Valvular Heart Disease Asymptomatic 62 y/o male Long-standing heart murmur 2/6 SEM at base of heart...
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Transcript of Valvular Heart Disease Asymptomatic 62 y/o male Long-standing heart murmur 2/6 SEM at base of heart...
Valvular Heart Disease
• Asymptomatic 62 y/o male
• Long-standing heart murmur
• 2/6 SEM at base of heart
• PMI and carotid upstroke normal
• S2 splits normally
• ECG, CXR normal
Valvular Heart Disease
• What would you do at this time? – Refer to cardiologist – Order an echocardiogram– Follow without further testing until symptoms
develop
Is the Murmur Significant?
• Is the patient symptomatic?
• Are symptoms consistent with cardiac limitation?
• Is there chamber or cardiac enlargement on CXR or examination?
• Is there LVH or RVH on present ECG?
Clues from the Circulatory System
• Jugular venous pulse• Carotid upstroke:
brisk, delayed or weak?
• Peripheral pulses and pulse pressure
• Apical impulse: displaced, sustained or normal?
• Right ventricular lift• Thrill• Heart rate and rhythm
Innocent Cardiac Murmurs
• Midsystolic (never diastolic)
• A2 heard clearly
• Crescendo-decrescendo
• Variable intensity (grade 1-2/6)
• Does not radiate widely
Useful Maneurvers
• Valsalva: decreased venous return during Phase 2
• Squat-Stand: Decreased venous return like Valsalva
• Sustained Hand Grip: increased SVR, increased cardiac output, increased BP
The Second Heart Sound
• Normal: Single S2 in expiration
• Wide: Right bundle branch block, RV pacing
• Fixed: ASD/common atrium
• Paradoxic: Left bundle branch block
Bedside Diagnosis of Pulmonary Hypertension
• P2 > A2 with P2 heard at LV apex
• Secondary findings of tricuspid insufficiency, elevated CVP, pedal edema
• Appropriate clinical situation: known CHF, severe lung disease, loud heart murmur, cardiac arrhythmia
Most Common Misdiagnosed Systolic Murmurs
• Mild Aortic Stenosis
• Mild Pulmonic Stenosis
• Atrial Septal Defect
• Mitral Valve Prolapse
• Hypertrophic Cardiomyopathy Question: Who warrants SBE prophylaxis?
SBE Prophylaxis-2007 Guidelines
• Prosthetic cardiac valve
• Previous infectious endocarditis
• Complex congenital heart disease
• Cardiac transplantation recipients who develop cardiac valvulopathy
Valvular Heart Disease Mild to Moderate Aortic Stenosis• Yearly history and physical examination
• Focus on symptoms of angina, CHF, near syncope
• Echocardiogram q 3-5 years (peak velocity < 3 M/sec)
Valvular Heart Disease:Moderate to Severe Aortic Stenosis
• Annual history and physical examination
• Angina, CHF or near syncope?
• Echocardiogram yearly
• Peak velocity > 3 M/sec
Pulmonic Stenosis
• Congenital lesion with systolic ejection click
• Systolic ejection murmur at left upper sternal border
• Infraclavicular radiation
• Right ventricular lift
Atrial Septal Defects
• Primum ASD: Associated with cleft mitral valve and marked LAD on ECG
• Secundum ASD: Most common with female predominance
• Sinus venosus ASD: Associated with partial anomalous venous return
• All have wide/fixed split of S2
MVP: A Syndrome with Too Many Names
• Myxomatous mitral valve prolapse
• Click/murmur syndrome
• Floppy mitral valve syndrome
• “Classic” MVP
• Barlow’s Syndrome
History of Mitral Valve Prolapse
• 1962 Barlow describes MVP syndrome
• 1970 VPC’s and sudden cardiac death
• 1976 Prevalance 5-15%???
• 1986 High risk markers for MVP complications identified
• 1989 Saddle shaped mitral annulus described
MVP: Clinical Exam
• Non-ejection click
• Mid-to-late systolic click
• Pansystolic murmur
• Mid-to-late systolic murmur
• Precordial “Honk”
• Changes with maneuvers
• “Silent” MVP
Complications of MVP Syndrome
• Ruptured chorda tendiniae
• Progressive mitral insufficiency
• Subacute bacterial endocarditis
• Sudden cardiac death
• Transient ischemic attacks
Complications in Classic and Nonclassic Mitral Valve Prolapse
Classic (N=319)
Nonclassic (N=137)
P Value
SBE 3.5% (11) 0 <0.02
Severe MR 11.9% (30) 0 <0.001
MV surgery 6.6% (21) 0.7% (1) <0.02
TIA/stroke 7.5% (24) 5.8% (8) ns
Hypertrophic Cardiomyopathy
• May occur with or without dynamic LVOT obstruction
• Systolic ejection murmur at lower left sternal border
• Murmur increases during Phase 2 of Valsalva
• Bisferiens pulse
Hypertrophic Cardiomyopathy Treatment: General Guidelines
• Physical Activity: Avoid strenuous activity (no competitive sports), avoid dehydration
• Endocarditis Risk: Dental care
• Genetic Counseling: Screen first degree relatives, pregnancy counseling
Hypertrophic Cardiomyopathy: Treatment
• General guidelines
• Medical therapy: Beta blockers, Ca channel blockers
• Catheter based septal ablation
• Surgical myectomy
• AICD implantation
HCM: ECG from 1995
HCM: ECG from 2002
HCM: ECG from January 2010
Is the Murmur Significant?
• Is the patient symptomatic?
• Are symptoms consistent with cardiac limitation?
• Is there cardiac enlargement or chamber enlargement on CXR or exam?
• Is there LVH or RVH on ECG?