Term
| which two valves have the most clinical importance? |
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Definition
| the mitral and aortic valves - to which either regurgitation (insufficiency) or stenosis may be a problem |
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Term
| what is tricuspid regurgitation usually associated with? |
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Definition
| infective endocarditis, IV drug use, and infection of the tricuspid valve |
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Term
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Definition
| how drs are introduced to pts, and why they come into the office initially |
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Term
| what are symptoms associated with valvular disease? |
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Definition
| shortness of breath, vertigo (arrhythmia), syncope, chest pain or RV strain, and infective endocarditis syndrome |
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Term
| can a pt with valvular disease be asymptomatic? |
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Definition
| yes, generally symptoms begin to arise when the pathology begins to progress. that said, pts w/severe aortic stenosis may be asymptomatic |
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Term
| how do you establish if a pt has SOB associated with valvular disease? |
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Definition
| ask a patient something within reasonable limits, such as asking, “do you get SOB while walking up one flight of stairs or while walking flat for 2 or 3 blocks?” |
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Term
| what are vertigo/arrhythmia/syncope symptoms of? |
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Definition
| this is a serious risk requiring that serious aortic stenosis be r/o, which carries a risk of sudden death b/c these pts are not getting enough perfusion to the brain |
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Term
| what are chest pain (AS) or RV strain associated with in terms of valvular disease? |
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Definition
| these are signs of coronary artery disease - generally telling us there is a disparity between flow and O2 consumption |
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Term
| what is infective endocarditis syndrome? |
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Definition
| pts w/this are septic, have emboli, and a murmur when listening to the tricuspid valve |
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Term
| what is a mid-systolic murmur? |
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Definition
| turbulence between the 1st and 2nd heart sounds that may have a crescendo and decrescendo (looks like a diamond). this is caused by mid systolic stenosis |
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Term
| what is a holo-systolic murmur? |
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Definition
| this or "pan systolic" murmurs continue through the entire systolic period and can be due to *mitral regurgitation, *tricuspid regurgitation or a congenital *ventricular septal defect |
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Term
| what are the next steps to be taken if a pt has a holosystolic murmur? |
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Definition
| palpate the carotids, feel the pulse at the first heart sound. |
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Term
| how would a holosystolic murmur manifest itself as a ventricular septal defect? |
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Definition
| if the murmur is felt throughout the chest and radiates in a spoke-like fashion, it is a ventricular septal defect. |
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Term
| how would a holosystolic murmur manifest itself as a mitral regurgitation? |
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Definition
| if it is only heard in the mitral areas (5th interspace, midclavicular line on L side of the heart) , it is a mitral regurgitation. |
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Term
| **how would a holosystolic murmur manifest itself as a tricuspid regurgitation? |
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Definition
| if the murmur is heard better on the R side of the sternum, it is a tricuspid regurgitation |
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Term
| how would a mid-systolic murmur manifest itself as a aortic or pulmonary stenosis? |
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Definition
| if the murmur is heard at the 2nd interspace on the R = aortic stenosis, if the murmur is heard at the 2nd interspace on the L = pulmonary stenosis |
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Term
| what is happening when a pt has mitral valve regurgitation? |
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Definition
| the mitral valve is not sealing correctly, and blood is flowing back into the L atrium during systole - this causes the audible holosystolic turbulence as well as a shortened systolic ejection fraction |
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Term
| what is an important determining factor w/mitral valve regurgitation? |
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Definition
