© Continuing Medical Implementation …...bridging the care gap Valvular Heart Disease Tulika Jain,...

© Continuing Medical Implementation …...bridging the care gap

Valvular Heart Valvular Heart DiseaseDisease

Tulika Jain, MDTulika Jain, MDResident Teaching Resident Teaching ConferenceConferenceDecember 5, 2008December 5, 2008

AuscultationAuscultation Use the diaphragm for high pitched sounds and Use the diaphragm for high pitched sounds and

murmursmurmurs Use the bell for low pitched sounds and Use the bell for low pitched sounds and

murmurs (diastolic rumble)murmurs (diastolic rumble) Sequence of auscultation Sequence of auscultation

– upper right sternal border (URSB)upper right sternal border (URSB)– upper left sternal border (ULSB) upper left sternal border (ULSB) – lower left sternal border (LLSB)lower left sternal border (LLSB)– apexapex– apex - left lateral decubitus positionapex - left lateral decubitus position– lower left sternal border (LLSB)- sitting, leaning lower left sternal border (LLSB)- sitting, leaning

forward, held expirationforward, held expiration

Innocent MurmursInnocent MurmursCommon in asymptomatic Common in asymptomatic adultsadults

Characterized byCharacterized by– Grade I – II @ LSBGrade I – II @ LSB– Systolic ejection pattern - no Systolic ejection pattern - no with Valsalva with Valsalva

– Normal precordium, apex, S1

– Normal intensity & splitting of second sound (S2)

– No other abnormal sounds or murmurs

– No evidence of LVH

S1 S2

Characteristic of the Characteristic of the NOT NOT Innocent MurmurInnocent Murmur Diastolic murmurDiastolic murmur Loud murmur - grade III or aboveLoud murmur - grade III or above Regurgitant murmurRegurgitant murmur Murmurs associated with a clickMurmurs associated with a click Murmurs associated with other Murmurs associated with other

signs or symptoms e.g. cyanosissigns or symptoms e.g. cyanosis Abnormal 2Abnormal 2ndnd heart sound – fixed heart sound – fixed

split, paradoxical split or singlesplit, paradoxical split or single

Heart Sounds PearlsHeart Sounds Pearls

Right sided valves open earlier and Right sided valves open earlier and close last due to lower pressure close last due to lower pressure gradient gradient

All right sided murmur and sounds All right sided murmur and sounds tend to augment with inspiration: tend to augment with inspiration: EXCEPTION: PULMONIC STENOSIS EXCEPTION: PULMONIC STENOSIS click DECREASES WITH INSPIRATIONclick DECREASES WITH INSPIRATION

Valsalva releases increases murmur Valsalva releases increases murmur of HOCM and MVPof HOCM and MVP

Heart Sounds: ClicksHeart Sounds: Clicks

Valve DisordersValve Disorders

EtiologyEtiology SymptomsSymptoms Physical ExamPhysical Exam TestingTesting SeveritySeverity Indications for SurgeryIndications for Surgery

Common Clinical Common Clinical ScenariosScenarios Younger Younger

peoplepeople– Functional Functional

murmur vs murmur vs MVP vs MVP vs bicuspid AVbicuspid AV

Older peopleOlder people– Aortic sclerosis Aortic sclerosis

vs aortic vs aortic stenosisstenosis

Aortic Stenosis - Aortic Stenosis - EtiologyEtiology Young patient think Young patient think

congenitalcongenital– Bicuspid AVDBicuspid AVD

2% population2% population 3:1 3:1

male:female male:female distributiondistribution

Co-existing Co-existing coarctation 6% coarctation 6% of patientsof patients

RarelyRarely– Unicuspid valveUnicuspid valve– Sub-aortic stenosisSub-aortic stenosis

DiscreteDiscrete Diffuse (Tunnel)Diffuse (Tunnel)

Middle aged Middle aged patient(4&5patient(4&5thth decades) decades) think bicuspid or think bicuspid or rheumatic diseaserheumatic disease

Old patient think Old patient think degenerative (6,7,8degenerative (6,7,8thth decades)decades)

Aortic Stenosis: Aortic Stenosis: EtiologyEtiology Valvular Valvular SubvalvularSubvalvular SupravalvularSupravalvular

Supravalvular Aortic Supravalvular Aortic StenosisStenosis

Aortic Stenosis: Aortic Stenosis: SymptomsSymptoms Cardinal SymptomsCardinal Symptoms

– Chest pain (angina)Chest pain (angina) Reduced coronary flow reserveReduced coronary flow reserve Increased demand-high afterloadIncreased demand-high afterload

