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Heart Valve Disorders

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by

Joseph Reed

on 27 July 2015

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Transcript of Heart Valve Disorders

Joseph Reed PA-C
Valve Disorders
photo (cc) Malte Sörensen @ flickr
Aortic Stenosis
Aortic Insufficiency
Mitral Stenosis
Mitral Insufficiency
Mitral Valve Prolapse
Tricuspid Stenosis
Tricuspid Insufficiency
Pulmonic Stenosis
Pulmonic Insufficiency
Topics
Narrowing of the aortic valve
Doesn't open fully
Obstructs blood from heart to the aorta
Heart has to pump harder against pressure
Aortic Stenosis
Mitral Stenosis
AKA Aortic Regurgitation
Inadequate closure of the aortic valve leaflets
Aortic Insufficiency
3 main causes:

1-Congenital deformity
biscupid valve (normally tricuspid)

2-Calcific disease
degenerative process
especially elderly patients

3-Rheumatic disease
rheumatic fever complication
after streptococcal infection
Common Clinical Sx:
Heart Failure
Syncope or dizziness
Chest pain
SOB/Dyspnea
Dec. exercise tolerance
Physical Exam:
-Murmur common at 2nd R ICS
-Systolic murmur, "harsh"
-Often radiates to carotid arteries
-Reduced or absent 2nd heart sound
-Split 2nd heart sound
-Diminished, late carotid pulsation (pulsus parvus et tardus)
Treatment
Generally, if good surgical candidate and symptomatic: get valve replacement or
Balloon valvulopasty
Diagnostics
Ecchocardiogram
Cardiac cath
CXR
+/-cardiomegaly
EKG- dysrhythmia
Symptoms
Palpitations- worse lying on left side or flat
Chest pain
Uncomfortable awareness of heart beating
Sx of Left HF:
Orthopnea
DOE
Edema
PND
Physical Exam
Wide pulse pressure
High systolic, reduced diastolic
ex, 180/45
High pitched, diastolic murmur
accentuated by: squatting, lean forward, hold breath
Heard best at the base (top) of heart
"Blowing" murmur
Quincke's pulse- pulsating nailbeds
Water-Hammer pulse- big radial pulses
deMusset's sign- head bob with each contraction
Diagnostics
Ecchocardiogram most common test ordered for confirmation
CXR: ? cardiomegaly
Cardiac cath
EKG: ?LVH
Treatment
When symptomatic or severe asymptomatic disease, surgery often advised
Valvuloplasty- repair of valve

Replacement- tissue valve or mechanical
Obstruction of flow from L atrium to L vent.
Thickening, immobility of mitral leaflets
Inc. pressure in L atrium
Fluid backs up to pulmonary vasculature
Causes
Rheumatic fever
Congenital
F:M 3:1
Many times unmasked during pregnancy
Symptoms
DOE
PND
Orthopnea
Angina
Hemoptysois (pulm edema)
Hoarseness- comp. laryngeal nerve
Afibb
Physical Exam
Low pitched diastolic murmur
"Rumbling"
Opening snap
Heard best at apex (bottom)
May radiate to the axilla
JVD
Edema
Afibb
Diagnostics
Ecchocardiogram
CXR: atrial enlargement, pulmonary edema
EKG: atrial enlargement, afibb
Cardiac catheterization
Treatment
Treat afibb
digitalis
anticoagulation
Valvuloplasty
Valve replacement
Mitral Insufficiency
Mitral Valve Prolapse
Tricuspid Stenosis
Tricuspid Insufficiency
Pulmonic Stenosis
Pulmonic Insufficiency
Incomplete closure of valve
Regurgitation of blood back into L atrium
Incomplete closure of valve
Valve bulges (prolapses) back into atrium
Narrowing through the tricuspid valve
Incomplete closure
Leakage back into R atrium

