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  1. 1. LECTURE 4. The syndrome affection of the heart valves. Mitral stenosis. Mitral regurgitation. Tricuspid stenosis. Tricuspid regurgitation. Aortic stenosis. Aortic regurgitation. 1
  2. 2. Cardiac Physiology 101 Systole AV/PV opens S1-S2 MV/TV closes Diastole AV/PV closes S2-S1 MV/TV opens 2
  3. 3. Cardiac Physiology 101 Regurg/ Insuff leaking (backflow) of blood across a closed valve Stenosis Obstruction of (forward) flow across an opened valve Systole AV/PV opens-------Aortic Stenosis S1-S2 MV/TV closes------Mitral Regurg Diastole AV/PV closes------Aortic Regurg S2-S1 MV/TV opens-------Mitral Stenosis These concepts are set in stone, it cant occur any other way, It would be anatomically impossible 3
  4. 4. Cardiac Anatomy 101 4
  5. 5. Cardiac Anatomy 101 5
  6. 6. Aortic Stenosis Etiologies Congenital 0-30 yrs Bicuspid 30-50 yrs Rheumatic 30-60 yrs Degenerative >60 yrs 6
  7. 7. Aortic Stenosis 7
  8. 8. Aortic Stenosis pathophysiology 8
  9. 9. Aortic Stenosis pathophysiology 9
  10. 10. Aortic Stenosis Symptoms Angina Syncope Congestive Heart Failure (CHF) 10
  11. 11. Aortic Stenosis 11
  12. 12. Aortic Stenosis 12
  13. 13. Aortic Stenosis Diagnosis Ecg LAE, LVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries 13
  14. 14. Aortic Stenosis Treatment of Symptomatic Aortic Stenosis or Decreased LV Function Medical Therapy treats the symptoms not the cause Aortic Valve Replacement Bioprosthetic vs Mechanical AVR 14
  15. 15. Valvular Heart Disease Aortic Valve Aortic Stenosis Aortic Regurgitation 15
  16. 16. Aortic Regurgitation 16
  17. 17. Aortic Regurgitation Etiologies Abnormalities of the Leaflets Rheumatic, Bicuspid, Degenerative Endocarditis Dilation of the Aortic Annulus Aortic Aneurysm / Dissection Inflammatory (Syphyllis, Giant Cell Arteritis. Coll Vasc Dis-Ankylosis Spondylitis, Reiters) Inheritable (Marfans, Osteogensis Imperfecta) 17
  18. 18. Plate 18 Left 18
  19. 19. Aortic Regurg pathophysiology 19
  20. 20. Aortic Regurg pathophysiology 20
  21. 21. Aortic Regurg pathophysiology 21
  22. 22. Aortic Regurgitation 22
  23. 23. Aortic Regurgitation Physical Exam Diastolic Decrescendo Blowing Murmur Hyperdynamic LV apical impulse Bounding Pulses S4, S3 Gallop-advanced AI Apical Rumble Austin Flint Murmur 23
  24. 24. Aortic Regurg Austin Flint Murmur Due to the vibration of the anterior leaflet of the mitral valve as it is buffetted simultaneously by the blood jets from the left atrium and the aorta. 24
  25. 25. Aortic Regurgitation Diagnosis Ecg LAE, LVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries 25
  26. 26. Aortic Regurgitation Treatment of Asymptomatic Aortic Regurg Medical Therapy treats the symptoms not the cause Serial Check ups with Echos (eval EF, Severity AR) SBE Prophylaxis Vasodialators (Nifedipine, ACE-I) Diuretics Treatment of Symptomatic Aortic Regurg Aortic Valve Replacement Bioprosthetic vs Mechanical AVR 26
  27. 27. If you're not confused, you're not paying attention. Tom Peters 27
  28. 28. Valvular Heart Disease Mitral Valve Mitral Regurgitation Mitral Stenosis 28
  29. 29. Mitral Regurgitation Etiologies Alterations of the Leaflets, Commissures, Annulus Rheumatic MVP Endocarditis Alterations of LV or LA size and Function Papillary Muscle (Ischemic, MI, Myocarditis, DCM) HOCM LV Enlargement Cardiomyopathies - LA Enlargement from MR MR begets MR 29
  30. 30. Mitral Regurgitation 30
  31. 31. Mitral Regurg pathophysiology 31
  32. 32. Mitral Regurg pathophysiology 32
  33. 33. Mitral Regurg pathophysiology 33
  34. 34. Mitral Regurgitation Symptoms Fatigue and weakness Dyspnea and orthopnea Right sided HF MVP Syndrome (if present) 34
  35. 35. Mitral Regurgitation Physical Exam Holosystolic Apical Blowing Murmur Laterally displaced apical impulse Split S2 (but is obscured by the murmur) S3 Gallop (increased volume during diastole) Radiation depends on the etiology 35
  36. 36. Mitral Regurgitation Diagnosis Ecg LAE, LVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries 36
  37. 37. Mitral Regurgitation - SBE Prophylaxis 37
  38. 38. Mitral Regurgitation 38
  39. 39. Mitral Regurgitation -MVP 39
  40. 40. Mitral Regurgitation MVP Pathophysiology 40
  41. 41. Mitral Regurgitation -MVP 41
  42. 42. 42
  43. 43. Mitral Regurgitation -MVP 43
  44. 44. Mitral Regurgitation -MVP Diagnosis and Treatment Echo 2D/Color B-Blockers (hyperadrenergic symptoms, Palpitations) Aspirin (TIAs without etiology) SBE Prophylaxis (only if associated with MR) Severe Symptomatic MR same as chronic MR 44