– Syncope (exertional pre-syncope)Syncope (exertional pre-syncope) Fixed cardiac outputFixed cardiac output Vasodepressor responseVasodepressor response

– Dyspnea on exertion & restDyspnea on exertion & rest Other signs of LV failure Other signs of LV failure

– Diastolic & systolic dysfunctionDiastolic & systolic dysfunction

Severity of StenosisSeverity of Stenosis

Normal aortic valve area 2.5-3.5 Normal aortic valve area 2.5-3.5 cmcm22

Mild stenosis 1.5-2.5 cmMild stenosis 1.5-2.5 cm22

Moderate stenosis 1.0-1.5 cmModerate stenosis 1.0-1.5 cm22

Severe stenosis < 1.0 cmSevere stenosis < 1.0 cm22

Onset of symptomsOnset of symptoms~0.9 cm0.9 cm22 with CAD with CAD~0.7 cm0.7 cm22 without CAD without CAD

Aortic Stenosis: Aortic Stenosis: Physical FindingsPhysical Findings

Intensity DOES NOT predict severityIntensity DOES NOT predict severity Presence of thrill DOES NOT predict Presence of thrill DOES NOT predict

severityseverity ““DiamondDiamond” shaped, systolic crescendo-” shaped, systolic crescendo-

decrescendo decrescendo Decreased, delay & prolongation of pulse Decreased, delay & prolongation of pulse

amplitude: “pulsus parvus and tardus”amplitude: “pulsus parvus and tardus” Paradoxical S2 Paradoxical S2 S4 (with left ventricular hypertrophy)S4 (with left ventricular hypertrophy) S3 (with left ventricular failure)S3 (with left ventricular failure)

Aortic Stenosis: Aortic Stenosis: Physical FindingsPhysical Findings

S1 S2 S1 S2

Mild-Moderate Severe

Wave Sound

Heart Sounds: Heart Sounds: SplittingSplitting

AS

Aortic Stenosis : Lab Aortic Stenosis : Lab

EKG: LVHEKG: LVH CXR: Intially have concentric LVH CXR: Intially have concentric LVH

so unremarkable; Critical AS may so unremarkable; Critical AS may show post stenotic dilation of the show post stenotic dilation of the aorta, hypertrophy, congestionaorta, hypertrophy, congestion

CXR: AS with Post CXR: AS with Post Stenotic Dilatation of Stenotic Dilatation of AortaAorta

Aortic Stenosis: Aortic Stenosis: TreatmentTreatment

Indications for surgery:Indications for surgery: Symptomatic Symptomatic Asymptomatic but EF < 50%Asymptomatic but EF < 50% Poor performance on ETTPoor performance on ETT Reasonable if asymptomatic true Reasonable if asymptomatic true

AS and operative mortality is lowAS and operative mortality is low If low output, low gradient AS then If low output, low gradient AS then

need dobutamine stress echoneed dobutamine stress echo

Aortic Stenosis: Aortic Stenosis: TreatmentTreatment Aortic stenosis is a surgical Aortic stenosis is a surgical

diseasedisease Treatment is valve replacementTreatment is valve replacement Aortic valve balloon valvuloplasty Aortic valve balloon valvuloplasty

rarely done due to stroke risk and rarely done due to stroke risk and other complicationsother complications

Current trials using catheter based Current trials using catheter based aortic valve replacementaortic valve replacement

Aortic Regurgitation:Aortic Regurgitation:EtiologyEtiology Any conditions Any conditions

resulting in resulting in incompetent aortic incompetent aortic leafletsleaflets

CongenitalCongenital– Bicuspid valveBicuspid valve

AortopathyAortopathy– Cystic medial necrosisCystic medial necrosis– Collagen disorders (e.g. Collagen disorders (e.g.

Marfan’s)Marfan’s)– Ehler-DanlosEhler-Danlos– Osteogenesis imperfectaOsteogenesis imperfecta– Pseudoxanthoma Pseudoxanthoma

elasticumelasticum

AcquiredAcquired– Rheumatic heart diseaseRheumatic heart disease– Dilated aorta (e.g. Dilated aorta (e.g.

hypertension..)hypertension..)– DegenerativeDegenerative– Connective tissue Connective tissue

disorders disorders E.g. ankylosing E.g. ankylosing

spondylitis, rheumatoid spondylitis, rheumatoid arthritis, Reiter’s arthritis, Reiter’s syndrome, Giant-cell syndrome, Giant-cell arteritis )arteritis )