| LA compliance. if a mitral valve regurgitation develops slowly over time, the LA gets bigger and pressure is dissipated = less symptoms. however, if something occurs abruptly to cause the regurgitation, such as a papillary muscle rupture due to an MI - the LA will be relatively tense/stiff and the backwash of the blood will be felt quickly - the pt will become SOB in a short period of time |
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Term
| what is the timing of sx w/mitral valve regurgitation dependent on? |
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Definition
| the end systolic volume and EF |
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Term
| with mitral valve regurgitation, can the 1st and 2nd heart sounds sometimes be drowned out? |
|
Definition
|
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Term
| what are 2 possible causes for mitral valve regurgitation? |
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Definition
| rheumatic fever, which can cause contraction and fibrosis, or mitral valve prolapse (MVP), which creates a redundant, fluffy valve (more tissue than necessary). MVPs are usually benign, congenital (genetic) issues accompanied by extra sounds - "clicks" of the excessive tissue whipping around (lufting) |
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Term
| how common is mitral valve prolapse (MVP)? what are common symptoms? |
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Definition
| this condition is congenital, seen in about 6% of females. most pts w/it are asymptomatic, though chest pain and clicks in systole may present |
|
|
Term
| what is a major concern for pts w/MVP? |
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Definition
| the extra tissue of the valve might become infected if the pt gets bacteremia - so endocarditis prophylaxis is useful |
|
|
Term
| how common is severe MVP? corrective sx? |
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Definition
|
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Term
| what are some possible causes of mitral regurgitation? |
|
Definition
| lupus (rare, associated with libman-sacks lesions), papillary muscle dysfunction due to an MI (may rupture acutely during an infarction) or due to chest trauma, and rheumatic fever |
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|
Term
| what are components of interdependent function that keep the mitral valve functional? |
|
Definition
| the papillary muscles and the chordae tendinae which they attach to the MV via |
|
|
Term
| what are etiologic events leading to chronic MV regurgitation? |
|
Definition
| mitral valve prolapse (congenital, myxomatous degeneration), CAD, L ventricular dilation (numerous causes), rheumatic feer, calcified mitral annulus, heritable disorders of connective tissue (marfan's, ehlers-danlos, osteogenesis imperfecta), papillary muscle dysfunction (infarction), and SLE |
|
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Term
| what are etiologic events leading to acute MV regurgitation? |
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Definition
| rupture of tendinous cords (myxoma, endocarditis, trauma), rupture of papillary muscles (infarction, trauma), perforation of leaflet (endocarditis) |
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|
Term
| **what are the 2 pathologies that can give you the biggest left ventricle? |
|
Definition
| mitral and aortic regurgitation |
|
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Term
| how is the volume in the ventricle affected by MV regurgitation? pressure? |
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Definition
| the volume of blood going into the ventricle is much higher, and the isovolumetric period cannot be maintained, leaking out volume until ejection into the aorta. the pressure is not changed significantly by this pathology. |
|
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Term
| what is MV stenosis caused by? is it common? what is the specific pathology? |
|
Definition
| MV stenosis is usually due to rheumatic fever, which is less common currently. the mitral valve is narrowed, the LA will not empty properly - increasing the pressure within it, which then increases pulmonary pressure -> SOB. the R side of the heart usually will fail eventually, and thus this problem needs to be fixed surgically |
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Term
| how does mitral valve stenosis present audibly? |
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Definition
| no murmur between the 1st and 2nd heart sounds, but an opening snap sound due to a calcified valve followed by a mid-diastolic murmur due to flow across the mitral valve |
|
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Term
| what are 2 problems that should be visible on a CXR due to mitral stenosis? |
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Definition
| the enlarged LA (*left atrium) 1) pushes into the esophagus and into the sternum and 2) the pressure eventually increases and is transmitted to the lungs |
|
|
Term
| what reduction of the aortic valve can still cause no symptoms or significant gradient? |
|
Definition
| a reduction of the valve area from 50% - normal (2.6-3.5 sq cm) |
|
|
Term
| how does the heart compensate for aortic stenosis? |
|
Definition
| the L ventricle continues to enlarge, which is initially OK, but becomes problematic as its O2 demand increases - this is when the pt begins to experience chest pain/arrhythmia/syncope |
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|
Term
