Valvular Heart Disease

cusps of the pulmonary valve

anterior, left, right SL

cusps of the aortic valve

left, right, posterior SL cusps

mitral valve cusps

anterior + posterior

tricuspid valve cusps

anterior

posterior

septal

when does cardiac remodeling occur

in response to hemodynamic load / cardiac injury

pathophysiology of pressure overload remodeling

sarcomeres added in parallel → myocytes become thicker → increased wall thickness + mass

concentric hypertrophy is _ overload

pressure

volume overload produces _ hypertrophy

eccentric

pathophysiology of volume overload remodeling

sarcomeres added in series → myocytes become longer → increased mass and normal/thin wall

3 main etiologies of aortic stenosis

degenerative

congenital

rheumatic

pathophys of degenerative aortic stenosis

atherosclerotic deposits and calcium in the cusps along commissures

what maintains aortic pressure

peripheral autoregulatory mechanisms

what is the connection between valvular disease and HF

cardiac remodeling

_ develop due to high pressure state in the ventricle

concentric hypertrophy

most stenotic valves lead to _ overload

pressure

aortic stenosis produces _ hypertrophy

concentric

_ increases to maintain gradient and flow across a stenotic aortic valve

LV pressure

most common cause of aortic stenosis

degenerative

what causes rheumatic heart disease

untreated streptococcus infection

rheumatic valvular disease should be associated with which valve

mitral valve

40-50 yo with stenotic aortic valve should make you think _

aortic bicuspid valve

what causes murmur with aortic stenosis

high velocity blood coming out of aortic valve

symptoms of aortic stenosis

exertional dyspnea

chest pain

syncope

when does the prognosis of aortic stenosis become poor

once symptoms develop

what type of murmur is aortic stenosis

systolic ejection murmur

timing of aortic stenosis murmur

later = more severe

3 PE findings of aortic stenosis

decreased + delayed carotid pulses

S4 heart sound

pulmonic valve closes before aortic valve

evaluation of aortic stenosis

echocardiography

cardiac catheterization

what might be done concomitantly with an aortic valve repair

CABG

normal aortic valve area

2.5 - 4.0 cm²

surgical options for aortic stenosis

valve replacement

transcatheter aortic valve replacement

accessory parts of the mtiral valve

chordae tendineae

AL and PM papillary muscles

mitral annulus

aortic stenosis patients should be followed up with _

serial echoes

mitral valve opens during _

diastole

_ pressure has to overcome LV pressure in order for the mitral valve to open

LA

_ has to rise in mitral stenosis

left atrium

normal mitral valve area

4 - 6 cm²

what happens to the LA in mitral stenosis

dilates

secondary effect of mitral stenosis

increase in pulmonary artery pressure

what happens to LV function in mitral stenosis

usually normal

most common cause of mitral stenosis

rheumatic heart disease

when do sx’s of rheumatic heart disease occur in relation to rheumatic fever

10-30 years post rheumatic fever

2 less common causes of mitral stenosis

mitral annular calcification in elderly

congenital

it is important to control _ in patients with mitral stenosis

heart rate

moderate/severe mitral stenosis is associated with what symptoms

pulmonary congestion

fatigue (low CO)

when are individuals with mild stenosis symptomatic

with increased HR or CO

what condition is common with mitral stenosis

atrial fibrillation → thrombus/stroke

PE findings of mitral stenosis

loud S1 opening snap

diastolic murmur at apex

signs of pulmonary HTN

goals of mitral stenosis treatment

symptom relief and stroke prevention

3 treatments of mitral stenosis

HR control (beta blockers)

diuretics (pulmonary congestion)

anticoag (all pt’s with Afib/dilated LA)

intervention for mitral stenosis

balloon valvuloplasty

requirements for balloon valvuloplasty for MS

minimal calcification

ABSENCE of LA thrombus or significant regurgitation

largest heart valve

tricuspid

normal tricuspid area

6-10 cm²

tricuspid stenosis is usually assoc with _

rheumatic mitral stenosis

tricuspid stenosis leads to _ (3)

elevated RA pressure

systemic venous congestion

reduced CO

when does tricuspid stenosis murmur increase

with insipiration

PE findings of tricuspid stenosis

signs of systemic venous congestion

(elevated neck veins, edema, hepatomegaly)

tricuspid stenosis is heard during diastole or systole?

diastole

prognosis of asymptomatic tricuspid stenosis

good

etiology of pulmonic stenosis

congenital

rare: (rheumatic heart disease, carcinoid tumor)

hemodynamics of pulmonic stenosis

pressure gradient develops between RV and pulmonary artery

symptoms of mod to severe pulmonic stenosis

exertional fatigue

dyspnea

syncope

murmur of pulmonic stenosis

harsh systolic ejection

treatment for pulmonic stenosis

balloon valvuloplasty

regurgitant lesions cause _

ventricular enlargement

impaired contraction

etiology of aortic regurgitation

leaflet problems

annulus problems

what causes aortic annulus problems

HTN

aortic-annular ectasia

aortic dissection

vasculitis

causes of aortic leaflet problems

endocarditis

rheumatic disease

bicuspid valves

trauma

myxomatous

aortic regurgitation hemodynamics

volume load increases in LV → increased LV diastolic pressure

passive increase in pulmonary venous pressure

what happens to the LV in aortic regurgitation

LV dilates

_ may be compromised in aortic regurgitation

coronary blood flow

acute aortic regurgitation clinical manifestations

acute illness (tachycardia, hypotension, pulm edema)

PE findings of ACUTE aortic regurgitation

soft/absent A2

short diastolic murmur

treatment for acute aortic regurgitation

prompt surgery

chronic aortic regurgitation clinical findings

WIDE pulse pressure (diastolic pressure low)

laterally displaced apical impulse

diastolic decrescendo

diastolic rumble (Austin Flint murmur)

austin flint murmur

diastolic rumble

aortic regurgitation murmur

diastolic descresendo

duration of aortic regurgitation

correlates with severity

when is the prognosis of aortic regurgitation worse

if LV size increases

indications for surgery for aortic regurgitation

symptoms of severe AR

progressive LV dilation

reduced EF

mitral regurgitation etiology

leaflet issue

chordae tendineae issue

myocardial disease

changes in LV geometry

acute mitral regurgitation hemodynamics

supranormal LV function

LOW forward stroke volume

when do symptoms of mitral regurgitation occur

after significant LV dysfunction (SOB, fatigue, weakness)

murmur in mitral regurgitation

holo-systolic murmur that radiates to the axilla, back, or sternum

murmur intensity of mitral regurgitation

does NOT correlate with severity

what happens to ejection fraction after mitral valve replacement?

reduces

survival is better in mitral regurgitation if surgery is performed before EF reaches _

<60 %

which type of mitral valve surgery has better survival

REPAIR

pulmonic regurgitation etiology

pulmonary HTN

endocarditis

congenital

Connective tissue

carcinoid

trauma

murmur of pulmonary regurgitation

soft diastolic decrescendo

when does pulmonic regurgitation murmur increase

w/ inspiration

pulmonic regurgitation causes _

RV volume overload

pulmonic regurgitation might sound like or mimic _

aortic insufficiency

tricuspid regurgitation is usually secondary to _

RV dilation or pulmonary HTN

tricuspid regurgitation leads to

RV volume overload

clinical mainfestations of tricuspid regurgitation

neck vein distention, pulsatile liver

murmur of tricuspid regurgitation

holo-systolic murmur that increases with inspiration

management of tricuspid regurgitation

annuloplasty ring

mechanical valves require therapy with _

LIFELONG anticoagulation (warfarin)