– Syphilis (chronic aortitis)Syphilis (chronic aortitis) Acute AI: aortic Acute AI: aortic

dissection, infective dissection, infective endocarditis, traumaendocarditis, trauma

Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND With extreme reductions in diastolic With extreme reductions in diastolic

pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina

Aortic Regurgitation:Aortic Regurgitation: Physical Exam Physical Exam Widened pulse pressureWidened pulse pressure

– Systolic – diastolic Systolic – diastolic = pulse pressure= pulse pressure

High pitched, High pitched, blowing, blowing, decrescendo diastolic decrescendo diastolic murmurmurmur at LSB at LSB

Best heard at Best heard at end-end-expiration & leaning expiration & leaning forwardforward

Hands & Knee positionHands & Knee positionS1 S2 S1

Wave Sound

Peripheral Signs of Peripheral Signs of Severe Severe Aortic RegurgitationAortic Regurgitation Quincke’s sign: Quincke’s sign:

capillary pulsationcapillary pulsation Corrigan’s sign: water Corrigan’s sign: water

hammer pulsehammer pulse Bisferiens pulse Bisferiens pulse

(AS/AR > AR) (AS/AR > AR) De Musset’s sign: De Musset’s sign:

systolic head bobbing systolic head bobbing Mueller’s sign: systolic Mueller’s sign: systolic

pulsation of uvulapulsation of uvula

Durosier’s sign: Durosier’s sign: femoral retrograde femoral retrograde bruits (bell)bruits (bell)

Traube’s sign: pistol Traube’s sign: pistol shot femoralsshot femorals

Hill’s sign:BP Lower Hill’s sign:BP Lower extremity >BP Upper extremity >BP Upper extremity by extremity by – > 20 mm Hg - mild AR> 20 mm Hg - mild AR– > 40 mm Hg – mod AR> 40 mm Hg – mod AR– > 60 mm Hg – severe > 60 mm Hg – severe

ARAR

Wave Sound

Central Signs of Central Signs of Severe Severe Aortic RegurgitationAortic Regurgitation Apex:Apex:

– EnlargedEnlarged– DisplacedDisplaced– Hyper-dynamicHyper-dynamic– Palpable S3 Palpable S3 – Austin-Flint Austin-Flint

murmurmurmur

Aortic diastolic Aortic diastolic murmurmurmur– length correlates length correlates

with severity with severity (chronic AR)(chronic AR)

– in acute AR in acute AR murmur shortens murmur shortens as Aortic as Aortic DP=LVEDPDP=LVEDP

– in acute AR - mitral in acute AR - mitral pre-closurepre-closure

Assessing Severity Assessing Severity of ARof AR

Assess severity by impact on Assess severity by impact on peripheral signs and LVperipheral signs and LV peripheral signs = peripheral signs = severity severity LV = LV = severity severity– S3S3– Austin -FlintAustin -Flint– LVHLVH– radiological cardiomegalyradiological cardiomegaly

Aortic RegurgitationAortic Regurgitation

Aortic Regurgitation:Aortic Regurgitation: Natural History Natural History

AsymptomaticAsymptomatic %/Y %/Y Normal LV function (~good prognosis)Normal LV function (~good prognosis)

– Progression to symptoms or LV dysfunction < 6Progression to symptoms or LV dysfunction < 6– Progression to asymptomatic LV dysfunction < 3.5Progression to asymptomatic LV dysfunction < 3.5– 75% 5-year survival75% 5-year survival– Sudden deathSudden death < 0.2 < 0.2

Abnormal LV functionAbnormal LV function– Progression to cardiac symptomsProgression to cardiac symptoms 25 25

Symptomatic (Poor prognosis)Symptomatic (Poor prognosis)– Mortality Mortality > 10 > 10

Bonow RO, et al, JACC. 1998;32:1486.

Aortic Regurgitation:Aortic Regurgitation: Treatment Treatment

Before development of heart failure, AI can be treated with vasodilators (ACE Inhibitors), diuretics, salt restriction

Goal: Surgery BEFORE LV dysfunction !!!!

“Rule of 55”

Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic AorticAortic & Mitral Regurgitation & Mitral Regurgitation

Type of Type of RegurgitationRegurgitation

LVESD mmLVESD mm EF %EF %

Aortic Aortic > 55> 55 < 55< 55

MitralMitral > 40> 40 < 60< 60

A 75 year old woman A 75 year old woman with Recent with Recent orthopnea/PNDorthopnea/PND

Chronic dyspnea Chronic dyspnea Class 2/4Class 2/4

FatigueFatigue Recent Recent

orthopnea/PNDorthopnea/PND Nocturnal Nocturnal

palpitationpalpitation Pedal edemaPedal edema

Mitral Stenosis: Mitral Stenosis: EtiologyEtiology

#1 Rheumatic#1 Rheumatic



#2 ?#2 ?