| does CO always change with increasing gradients in aortic valve stenosis? at what valve areas is an increase in CO not seen w/exercise? |
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Definition
| no, due to increased LVH O2 requirements. at the critical valve areas of .5-.7 sq cm - there is no increase in CO w/exercise |
|
|
Term
| how does LVH affect LV compliance? |
|
Definition
|
|
Term
| when do symptoms occur w/aortic stenosis? |
|
Definition
| SOB occurs with an increase in LA and LV pressures |
|
|
Term
| what is the angina associated with aortic stenosis due to? |
|
Definition
| an increase in O2 consumption |
|
|
Term
| what can happen to the the intramyocardial small arteries with LVH? |
|
Definition
| systolic compression which can lead to ischemia and infarction |
|
|
Term
| what happens w/pts with a bicuspid aortic valve? |
|
Definition
| 1/3 will have mitral insufficiency, 1/3 will have aortic stenosis (eventually calcifies, thickens, and fibroses), and 1/3 will have both |
|
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Term
| what is the classic cath lab presentation for aortic stenosis? |
|
Definition
| the aortic pressure and LV pressure should match, but in the case of aortic stenosis - the LV pressure is extremely high |
|
|
Term
| what kind of murmur is associated with aortic stenosis? |
|
Definition
| mid-systolic or a diamond shaped murmur |
|
|
Term
| what valvular disease has the highest mortality rate if untreated? |
|
Definition
|
|
Term
| how will aortic regurgitation present audibly? what is happening? |
|
Definition
| as a high pitched early diastolic murmur. w/aortic regurgitation, the LV has ejected into the aorta, and the aortic valve should close - but if it doesn't, diastolic turbulence (unusual sound) arises from blood backing into the LV from the aorta |
|
|
Term
| how does the LV compensate for aortic regurgitation? |
|
Definition
| the LV will compensate well, keeping symptoms at a minimum - thus auscultation skills will be important b/c LA pressure does not increase until very late and neither does the lung pressure |
|
|
Term
| why are pts showing symptoms of aortic regurgitation usually at a severe risk? how is timing for sx determined? |
|
Definition
| there are usually no symptoms for years w/progressive LV dilation, sx needs to be timed according to the size of the ventricle and how well it contracts (use echo and physical exams) |
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|
Term
| **what 2 valvular diseases are the largest LVs due to? |
|
Definition
| aortic and mitral valve regurgitation |
|
|
Term
| what are some common causes of chronic aortic regurgitation? |
|
Definition
| rheumatic fever, syphilis, takayasu aortitis, heritable disorders of connective tissue (marfans, ehlers-danlos, osteogenesis imperfecta), congential heart disease (bicuspid aortic valve, interventricular septal defect, sinus of valsalva aneurysms), arthritis disease (ankylosing spondylitis, reiters syndrome, reumatoid arthritis, lupus erythematosus), aortic root disease, aorticoannuloectasia, cystic medial necrosis of the aorta, HTN, arteriosclerosis, myxmatous degeneration of the valve, infectious endocarditis, prosthetic valve sx, association w/aortic stenosis |
|
|
Term
| what are some common causes of acute aortic regurgitation? |
|
Definition
| rheumatic fever, infective endocarditis, congenital (rupture of sinus valsalva), acute aortic dissection, following prosthetic valve sx, trauma |
|
|
Term
| what is a consequence of the fact that aortic regurgitation is so well adapted by the LV? |
|
Definition
| the CO may increase to as high as 30L/min (due to increased LV volume) and some pts may live as long as 15 yrs w/out significant AR due to slow progression |
|
|
Term
| what happens in aortic regurgitation failure? |
|
Definition
| the ventricle becomes too large, fibrotic, stops contracting well due to myocyte disruption and the EF drops, which causes the EDV to drop |
|
|
Term
| how will aortic regurgitation sound? |
|
Definition
| 1st, 2nd heart sound followed by a very high pitched decrescendo murmur (goes down in intensity) |
|
|
Term
| how will a tricuspid valve affected by endocarditis appear? what might this be due to? |
|
Definition
| possibly ruptured, vegetations. this can be due to injection of dirty material into the veins - it will seed on the R side of the heart |
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|
Term
| how does infective carditis present? how is it treated? |
|
Definition
| the pt will come in febrile, w/petechiae and signs of emboli on the fingertips. it is treated with long term antibx |
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|
Term
| can pts live w/o a tricuspid valve? |
|
Definition
| yes, but prosthetic valves are sometimes installed |
|
|
Term
| what is the pressure volume loop of mitral valve regurgitation marked by? |
|
Definition
| no isovolumetric period, large volume (blood is ejected in 2 directions) |
|
|
Term
| what is the pressure volume loop of aortic valve regurgitation marked by? |
|
Definition
| there is only a slightly higher end volume |
|
|
Term
| what is the pressure volume loop of aortic valve stenosis marked by? |
|
Definition
| this will produce the highest pressure, even diastolic |
|
|
Term
| what is the pressure volume loop of mitral valve stenosis marked by? |
|
Definition
| the L ventricle is least affected by this valvular disease, the pressures and volumes are not high |
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