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Valvular Heart Disease

Valvular Heart Disease. Tulika Jain, MD Resident Teaching Conference December 5, 2008. Auscultation. Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs (diastolic rumble) Sequence of auscultation upper right sternal border (URSB)

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Valvular Heart Disease

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  1. Valvular Heart Disease Tulika Jain, MD Resident Teaching Conference December 5, 2008

  2. Auscultation • Use the diaphragm for high pitched sounds and murmurs • Use the bell for low pitched sounds and murmurs (diastolic rumble) • Sequence of auscultation • upper right sternal border (URSB) • upper left sternal border (ULSB) • lower left sternal border (LLSB) • apex • apex - left lateral decubitus position • lower left sternal border (LLSB)- sitting, leaning forward, held expiration

  3. Innocent MurmursCommon in asymptomatic adults • Characterized by • Grade I – II @ LSB • Systolic ejection pattern - no  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

  4. Characteristic of the NOT Innocent Murmur • Diastolic murmur • Loud murmur - grade III or above • Regurgitant murmur • Murmurs associated with a click • Murmurs associated with other signs or symptoms e.g. cyanosis • Abnormal 2nd heart sound – fixed split, paradoxical split or single

  5. Heart Sounds Pearls • Right sided valves open earlier and close last due to lower pressure gradient • All right sided murmur and sounds tend to augment with inspiration: EXCEPTION: PULMONIC STENOSIS click DECREASES WITH INSPIRATION • Valsalva releases increases murmur of HOCM and MVP

  6. Heart Sounds: Clicks

  7. Valve Disorders • Etiology • Symptoms • Physical Exam • Testing • Severity • Indications for Surgery

  8. Younger people Functional murmur vs MVP vs bicuspid AV Older people Aortic sclerosis vs aortic stenosis Common Clinical Scenarios

  9. Young patient think congenital Bicuspid AVD 2% population 3:1 male:female distribution Co-existing coarctation 6% of patients Rarely Unicuspid valve Sub-aortic stenosis Discrete Diffuse (Tunnel) Middle aged patient(4&5th decades) think bicuspid or rheumatic disease Old patient think degenerative (6,7,8th decades) Aortic Stenosis - Etiology

  10. Aortic Stenosis: Etiology • Valvular • Subvalvular • Supravalvular

  11. Supravalvular Aortic Stenosis

  12. Aortic Stenosis: Symptoms • Cardinal Symptoms • Chest pain (angina) • Reduced coronary flow reserve • Increased demand-high afterload • Syncope (exertional pre-syncope) • Fixed cardiac output • Vasodepressor response • Dyspnea on exertion & rest • Other signs of LV failure • Diastolic & systolic dysfunction

  13. Severity of Stenosis • Normal aortic valve area 2.5-3.5 cm2 • Mild stenosis 1.5-2.5 cm2 • Moderate stenosis 1.0-1.5 cm2 • Severe stenosis < 1.0 cm2 • Onset of symptoms • 0.9 cm2 with CAD • 0.7 cm2 without CAD

  14. Aortic Stenosis: Physical Findings • Intensity DOES NOT predict severity • Presence of thrill DOES NOT predict severity • “Diamond” shaped, systolic crescendo-decrescendo • Decreased, delay & prolongation of pulse amplitude: “pulsus parvus and tardus” • Paradoxical S2 • S4 (with left ventricular hypertrophy) • S3 (with left ventricular failure)

  15. Aortic Stenosis: Physical Findings S1 S2 S1 S2 Mild-Moderate Severe

  16. Heart Sounds: Splitting AS

  17. Aortic Stenosis : Lab • EKG: LVH • CXR: Intially have concentric LVH so unremarkable; Critical AS may show post stenotic dilation of the aorta, hypertrophy, congestion

  18. CXR: AS with Post Stenotic Dilatation of Aorta

  19. Aortic Stenosis: Treatment Indications for surgery: • Symptomatic • Asymptomatic but EF < 50% • Poor performance on ETT • Reasonable if asymptomatic true AS and operative mortality is low • If low output, low gradient AS then need dobutamine stress echo

  20. Aortic Stenosis: Treatment • Aortic stenosis is a surgical disease • Treatment is valve replacement • Aortic valve balloon valvuloplasty rarely done due to stroke risk and other complications • Current trials using catheter based aortic valve replacement