#3 Rheumatic . . .#3 Rheumatic . . .

#99 ?#99 ?


#1 Rheumatic#1 Rheumatic#2 Rheumatic#2 Rheumatic#3 Rheumatic#3 Rheumatic#99 Rheumatic#99 Rheumatic#100 ?#100 ?


#1 Rheumatic#1 Rheumatic#2 Rheumatic#2 Rheumatic#3 Rheumatic#3 Rheumatic#99 Rheumatic#99 Rheumatic#100 Congenital, #100 Congenital,

endocarditis, Carcinoid, endocarditis, Carcinoid, Fabray, Hurler, Whipple, Fabray, Hurler, Whipple, Atrial MyxomaAtrial Myxoma

Mitral Stenosis Mitral Stenosis EtiologyEtiology Primarily a result of rheumatic feverPrimarily a result of rheumatic fever

– ~ 99% of MV’s @ surgery show ~ 99% of MV’s @ surgery show rheumatic damage)rheumatic damage)

Scarring & fusion of valve apparatusScarring & fusion of valve apparatus Rarely congenitalRarely congenital Pure or predominant MS occurs in Pure or predominant MS occurs in

approximately 40% of all patients with approximately 40% of all patients with rheumatic heart diseaserheumatic heart disease

Two-thirds of all patients with MS are Two-thirds of all patients with MS are female.female.

Mitral Stenosis Mitral Stenosis PathophysiologyPathophysiology

Normal valve area: 4-6 cmNormal valve area: 4-6 cm22

Mild mitral stenosis: Mild mitral stenosis: – MVA 1.5-2.5 cmMVA 1.5-2.5 cm22

– Minimal symptomsMinimal symptoms Mod mitral stenosisMod mitral stenosis

– MVA 1.0-1.5 cmMVA 1.0-1.5 cm2 2 usually does not produce usually does not produce symptoms at restsymptoms at rest

Severe mitral stenosisSevere mitral stenosis– MVA < 1.0 cm2MVA < 1.0 cm2

Right Heart Right Heart Failure:Failure:

Hepatic Hepatic CongestionCongestion

JVDJVD

Tricuspid Tricuspid RegurgitationRegurgitation

RA EnlargementRA Enlargement

Pulmonary HTNPulmonary HTN

Pulmonary Pulmonary CongestionCongestion

LA EnlargementLA Enlargement

Atrial FibAtrial Fib

LA ThrombiLA Thrombi

LA PressureLA Pressure

RV Pressure RV Pressure OverloadOverload

RVHRVH

RV FailureRV Failure LV FillingLV Filling

Mitral Valve Stenosis Mitral Valve Stenosis PathophysiologyPathophysiology

Mitral Stenosis: Mitral Stenosis: SymptomsSymptoms Dyspnea, PND, orthopneaDyspnea, PND, orthopnea

– Slow progressive courseSlow progressive course– May not admit to symptomsMay not admit to symptoms

HemoptysisHemoptysis PalpitationsPalpitations EmboliEmboli

Mitral Stenosis Mitral Stenosis ExaminationExamination

Mitral Stenosis Mitral Stenosis Physical ExamPhysical Exam

First heart sound (S1) is accentuated and snappingFirst heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closureOpening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apexLow pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm)Pre-systolic accentuation (esp. if in sinus rhythm)

S1 S2 OS S1

Auscultation-Timing of Auscultation-Timing of A2 to OS IntervalA2 to OS Interval

Width of A2-OS Width of A2-OS inversely correlates inversely correlates with severitywith severity

The more severe the The more severe the MS the higher the LAP MS the higher the LAP the earlier the LV the earlier the LV pressure falls below pressure falls below LAP and the MV LAP and the MV opensopens

Shorter A2-OS=more Shorter A2-OS=more severe mitral stenosissevere mitral stenosis

