing

Valsalva Maneuver

Diseases associated with Pulmonic Regurgitation (Insufficiency)

Pulmonary HTN

Tetralogy of Fallot

Less common

¬Infective endocarditis

¬Carcinoid syndrome

¬Rheumatic fever

Usually treatable, often curable depending on etiology

WorkupPulmonic Insufficiency (Regurg)

ECHOCARDIOGRAM

CXR

EKG

RIGHT HEART CATH

Clinical managementPulmonic Insufficiency (Regurg)

¬No treatment needed in most

¬Progressive/Severe/Symptomatic

¬Treat Underlying etiology

¬Severe cases

Repair

Replacement

Definition Pulmonic Stenosis

Restriction through pulmonic valve to pulmonary arterial vasculature

Etiology Pulmonic Stenosis

Most often congenital: •Congenital rubella syndrome

Disease of the young

Part of the tetralogy of Fallot syndrome

Clinical History Pulmonic Stenosis

¬Often asymptomatic until childhood

¬Chest pain

¬Exertional Dyspnea

¬Fatigue

¬Syncope

¬CHF

Physical exam Pulmonic Stenosis

•JVD

•Cyanosis, severe cases

•HF

•Edema

•Wide split S2

•Delayed P2

•+/- presence of S4 heart sound

PULMONIC STENOSIS" The Murmur"

Type of Murmur:

Harsh

Midsystolic ejection

Crescendo-decrescendo

Systolic ejection click

Murmur Location:

L USB

Radiation: Left Shoulder/Neck

Hearing Aid: Increases

Full Inspiration

Diseases associated with Pulmonary Stenosis

•Tetralogy of Fallot

•Noonan syndrome

•Williams syndrome

•Maternal rubella syndrome (German measles) ® risk of baby having pulmonary stenosis

•Rheumatic fever

•Chest radiation

Workup Pulmonic Stenosis

•Echocardiogram

•CXR

•EKG

•CATH

Clinical management Pulmonic Stenosis

Balloon valvuloplasty is preferred treatment

Mitral regurgitation

Incomplete closure of valve regurgitation of blood back into L atrium

EtiologyMitral Insufficiency (Regurg)

Abnormal retrograde flow from LV to LA

Acute:

Infective endocarditis

Chordae tendinea rupture

Papillary Muscle

Ischemia/Infarction

Chronic:

Rheumatic fever

Congenital

MVP

Calcification

Clinical historyMitral Insufficiency (Regurg)

CHRONIC ® HF sx

¬Dyspnea

¬Fatigue

¬A-fib

SOB

¬Paroxysmal Nocturnal Dyspnea (PND)

¬Pulmonary HTN

Acute

¬Pulmonary Edema

¬Hypotension

Physical examMitral Insufficiency (Regurg)

•S1 may be diminished in acute mitral regurgitation (MR) and chronic severe MR with defective valve leaflets

•Wide splitting of S2

•S3 may be present due to LV dysfunction or as a result of increased blood flow across the mitral valve

•Palpation

•Brisk carotid upstroke and hyperdynamic cardiac impulse may be noted

•Lateral displacement of the PMI Prominent left ventricular (LV) filling wave may be present

MITRAL regurgitation"The Murmur"

Type of Murmur: Pansystolic (holosystolic)

Blowing quality may be heard

Murmur Location : Apex

Radiation : Left axilla (high pitched)

Hearing Aid:

Increases

Left lateral position

Expiration

Squatting

Leg raise

Hand grip

Decreases

Valsalva/standing

Inspiration

Amyl nitrate

Diseases associated with Mitral Regurgitation

MVP

Rheumatic disease

Acute MI

Infective endocarditis

Workup Mitral Insufficiency (Regurg)

Echocardiogram

CXR:•Left atrial enlargement

LVH -Pulmonary edema

EKG-arrythmia: •Most common is Afib -LVH and LA enlargement

Cardiac cath

Clinical managementMitral Insufficiency (Regurg)

1- Asymptomatic Patient :

¬Generally Observed

¬Yearly Echo

¬Treat A-fib if present

¬Treat CHF

¬Vasodilators

¬Nitroglycerin

¬Cialis

2 Symptomatic patient :

Medical

¬ACE-I, ARBs or Hydralazine, Nitrates

¬+/- diuretics

Surgical intervention indication

¬EF < 60% or refractory to medical tx

¬*Valvuloplasty

¬Replacement

Mitral valve prolapse (MVP)

Incomplete closure of the valve bulges ( Prolapses) back into atrium

Malfunctioning mitral valve allows backflow of blood into the left atrium causing progressive enlargement

EtiologyMitral Valve Prolapse (MVP)

¬Not well understood

¬Genetic

¬MC in young women 15-35

¬Common in connective tissue diseases

¬Myxomatous change

Pathological weakening of connective tissues

¬Congenital

¬Marfan Syndrome

Clinical historyMitral Valve Prolapse (MVP)

