Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and...
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Transcript of Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and...
Learning Objectives
Describe the pathophysiology, etiology,
signs and symptoms, natural history, and
treatment of aortic stenosis.
Aortic Stenosis
Pathophysiology
Related to pressure changes, Valve obstructed,
LV > pressure, LV hypertrophy,
LA enlarges, Decreased cardiac output
Etiology
Rheumatic Heart Disease Congenital AV Disease Bicuspid Aortic Valve
Idiopathic Calcific Aortic Stenosis
Aortic Stenosis“Valvular”
Symptoms
Fatigue Dyspnea on exertion
Angina Exertional Syncope
Heart Failure Sudden Cardiac Death
Aortic Stenosis“Valvular”
ECGHypertrophy
CXR Cardiomegaly 50% of the time
ECHOConfirm, Severity
LHCSeverity, Coronary Artery Disease
Aortic Stenosis“Valvular”
Natural History
AsymptomaticFor many years
Duration of symptoms
(until death)
Angina - 3 yearsSyncope - 2 yearsCHF - 18 months
Aortic Stenosis“Valvular”
Treated Aortic Stenosis40% survived for 5 years
20% survived for 10 years
Sudden Cardiac DeathDecreased cerebral blood flow
Arrhythmias
Natural History
Aortic Stenosis“Valvular”
Treatment
Strenous ActivityLimit for symptomatic
Medical treatment of HFACC/AHA guidelines for
preload/afterload reduction&fluid management
Aortic Stenosis“Valvular”
Treatment
Surgical treatmentindications, techniques, outcome
depend on age/cause
Adults: valve replacement
Aortic Stenosis“Valvular”
Learning Objectives
Describe the etiology, signs and symptoms,
findings and treatment for aortic insufficiency.
Etiology
Valvular DiseaseRheumatic Heart Disease
Infective EndocarditisTrauma
(tear of the ascending aorta)
Bicuspid valve
Aortic Insufficiency
Etiology
Aortic root disease (1/3 of patients)Marfan’s syndrome
Cystic medial necrosisSyphilitic aortitis
Ankylosing spondylitisBehcets syndromeReiter’s syndrome
Systemic Hypertension
Aortic Insufficiency
SymptomsAngina, Palpitations, CHF symptoms
Vital SignsWide pulse pressure
Pulses
Abrupt distension/quick collapse: Corrigan’s pulseBisferiens pulse
Aortic Insufficiency
PalpationPMI, Thrill
Auscultation
S2 variable, A2 absentMurmur
Diastolic: patient sitting, leaning forward, on expiration,
diaphragm at Erb’s pointAustin Flint Murmur, De Musset’s
Aortic Insufficiency
Findings
EKGLVH CXR
Marked enlargement if AI is chronic ECHO
Confirms/severity LHC
Severity/CAD
Aortic Insufficiency
Treatment
Follow clinically (q 6 mos)Asymptomatic with normal LV
Use IE prophylaxis
TreatedSymptomatic with LV function decrease
MedicationsAVR
Aortic Insufficiency
Learning Objectives
Describe the etiology, pathophysiology, signs and symptoms, physical exam, and treatment of
mitral stenosis.
Etiology
Rheumatic heart disease (female)
Congenital
Rare:SLE
AmyloidCarcinoid
Rheumatoid Arthritis
Mitral Valve Stenosis
Pathophysiology
Minimum of 2 yrs for severe MS to develop after ARF
Pressure elevates in:
Left atriumPulmonary tree
Right heart
Atrial contraction30% of CO, Atrial fibrillation
Mitral Valve Stenosis
Dyspnea on exertion Hemoptysis Chest pain
CHF symptoms Hoarseness
Pulmonary Embolism Infective Endocarditis
Mitral Valve Stenosis
Physical Exam
InspectionJVP
Sternal lift Palpation
Sternal heaveApex
AuscultationAccentuated S1, Opening snap,
Diastolic murmur
Mitral Valve Stenosis
Treatment
MedicalSBE prophylaxisAvoid strenuous exerciseDiureticsAnticoagulants
Rheumatic heart diseaseAtrial fibrillation
Treatment AFDigoxin
Mitral Valve Stenosis
Treatment
SurgicalAsymptomatic
FollowSymptomatic
Balloon ValvuloplastyOpen commissurotomyValve replacement
Mechanical Bio-prosthetic
Mitral Valve Stenosis
Mitral Valve Prolapse
Other terms: Floppy valve, Barlow’s
Etiology Congenital
Marfan’s syndrome RHD
Sequelae of CM or MI Pathophysiology
Valve leaflet has redundant tissue Extra tissue balloons into LA, click sound
Mitral Valve Prolapse
Incidence10-20 % of population
F > MClinical Presentation
AsymptomaticSymptomaticPalpitationsArrhythmias
Atypical Chest Pain
Mitral Valve Prolapse
MVP-Physical Exam/Diagnosis
Thin, young females Abnormalities
Skeletal Heart
Auscultation Mid-systolic click
MVP-Physical Exam/Diagnosis
EKG Normal Abnormal
Arrhythmias: SVT NSST-T changes
ECHO Confirm the diagnosis R/O other abnormalities
Etiology
Valve leaflets: (Do not close properly/Do not stay closed)
Chronic RHDSLE
TraumaEndocarditis
Mitral Valve Regurgitation
Etiology
Mitral annulus:Dilation
Calcification
Chordae tendinae:Congenital, Rupture, Endocarditis
Mitral Valve Regurgitation
Etiology
Papillary muscles:Ischemia;Dysfunction
Scarring
Infarction:NecrosisRupture
Mitral Valve Regurgitation
Pathophysiology
MV and AV are in parallel Amount of MR is dependent on LV
outflow impedence, Increased by aortic stenosis
Symptoms
ChronicAcute
Mitral Valve Regurgitation
Clinical Findings
Auscultation
S1: DiminishedS2: Wide splitting
Murmur: Holosystolic, Loudest at apex
Mitral Valve Regurgitation
Treatment
Low sodium diet Preload reduction: Diuretics
Afterload reduction: Vasodilators(Nitroprusside, ACE inhibitors, Hydralazine)
Digoxin SBE prophylaxis
Mitral Valve Regurgitation
Treatment
Surgical
Symptomatic:Class II, III, IV
Asymptomatic:Monitor Symptoms
Echo
Mitral Valve Regurgitation
EtiologyRheumatic
Pathophysiology
Pressures elevate in RA
SymptomsFatigue
Right sided symptoms
Tricuspid Stenosis
Physical findingsJVD
Right sided failure sxs
EKGRAE
CXR
ECHO
TreatmentDiet restriction, Diuretics, Surgery
Tricuspid Stenosis
EtiologyValvular:
SBE, RHD, CHDAnnular:
Cor PulmonaleEbstein’s anomaly
Clinical features
SOB/DOE
Tricuspid Regurgitation