Mitral Stenosis: ECGMitral Stenosis: ECG

LAELAE With pulm HTN: RAD, RVHWith pulm HTN: RAD, RVH AFIBAFIB

Mitral Stenosis: CXRMitral Stenosis: CXR

Mitral Stenosis: Mitral Stenosis: TreatmentTreatment

An 80 year old woman An 80 year old woman with increasing with increasing dyspneadyspnea Longstanding Longstanding

heart murmurheart murmur Increasing Increasing

dyspnea & dyspnea & fatiguefatigue

Recent ER visit Recent ER visit Dx CHFDx CHF

Mitral Regurgitation:Mitral Regurgitation:EtiologyEtiology

Valvular-leafletsValvular-leaflets– Myxomatous MV Myxomatous MV

DiseaseDisease– RheumaticRheumatic– EndocarditisEndocarditis– Congenital-cleftsCongenital-clefts

ChordaeChordae– Fused/inflammatoryFused/inflammatory– Torn/tTorn/traumarauma– DegenerativeDegenerative– IEIE

AnnulusAnnulus– Calcification, Calcification, IE (abcess)IE (abcess)

Papillary MusclesPapillary Muscles– CAD (Ischemia, CAD (Ischemia,

Infarction, Rupture)Infarction, Rupture)– HCMHCM– Infiltrative disordersInfiltrative disorders

LV dilatation & LV dilatation & functional functional regurgitationregurgitation

TraumaTrauma

MR Etiology:Surgical MR Etiology:Surgical series series MVP(20-70%)MVP(20-70%) Ischemia (13-40%)Ischemia (13-40%) RHD (3-40%)RHD (3-40%) Infectious endocarditis(10-12%)Infectious endocarditis(10-12%)

MR PathophysiologyMR Pathophysiology

Chronic LV volume overload -» Chronic LV volume overload -» compensatory LVE initially compensatory LVE initially maintaining cardiac outputmaintaining cardiac output

Decompensation (increased LV wall Decompensation (increased LV wall tension) -»CHFtension) -»CHF

LVE – » annulus dilation – » increased LVE – » annulus dilation – » increased MRMR

Backflow – » LAE, Afib, Pulmonary HTNBackflow – » LAE, Afib, Pulmonary HTN

MRMR SymptomsSymptoms

Similar to MSSimilar to MS Dyspnea, Orthopnea, PNDDyspnea, Orthopnea, PND FatigueFatigue Pulmonary HTN, right sided Pulmonary HTN, right sided

failurefailure HemoptysisHemoptysis Systemic embolization in A FibSystemic embolization in A Fib

Recognizing ChronicRecognizing ChronicMitral RegurgitationMitral Regurgitation

Pulse:Pulse:– brisk, low volumebrisk, low volume

Apex:Apex:– hyperdynamichyperdynamic– laterally displacedlaterally displaced– palpable S3 +/- thrillpalpable S3 +/- thrill– late parasternal lift 2late parasternal lift 2

to LA fillingto LA filling S 1 soft or normalS 1 soft or normal S 2 wide split (early S 2 wide split (early

A2) unless LBBBA2) unless LBBB

Murmur-Fixed MR:Murmur-Fixed MR:– pansystolicpansystolic– loudest apex to axillaloudest apex to axilla– no post extra-systolic no post extra-systolic

accentuationaccentuation Murmur-Dynamic Murmur-Dynamic

MR(MVP)MR(MVP)– mid systolicmid systolic– +/- click+/- click uprightupright

S 3 / flow rumble if S 3 / flow rumble if severesevere

Wave Sound

Recognizing Acute Recognizing Acute SevereSevereMitral RegurgitationMitral Regurgitation Acute severe dyspnea, Acute severe dyspnea,

CHF & hypotensionCHF & hypotension LV size normalLV size normal LV may/may not be LV may/may not be

hyperdynamichyperdynamic Loud S1Loud S1 Systolic murmur Systolic murmur

may/may not be pan-may/may not be pan-systolicsystolic

Inflow/rumbleInflow/rumble S3 present-may be S3 present-may be

only abnormalityonly abnormality

RV liftRV lift TTE/TEE for diagnosisTTE/TEE for diagnosis

– Chordal or papilllary Chordal or papilllary muscle rupture/tearmuscle rupture/tear

– Infarction with Infarction with papillary muscle papillary muscle ischaemia or tearischaemia or tear

– Infectious Infectious endocarditis with endocarditis with leaflet perforation or leaflet perforation or disruption or chordal disruption or chordal teartear

– Flail MV segmentFlail MV segment

Recognizing Mitral Recognizing Mitral RegurgitationRegurgitation

ECG:ECG:– LA enlargementLA enlargement– AfibAfib– LVH (50% pts. LVH (50% pts.