¬Most pts asx

¬Anxiety/panic attacks

¬Atypical CP

¬Dizziness/syncope

¬Very mild fatigue

¬Arrhythmia

¬Palpitations

Physical exam Mitral Valve Prolapse (MVP)

¬Narrow AP diameter

¬Pectus excavatum

¬Arm span greater than height

¬Low body weight or body mass index (BMI)

¬Straight-back syndrome

¬Scoliosis or kyphosis

¬Hypermobility of the joints

¬Hypotension

MITRAL VALVE PROLAPSE"The Murmur"

Type of Murmur:

Mid-Late Systolic Ejection Click

May be associated with mid-late systolic murmur (MR)

Murmur Location:

Apex

Radiation: One

Hearing Aid:

Valsalva/Standing/inspiration

Earlier click and longer murmur duration

Lying supine/squatting/leg raise/handgrip

Delayed click

Workup Mitral Valve Prolapse (MVP)

¬Echocardiogram

¬EKG

¬Cardiac Cath

Management Mitral Valve Prolapse (MVP)

Asymptomatic:

¬Generally, not treated/observed

¬Antiarrhythmics if needed

¬Beta Blockers for palpitations

Symptomatic:

¬Valvuloplasty

¬Valve Replacement

¬Beta blockers (autonomic dysfunction)

Definition Mitral Stenosis

Obstruction of flow from L atrium to L ventricle, Thickening, immobility of mitral leaflets ,Increase pressure backs up to pulmonary vasculature

Etiology/epidemiology Mitral Stenosis Etiology

¬Rheumatic heart disease

Almost always the cause

¬Congenital

¬Thrombus

Valvulitis

¬SLE

¬Amyloid

¬Carcinoid

Etiology/epidemiology Mitral Stenosis Epidemiology

¬F > M [3 : 1]

¬If rheumatic fever origin

¬MC age dx 20s-30s

¬MC valve disease in pregnancy

¬Common in infective endocarditis

Clinical history Mitral Stenosis

•Dyspnea is MC sx : DOE

•Hemoptysis 2◦ Pulmonary Edema

•Atrial Fibrillation (Afib)

•Orthopnea/PND

•Dysphagia 2° esophageal compression

•Ruddy cheeks and facial pallor

•Anginal CP

Hoarseness

•Compression of laryngeal nerve

•R HF due to prolonged pulmonary HTN

Physical examMitral Stenosis

¬Mitral Facies

¬Ruddy flushed cheeks with facial pallor (chronic hypoxia)

¬Jugular Vein Distention (JVD)

¬R side HF ® Edema

¬Afib

¬Irregularly Irregular rhythm

¬May also see dysphagia due to atrial enlargement and pressure on the esophagus

¬Or hoarseness due to laryngeal nerve compression

MITRAL STENOSIS"The Murmur"

Type of Murmur"

Mid-diastolic Rumble

Prominent Loud S1 with Opening Snap—as stenotic valve opens

Murmur Location:

Apex

Radiation:

Usually none

Hearing Aid:

Increases

Left lateral decubitus position

Full exhalation

Squatting/Leg raise

Lying supine

Decreases

Valsalva/standing

Inspiration

Disease associated with mitral stenosis

Rheumatic fever

radiation therapy

Autoimmune disease (SLE)

WorkupMitral Stenosis

¬Echocardiogram

¬CXR

¬Atrial Enlargement (straightening of the left border, prominent pulmonary arteries)

¬Posterior displacement of esophagus

¬EKG

¬Atrial Enlargement (p wave > 3mm, biphasic p wave V1 & V2)

¬A-fib

¬Right axis deviation (90°-150°)

Clinical interventionsMitral Stenosis

¬Surgical Intervention

¬Percutaneous Balloon Valvuloplasty ® noncalcified

¬CI if unfavorable valve morphology

¬Valve Replacement

Clinical pharmacotherapeutics Mitral Stenosis

¬Treat A-fib

¬Rate control with BB and CCB

¬Diuretics and salt restriction

Aortic insufficiency (Regurg) Etiology

Young patient

Isolated aortic regurgitation : Valvular leaflet abnormalities

aneurysm>>>Aortic dissection >>> Sudden cardiac death

DefinitionAortic Insufficiency (Regurg)

•Leaking of the aortic valve

•Causes blood to flow in the reverse direction during ventricular diastole

•Cardiac muscle is forced to work harder than normal

EtiologyAortic Insufficiency (Regurg)

Congenital causes : •Bicuspid aortic valve is the most common congenital cause

Acquires causes : •Acute ® Acute MI, aortic dissection, endocarditis

•Chronic ® aortic dilation, Marfan's, inflammatory disorders, rheumatic fever, syphilis, HTN

•Degenerative aortic valve disease

•Traumatic

•Postsurgical (including post-transcatheter aortic valve replacement)

Clinical history Aortic Insufficiency (Regurg)

Palpitations

Chest pain

Uncomfortable awareness of heart beating

Left heart failure :