  21. Any conditions resulting in incompetent aortic leaflets Congenital Bicuspid valve Aortopathy Cystic medial necrosis Collagen disorders (e.g. Marfan’s) Ehler-Danlos Osteogenesis imperfecta Pseudoxanthoma elasticum Acquired Rheumatic heart disease Dilated aorta (e.g. hypertension..) Degenerative Connective tissue disorders E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis ) Syphilis (chronic aortitis) Acute AI: aortic dissection, infective endocarditis, trauma Aortic Regurgitation:Etiology

  22. Aortic Regurgitation:Symptoms • Dyspnea, orthopnea, PND • With extreme reductions in diastolic pressures (e.g. < 40) may see angina

  23. Aortic Regurgitation: Physical Exam • Widened pulse pressure • Systolic – diastolic = pulse pressure • High pitched, blowing, decrescendo diastolic murmur at LSB • Best heard at end-expiration & leaning forward • Hands & Knee position S1S2 S1

  24. Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula Durosier’s sign: femoral retrograde bruits (bell) Traube’s sign: pistol shot femorals Hill’s sign:BP Lower extremity >BP Upper extremity by > 20 mm Hg - mild AR > 40 mm Hg – mod AR > 60 mm Hg – severe AR Peripheral Signs of Severe Aortic Regurgitation

  25. Apex: Enlarged Displaced Hyper-dynamic Palpable S3 Austin-Flint murmur Aortic diastolic murmur length correlates with severity (chronic AR) in acute AR murmur shortens as Aortic DP=LVEDP in acute AR - mitral pre-closure Central Signs of Severe Aortic Regurgitation

  26. Assessing Severity of AR • Assess severity by impact on peripheral signs and LV •  peripheral signs =  severity •  LV =  severity • S3 • Austin -Flint • LVH • radiological cardiomegaly

  27. Aortic Regurgitation

  28. Aortic Regurgitation: Natural History Asymptomatic %/Y • Normal LV function (~good prognosis) • Progression to symptoms or LV dysfunction < 6 • Progression to asymptomatic LV dysfunction < 3.5 • 75% 5-year survival • Sudden death < 0.2 • Abnormal LV function • Progression to cardiac symptoms 25 Symptomatic (Poor prognosis) • Mortality > 10 Bonow RO, et al, JACC. 1998;32:1486.

  29. Aortic Regurgitation: 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”

  30. Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation

  31. A 75 year old woman with Recent orthopnea/PND • Chronic dyspnea Class 2/4 • Fatigue • Recent orthopnea/PND • Nocturnal palpitation • Pedal edema

  32. Mitral Stenosis: Etiology #1 Rheumatic

  33. Mitral Stenosis: Etiology #1 Rheumatic #2 ?

  34. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic

  35. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic

  36. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic . . . #99 ?

  37. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic

  38. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic #100 ?

  39. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic #100 Congenital, endocarditis, Carcinoid, Fabray, Hurler, Whipple, Atrial Myxoma

  40. Mitral Stenosis Etiology • Primarily a result of rheumatic fever • ~ 99% of MV’s @ surgery show rheumatic damage) • Scarring & fusion of valve apparatus • Rarely congenital • Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease • Two-thirds of all patients with MS are female.

  41. Mitral Stenosis Pathophysiology • Normal valve area: 4-6 cm2 • Mild mitral stenosis: • MVA 1.5-2.5 cm2 • Minimal symptoms • Mod mitral stenosis • MVA 1.0-1.5 cm2 usually does not produce symptoms at rest • Severe mitral stenosis • MVA < 1.0 cm2

  42. Mitral Valve Stenosis Pathophysiology

  43. Mitral Stenosis: Symptoms • Dyspnea, PND, orthopnea • Slow progressive course • May not admit to symptoms • Hemoptysis • Palpitations • Emboli

  44. Mitral Stenosis Examination

  45. Mitral Stenosis Physical Exam • First heart sound (S1) is accentuated and snapping • Opening snap (OS) after aortic valve closure • Low pitch diastolic rumble at the apex • Pre-systolic accentuation (esp. if in sinus rhythm) S1 S2 OS S1

  46. Auscultation-Timing of A2 to OS Interval • Width of A2-OS inversely correlates with severity • The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens • Shorter A2-OS=more severe mitral stenosis

  47. Mitral Stenosis: ECG • LAE • With pulm HTN: RAD, RVH • AFIB

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