With severe MR)With severe MR)– RVH (15%)RVH (15%)– Combined Combined

hypertrophy hypertrophy (5%)(5%)

CXR:CXR: LVLV LALA pulmonary pulmonary

vascularityvascularity– CHFCHF– Ca++ MV/MACCa++ MV/MAC

Mitral RegurgitationMitral Regurgitation

CXR: MS vs MRCXR: MS vs MR

CXR: Mitral stenosis CXR: Mitral stenosis with MR and TRwith MR and TR

Chronic MR Chronic MR EchocardiographyEchocardiography Baseline evaluation to identify Baseline evaluation to identify

etiology, quantify severity of MRetiology, quantify severity of MR Assess and quantify LV function and Assess and quantify LV function and

dimensionsdimensions Annual or semi-annual surveillance of Annual or semi-annual surveillance of

LV function, estimated EF and LVESD LV function, estimated EF and LVESD in asymptomatic severe MRin asymptomatic severe MR

To establish cardiac status after To establish cardiac status after change in symptomschange in symptoms

Baseline study post MVR or repair Baseline study post MVR or repair

Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic AorticAortic & & Mitral RegurgitationMitral Regurgitation

Type of Type of RegurgitationRegurgitation

LVESD mmLVESD mm EF %EF %

Aortic Aortic > 55> 55 < 55< 55

MitralMitral > 40> 40 < 60< 60

Mitral Valve Prolapse: Mitral Valve Prolapse: EpidemiologyEpidemiology Affects 5-10% of population Affects 5-10% of population Most common cause of isolated severe MR Most common cause of isolated severe MR Females >> males; Ages of 14 and 30years Females >> males; Ages of 14 and 30years Strong hereditary component (? autosomal Strong hereditary component (? autosomal

dominant)dominant) 22ºº to failure of apposition/coaptation of the to failure of apposition/coaptation of the

anterior and posterior mitral valve leaflets.anterior and posterior mitral valve leaflets. Results form diverse pathologic conditions, Results form diverse pathologic conditions,

but cause is unknown in a majority of ptsbut cause is unknown in a majority of pts

Mitral Valve Prolapse: Mitral Valve Prolapse: SymptomsSymptoms Majority are asymptomatic for Majority are asymptomatic for

entire lifeentire life PalpitationsPalpitations Chest pain (atypical).Chest pain (atypical).

– Often substernal, prolonged, poorly Often substernal, prolonged, poorly related to exertion, and rarely related to exertion, and rarely resembles typical anginaresembles typical angina

SyncopeSyncope

Fixed mitral regurgitationFixed mitral regurgitation

Mitral valve prolapseMitral valve prolapse

Mitral Insufficiency:Mitral Insufficiency: Physical Exam Physical Exam

S1 S2 S1

S1 C S2

Wave Sound

Wave Sound

MVP Physical Exam:MVP Physical Exam:Click MurmurClick Murmur

Standing broadens murmur

Squatting squishes murmur

Mitral Valve Prolapse: Mitral Valve Prolapse: ComplicationsComplications Arrhythmias (Usually PVC, Arrhythmias (Usually PVC,

PSVT>>VT)PSVT>>VT) Transient cerebral ischemic Transient cerebral ischemic

(embolic – rare)(embolic – rare) Infective endocarditis (if assoc w/ Infective endocarditis (if assoc w/

MR)MR) Sudden death (rare)Sudden death (rare)

MVP TreatmentMVP Treatment

Watch for mitral regurgitationWatch for mitral regurgitation As with MR, surgery when As with MR, surgery when

LVESD>40 mm or EF <60%.LVESD>40 mm or EF <60%.

Recognizing AorticRecognizing Aortic Stenosis Stenosis

Sign Correlation with Severity

JVP-prominent A wave No Carotid-delayed, anacrotic Yes A2 audible over carotids Mean AV gradient 50 mm Hg and stenosis not

severe i.e. AVA > 1.0 cm2 Apex- sustained, atrial kick - enlarged, displaced

Yes Yes

Thrill No Cardiomegaly- Clinical/CXR Yes Soft S1 Yes Paradoxical S2 Yes S3, S4 Yes SEM- intensity - late peak

No Yes

ECG- LAE, LVH Yes

Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic Aortic & Mitral RegurgitationAortic & Mitral Regurgitation

Type of Type of RegurgitatioRegurgitatio

nn

LVESD LVESD mmmm

EF EF %%

FSFS

Aortic Aortic > 55> 55 < 55< 55 < 0.27< 0.27

MitralMitral > 45> 45 < 60< 60 < 0.32< 0.32

Auscultation-Timing of Auscultation-Timing of A2 to OS IntervalA2 to OS Interval

Width of A2-OS Width of A2-OS inversely inversely correlates with correlates with severityseverity