Physical examAortic Insufficiency (Regurg)

¬Bounding pulses

¬Wide pulse pressure

¬High systolic, reduced diastolic

¬Ex. 180/45

¬Water-Hammer pulse

¬Elevate wrist

¬Bounding, forceful pulse with a rapid upstroke and descent

¬Rapid fall of radial pulse

¬Corrigan Pulse

¬Bounding and forceful, rapidly increasing and subsequently collapsing

¬Similar to water hammer except refers to carotid artery

¬Displaced PMI

Physical exam - Peripheral signsAortic Insufficiency (Regurg)

Hill's sign:

•Popliteal artery systolic pressure > brachial artery by 60mmhg

•Most sensitive of the peripheral signs

•Quincke pulse: •Systolic pulsations seen upon light compression of the nail bed

•de Musset's sign: •Head bob with each ventricular contraction

AORTIC INSUFFICIENCY"The Murmur"

Type of Murmur:

Diastolic (Decrescendo)

Blowing quality may be heard

+/- Austin Flint Murmur

Murmur Location:

L USB

Left 2-4 Intercostal Space (L ICS)

Mid-late diastolic rumble at the apex

Radiation:

Along LSB

Hearing Aid:

Increases with handgrip, sitting while leaning forward and expiration

Decreases with amyl nitrate, Valsalva & standing

Diseases associated with Aortic Regurgitation

¬Connective tissue disorders ® Marfan syndrome

¬Rheumatic fever

¬Ankylosing spondylitis

¬Aortic dissection

¬Infective endocarditis

¬HTN

¬Lupus

¬Reiter syndrome

Workup Aortic Insufficiency (Regurg)

•Echocardiogram

•CXR may show cardiomegaly

•Cardiac Cath

•EKG: possible LVH

Clinical interventionAortic Insufficiency (Regurg)

Surgical intervention valve repair or replacement is definitive

¬Severe sx AR

¬Asx AR with EF < 55%

Clinical pharmacotherapeuticsAortic Insufficiency (Regurg)

¬Vasodilators

Nifedipine

¬ACE-I

¬ARBs

¬Hydralazine

Definition Aortic Stenosis

Narrowing of the aortic ,doesn't open fully, heart has to pump harder against pressure

Etiology Aortic Stenosis

¬Congenital Deformity

¬Bicuspid valve

¬Calcific Disease

¬Degenerative Process

¬Especially in elderly (those greater than 70)

¬Rheumatic Heart Disease

¬Complication of Rheumatic Fever

¬Post-streptococcal infection

Pathology Aortic Stenosis

LV outflow obstruction >>> LV hyperthrophy >>> LV Failure >>>Heart failure

Clinical historyAortic Stenosis

¬Angina is MC sx

¬Exertional Dyspnea (DOE)

¬Syncope

¬CHF

Physical examAortic Stenosis Exam Findings

¬Pulsus parvus et tardus

¬Narrow pulse pressure

¬LV heave

¬Heart tones

¬Paradoxical split S2 (if severe)

¬S4 if LVH present

Physical examAortic Stenosis Murmur

¬Systolic ejection crescendo-decrescendo

¬Best heard at Right Upper Sternal Border (RUSB)

¬Radiates to carotid arteries

¬Valsalva/standing

¬Decreases murmur (Attenuates)

¬Lying supine, squatting, leg raise

¬Increases murmur (Accentuates)

¬

AORTIC STENOSIS"The Murmur"

Type of Murmur:

Systolic crescendo-decrescendo murmur

Murmur Location: Right USB

Right 2nd ICS

Radiation:

Carotids

Hearing Aid:

Increase murmur intensity

Sitting ® leaning forward

Squatting, lying supine leg raise

Expiration

Decrease murmur intensity Valsalva/standing

Handgrip

Inspiration

Diseases associated with Aortic Stenosis

¬Bicuspid aortic valve

¬Rheumatic fever

¬Autoimmune disorders

SLE

RA

¬Paget's disease of the bone

¬Renal failure

WorkupAortic Stenosis

¬Echocardiogram

¬Small aortic opening

¬LVH

¬Thick +/- calcified aortic valve

¬CXR

¬EKG

¬LVH

¬LBBB - what is the finding for LBBB?

¬Left axis deviation (-30° to -90°)

¬+/- A-fib

¬Right heart Cath

¬

Clinical intervention Aortic Stenosis

Aortic valve replacement

is only effective tx

Complications of surgical replacementAortic Stenosis

¬Surgical replacement

Mechanical valve

Bioprosthetic valve

¬Requires post-surgical anticoagulation

¬Can cause hemolysis due to shearing force

Schistocytes seen on peripheral smear

¬Elevated LDH, decreased haptoglobin, and mild hyperkalemia

Clinical pharmacotherapeutics Aortic Stenosis

¬Typically in mild AS, no exercise restrictions

¬Severe—avoid physical exertion

¬No medical therapy is effective

¬Avoid

Venodilators (nitrates)

CCB & BB