Restriction through pulmonic valve to
pulmonary arterial vasculature
Retrograde flow from pulmonary artery through valve into R ventricle
Etiologies
Acute:
Infective endocarditis
Chordae tendinae rupture
Paipllary muscle ischemia/infarction
Chronic:
Rheumatic fever
Congenital
Mitral Valve Prolapse
Caclcification
Clinical Presenation
Generally, best tolerated valve lesion
Dyspnea
Fatigue
SOB
PND
Afibb occasionally seen
Pulm. HTN
Pulm. Edema
Physical Exam
Systolic, blowing murmur
Best heard at apex
Radiation to axilla
Diagnostics
Ecchocardiogram
CXR- atrial enlargement
EKG-arrhythmia
Cardiac cath
Treatment
Asymptomatic
generally observed
? yearly eccho
treat afibb
treat HF
Symptomatic
valvuloplaty
replacement
Etiology
Not well understood

Myxomatous changes- pathological weakening of connective tissues

Congenital

Marfan Syndrome
Think of it as a "floppy" valve
Clinical Presentation
Dizziness
SOB
Fatigue
Arrhythmia
Dizziness
Chest pain
Palpitations
Physical Exam
Classic finding:
"mid systolic click"
Diagnostics
Ecchocardiogram
EKG
Cardiac cath
Treatment
Asymptomatic
generally not treated
Anti arrhythmics
Beta blockers for palpitations

Symptomatic
valvuloplasty
valve replacement
Causes
Uncommon disorder
Thought to be mostly a rheumatic disorder
connective tissue problem
Can also be:
congenital
endocarditis
tumor obstruction
Clinical Presentation
Fatigue
Dyspnea
Fluttering
Abdominal pain
hepatic congestion
Physical Examination
Similar to Mitral stenosis
Often coexists with MS
JVD
Hepatomegaly
Ascites
Edema
Low frequency diastolic murmur
Left lower sternal border
Similar "snap" as w/ MS
Diagnosis
Ecchocardiogram
CXR
EKG
Cardiac cath
Treatment
Monitor sx
Valve repair
Replacement
Treatment
Monitoring
Repair
Replacement
Etiology
Relatively common
70% healthy adults will have small degree
Congenital
Endocarditis
Marfan Syndrome- connective tissue disorder
Rheumatic fever
Chest trauma
Endocarditis
Clinical Presentation
Most often asymptomatic
Sensation of pulsation in neck
Hepatomegaly
Ascites
Edema
Physical Examination
Edema
JVD
Hepatomegaly
Systolic murmur
Heard best left sternal border
Diagnostics
Ecchocardiogram
EKG
CXR
Cath
Take Home:
Careful auscultation reveals "murmur:"
Note systolic, diastolic, holosystolic
Location best heard
Accentuating maneuvers- inspiration, squatting, valsalva, standing
Grade
Radiation
Note pertinent ROS, assoc. PE findings
Order Eccho, EKG, CXR for baseline
Consider cardiology referral

Diagnostics
Ecchocardiogram
CXR
EKG
Cath
Diagnostics
Ecchocardiogram
CXR
EKG
Cardiac cath
Treatment
Physical Examination
Clinical Presentation
Etiology
Treatment
Physical Examination
Clinical Presentation
Etiology
Most often congenital
Part of the Tetrology of Fallot syndrome
often asymptomatic in childhood
With aging:
calcification and thickening of the valve cause symptoms:
chest pain
exertional dyspnea
fatigue
syncope
HF
JVD, usually mild
Systolic murmur, left upper sternal border
May radiate to neck
Split 2nd heart sound
Cyanosis, severe cases
HF
edema
Observation in asymptomatic
Valvuloplasty or replacement w/ symptoms
Most commonly congenital
Endocarditis
Post tetrology of fallot complication
Pulmonary HTN
COPD
other lung disease
Asymptomatic in most cases
Decreased exercise tolerance
Fatigue
Graham Steell murmur
high pitched diastolic murmur
best heard 2nd L intercostal space

Low pitched diastolic murmur also seen
Progressive, severe, symptomatic disease may require valve repair/replacement
Full transcript