The more severe The more severe the MS the higher the MS the higher the LAP the earlier the LAP the earlier the LV pressure the LV pressure falls below LAP and falls below LAP and the MV opensthe MV opens

Say Timing seconds

Severity of MS

Other HS’s

Prrr 0.06 Severe

Pada .07-.08 Mod-severe

Pata .08-.09 Mod

Papa 0.10 Mild PK 0.1-0.110

Tu-huh

.12 A2-S3 0.12-0.18

Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic Aortic & Mitral RegurgitationAortic & Mitral Regurgitation

Type of Type of RegurgitatiRegurgitati

onon

LVESD LVESD mmmm

EF EF %%

FSFS

Aortic Aortic > 55> 55 < 55< 55 < 0.27< 0.27

MitralMitral > 45> 45 < 60< 60 < 0.32< 0.32

Recognizing Mitral Recognizing Mitral StenosisStenosis

Palpation:Palpation: Small volume pulseSmall volume pulse Tapping apex-Tapping apex-

palpable S1palpable S1 +/- palpable opening +/- palpable opening

snap (OS)snap (OS) RV liftRV lift Palpable S2Palpable S2

ECG:ECG: LAE, AFIB, RVH, RADLAE, AFIB, RVH, RAD

Auscultation:Auscultation: Loud S1- as loud as S2 in Loud S1- as loud as S2 in

aortic areaaortic area A2 to OS interval inversely A2 to OS interval inversely

proportional to severityproportional to severity Diastolic rumble: length Diastolic rumble: length

proportional to severityproportional to severity In severe MS with low In severe MS with low

flow- S1, OS & rumble flow- S1, OS & rumble may be inaudiblemay be inaudible

Wave Sound

Mitral Stenosis: Mitral Stenosis: SymptomsSymptoms

Heart Sounds: Heart Sounds: MurmurMurmur Systolic murmurSystolic murmur

– Right sided vs left sided:Right sided vs left sided: Effect of respiration (RIGHT SIDED INCREASE WITH Effect of respiration (RIGHT SIDED INCREASE WITH

INSPIRATION)!!!!!!!! Except PS decreasesINSPIRATION)!!!!!!!! Except PS decreases Valsalva release– two systolic murmurs that increase are Valsalva release– two systolic murmurs that increase are

HOCM and MVPHOCM and MVP Diastolic murmur: Diastolic murmur:

– Early diastolic (Great vessel origin): Semilunar: AI or PREarly diastolic (Great vessel origin): Semilunar: AI or PR– Mid diastolic: AV valve flow, MS, TS, increased cardiac Mid diastolic: AV valve flow, MS, TS, increased cardiac

output, severe MR/TR with rumble from increased flowoutput, severe MR/TR with rumble from increased flow Continuous MurmurContinuous Murmur

– PDA – infraclavicular and peaks at S2PDA – infraclavicular and peaks at S2– AV fistulaAV fistula– Venous HumVenous Hum– To and Fro is AS and AITo and Fro is AS and AI

Mitral Stenosis Mitral Stenosis SymptomsSymptoms Fatigue Fatigue PalpitationsPalpitations CoughCough SOBSOB Left sided failureLeft sided failure

– OrthopneaOrthopnea– PNDPND

PalpitationPalpitation

AFibAFib Systemic embolismSystemic embolism Pulmonary infectionPulmonary infection HemoptysisHemoptysis Right sided failureRight sided failure

– Hepatic CongestionHepatic Congestion– EdemaEdema

Worsened by conditions Worsened by conditions that that cardiac output. cardiac output.– Exertion,fever, anemia, Exertion,fever, anemia,

tachycardia, Afib, tachycardia, Afib, intercourse, pregnancy, intercourse, pregnancy, thyrotoxicosisthyrotoxicosis

Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND With extreme reductions in diastolic With extreme reductions in diastolic

pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina

Percutaneous AVRPercutaneous AVR

Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND Chest pain.Chest pain.