  45. 45. Valvular Heart Disease Mitral Valve Mitral Regurgitation Mitral Stenosis 45
  46. 46. Mitral Stenosis Etiologies Rheumatic almost all cases in adults Mitral Annular Ca+ - massive (rare) Congenital rare 60% of pts dont have a history of ARC 50% of pts who have ARC dont develop VHD 46
  47. 47. 47
  48. 48. Mitral Stenosis 48
  49. 49. Mitral Stenosis 49
  50. 50. Mitral Stenosis 50
  51. 51. Mitral Stenosis 51
  52. 52. Mitral Stenosis Physical Exam Loud S1 Opening Snap Diastolic Apical Rumble (murmur) May be associated with: MR or AS Right Sided Murmurs o PI Graham Steel Murmur o TR 52
  53. 53. Mitral Stenosis Diagnosis Ecg A Fib, LAE, RAE, RVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries 53
  54. 54. Mitral Stenosis Treatment of Symptomatic Mitral Stenosis Medical Therapy treats the symptoms not the cause Diuretics for congestion Digoxin, Beta and Ca Channel Blockers for Afib rate control Anticoagulation for AFib and LA clots SBE Prophylaxix prevent endocarditis 54
  55. 55. Mitral Stenosis Treatment of Symptomatic Mitral Stenosis Surgical Therapy treats the cause Percutaneous Ballon Valvulaoplasty Non- calcified, pliable valve 55
  56. 56. Mitral Stenosis Treatment of Symptomatic Mitral Stenosis Surgical Therapy treats the cause Open Commisurotomy valve repair Mitral Valve Replacement 56
  57. 57. Spectrum of VHD for Boards Classic Areas boards will focus on Physical Exams Aotric Stenosis -severe Aortic Regurg Acute and Chronic Mitral Stenosis MVP changes in MR with manuvers IHSS/HOCM changes in MR with manuvers Mitral Regurg Acute or chronic typically associated with CAD or Ischemic HD 57
  58. 58. Aortic Stenosis Physical Exam Harsh Systolic Ejection Murmur late peaking S4 gallop (from LVH) Sustained Bifid LV impulse (from LVH) Pulsus Parvus et Tardus (Carotid Impulse) 58
  59. 59. Mitral stenosis Obstacle to a bloodflow from the left atrium to the left ventricule, caused by narrowing left atrio-ventricular apertures. The causes: the causes at adults practically always is earlier transferred rheumatic fever. Children with congenital mitral stenosis seldom live more than 2th years. The causes of obstruction left V apertures can be and micsoma the left atrium. 59
  60. 60. Plate 17 Left 60
  61. 61. 61
  62. 62. 62
  63. 63. 63
  64. 64. 64
  65. 65. 65
  66. 66. 66
  67. 67. 67
  68. 68. 68
  69. 69. 69 Echocardiography
  70. 70. 70 Echocardiography
  71. 71. 71 Physical Exam Review:
  72. 72. 72
  73. 73. Complaints: at early stages the mitral stenosis usually there is a dyspnea at physical activity and fatigue. At the moderate and severe stage the dyspnea disturbs even in rest, palpitation, cough, hemoptysis, hypostases of feet. The fever, a tachycardia at physical activity or atrial fibrillation shortens time diastolic fillings of ventricules, the insufficient bloodflow through narrowed left V aperture in a diasdolic phase promotes increase of pressure in the left atrium and to reduction of cardiac output. Sudden increase of pressure in the left atrium conducts to the expressed hypostasis of lungs. Hemoptysis, caused by rupture of small pulmonary vessels, and also a hypostasis of lungs, it is especially probable at pregnant women that is connected with increase in volume of blood. The dilations left atrium and the expanded pulmonary trunk can press the left returnable nerve, cause its paralysis and hoarse voices. 73
  74. 74. Survey: Acrocyonosis, mitral face - dark-violet colouring of cheekbones against a pale skin (is more characteristic for patients with low cardiac output and a high pulmonary hypertensia). There can be a backlog in physical development, presence of "a cardiac hump at defect formation in the early childhood. Palpation: On heart apex - diastolic trembling the cat's purring, apex beat more often it is not changed, in left parasternal areas - the expressed pathological pulsation connected with a hypertrophy and dilatation of right ventricule. In some cases are palpated I tone on an apex of heart and click of opening of the mitral valve at a left edge of the inferior part of a breast. Percussion: The upper and right borders of relative dullness of heart are displaced accordingly upwards and to the right. 74
  75. 75. Auscultation: On an apex it is audible loud hight I sound, or tone of closing of the mitral valve. In position of the patient on left to a side over area where it is palpated apex beat, it is listened rolling diastolic noise, usually with presystolic murmur (if at the patient remai