– Nocturnal angina >> exertional angina Nocturnal angina >> exertional angina – (( diastolic aortic pressure and increased diastolic aortic pressure and increased

LVEDP thus LVEDP thus coronary artery diastolic coronary artery diastolic flow)flow)

With extreme reductions in diastolic With extreme reductions in diastolic pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina

Common Murmurs and Common Murmurs and TimingTiming

Systolic MurmursSystolic Murmurs Aortic stenosisAortic stenosis Mitral insufficiencyMitral insufficiency Mitral valve prolapseMitral valve prolapse Tricuspid insufficiency Tricuspid insufficiency

Diastolic MurmursDiastolic Murmurs Aortic insufficiencyAortic insufficiency Mitral stenosisMitral stenosis

S1 S2 S1

Assessing Severity of Assessing Severity of Chronic Chronic Mitral RegurgitationMitral Regurgitation

Measure the Impact on the LV:Measure the Impact on the LV: Apical displacement and sizeApical displacement and size Palpable S3Palpable S3 Longer/louder MR murmer (chronic MR)Longer/louder MR murmer (chronic MR) S3 intensity/ length of diastolic flow S3 intensity/ length of diastolic flow

rumblerumble Wider split S2 (earlier A2) unless HPT Wider split S2 (earlier A2) unless HPT

narrows the splitnarrows the split

Mitral Valve Prolapse: Mitral Valve Prolapse: Physical ExamPhysical Exam

Most important finding: mid Most important finding: mid late systolic late systolic clickclick..– Acute tensing of the mitral valve chordaeAcute tensing of the mitral valve chordae

Variable murmurs:Variable murmurs:– high pitched late high pitched late systolicsystolic crescendo-crescendo-

decrescendo murmurdecrescendo murmur, , – Occasionally “whooping” or “honking” at the Occasionally “whooping” or “honking” at the

apexapex

S1 C S2

MR EchocardiographyMR Echocardiography

Etiology: Etiology: – flail leaflets (chord/pap rupture)flail leaflets (chord/pap rupture)– thick (RHD)thick (RHD)– post mvt of leaflets (MVP)post mvt of leaflets (MVP)– vegetations(IE)vegetations(IE)

Severity: Severity: – regurgitant volume/fraction/orifice arearegurgitant volume/fraction/orifice area– LV systolic functionLV systolic function– increased LV/LA size, EFincreased LV/LA size, EF

MR StagesMR StagesMR StagesMR Stages

LV size and function defined by echoLV size and function defined by echo Stage 1-compensated: Stage 1-compensated:

– End-diastolic dimension less 63mm, ESD End-diastolic dimension less 63mm, ESD less 42mmless 42mm

– EF more than 60EF more than 60 Stage 2-transitionalStage 2-transitional

– EDD 65-68mm, ESD 44-45mm, EF 53-57EDD 65-68mm, ESD 44-45mm, EF 53-57 Stage 3-decompensatedStage 3-decompensated

– EDD more than 70mm, ESD more than EDD more than 70mm, ESD more than 45mm, EF less than 5045mm, EF less than 50

RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYRECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYIN PATIENTS WITH CHRONIC MITRAL REGURGITATIONIN PATIENTS WITH CHRONIC MITRAL REGURGITATIONAND PRIMARY MITRAL-VALVE DISEASE. AND PRIMARY MITRAL-VALVE DISEASE.

SEVERITY OFSEVERITY OF

MITRALMITRAL

REGURGITATIONREGURGITATION

LEFT LEFT VENTRICULAR VENTRICULAR

FUNCTION*FUNCTION*

FREQUENCY OFFREQUENCY OF

ECHOCARDIOGRA-ECHOCARDIOGRA-PHIC FOLLOW-UPPHIC FOLLOW-UP

MildMild Normal ESD and EFNormal ESD and EF Every 5 yrEvery 5 yr

ModerateModerate Normal ESD and EFNormal ESD and EF Every 1 –2 yrEvery 1 –2 yr

ModerateModerate ESD >40 mm or EF ESD >40 mm or EF <0.65<0.65

AnnuallyAnnually

SevereSevere Normal ESD and EFNormal ESD and EF AnnuallyAnnually

SevereSevere ESD >40 mm or EF ESD >40 mm or EF <0.65<0.65

Every 6 moEvery 6 mo

*ESD denotes end-systolic dimension and EF ejection fraction. Otto C.M. NEJM 345:10.

Mitral Valve Prolapse: Mitral Valve Prolapse: Physical ExamPhysical Exam

Most important finding: mid Most important finding: mid late systolic late systolic clickclick..– Acute tensing of the mitral valve chordaeAcute tensing of the mitral valve chordae

Variable murmurs:Variable murmurs:– high pitched late high pitched late systolicsystolic crescendo-crescendo-

decrescendo murmurdecrescendo murmur, , – Occasionally “whooping” or “honking” at the Occasionally “whooping” or “honking” at the

apexapex

S1 C S2

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