questions 10

Valvular Diseases

Topic updated on 12/12/17 6:00pm

  • A 57-year-old man presents to the emergency department ECHO of patient with aortic stenosiscomplaining of severe chest pain and difficulty breathing. His  exam reveals a weak, delayed carotid upstroke and a parodoxically-spliting S2. His EKG is shown. 
  • The leading cause of valvular heart disease in the United States is
    • mechanical degeneration
  • In the developing world
    • rheumatic fever is the most common etiology
  • Types
    • aortic stenosis
    • aortic regurgitation
    • mitral stenosis
    • mitral regurgitation
Aortic Stenosis
  • See topic
Aortic Regurgitation
  • May appear acutely or as a chronic condition
    • acute causes include trauma, aortic dissection, and infection
    • chronic cases include
      • birth defects 
      • rheumatic fever
      • connective tissue disorders
  • Symptoms/Physical exam
    • patients may present with worsening symptoms including
      • dyspnea on exertion
      • paroxysmal nocturnal dyspnea
      • lightheadedness on standing or changing positions too quickly
    • chest ausculation characterized by three distinct murmurs  
      • blowing diastolic murmur at LSB
      • midsystolic murmur at the apex
      • mid-diastolic rumble
    • other signs 
      • head-bobbing with heart beats
        • caused by caudal venous outflow obstruction
      • water hammer pulse
      • femoral bruits on compression of femoral pulse 
        • Duroziez sign
  • Evaluation
    • echocardiography is diagnostic
      • Doppler imaging shows back-flow across the aortic valve during diastole
    • EKG may show signs of dilated ventricles
  • Differential Diagnosis
    • other valvular disease, including aortic stenosis or mitral regurgitation, CHF
  • Treatment
    • Medical management until symptoms warrant intervention
      • Vasodilator therapy
        • CCBs and ACEIs
  • Prevention, Prognosis, and Complications
    • acute cases rapidly progress to pulmonary congestion, shock, and death if not treated 
Mitral Valve Stenosis
  • Most common etiology continues to be rheumatic fever
  • Symptoms/Physical exam
    • presents with wide range of symptoms
      • dyspnea on exertion
      • arrhythmias
      • orthopnea
      • infective endocarditis
      • paroxysmal nocturnal dyspnea
    • chest auscultation may reveal
      • opening snap
    • other signs include
      • crackles and rales indicative of pulmonary edema
  • Evaluation
    • Doppler echocardiography is diagnostic   
    • CXR will likely demonstrate mild to severe pulmonary edema
  • Differential Diagnosis
    • other valvular disease, CHF
  • Treatment 
    • Antiarrhythmics for symptom relief
      • Beta blockers, digoxin
    • Severe cases require surgical intervention
      •  Repair by commissurotomy preferred over replacement 
      • Balloon valvotomy 
      • Valve replacement
  • Prevention, Prognosis, and Complications
    • If left untreated, can progress to severe CHF and ultimately death
Mitral Valve Regurgitation
  • Two major causes include
    • rheumatic fever
    • chordae tendonae rupture
  • Symptoms/Physical exam
    • presents with a range of symptoms including
      • dyspnea
      • orthopnea
      • fatigue
    • chest auscultation reveals
      • holosystolic murmur that radiates to the axillae
  • Evaluation
    • Doppler echocardiography is diagnostic
      • shows regurgitant flow
    • CXR may show enlarged left atrium
    • Angiography used to assess severity of disease
  • Differential Diagnosis
    • other valvular diseases, CHF
  • Treatment
    • Decrease afterload
      • ACE inhibitors and ARBs
    • Antiarrythmics may be necessary if AF or others develop
  • Prevention, Prognosis, and Complications
    • at increased risk of developing atrial fibrillation due to enlargement
Cardiac Auscultation in Valvular Disease
  • Aortic Stenosis
    • loud crescendo-decrescendo systolic ejection murmor in right 2nd intercostal space
  • Mitral Regurgitation
    • high pitched holosystolic loudest at apex radiating to axilla
  • Tricuspid Regurgitation
    • soft holosystolic at left sternal border
  • Mitral Prolapse
    • crisp midsystolic click and a delayed or late systolic regurgitation murmur.
  • Aortic Regurgitation
    • high pitched blowing early diastolic decrescendo murmor at left sternal border
  • Mitral Stenosis
    • rumbling mid-diastolic murmor with ccenuated S1. S2, best heard on expiration or when the patient is squating or excercising because venous return is increase


Qbank (4 Questions)

(M3.CV.11) A 68-year-old woman is admitted to the hospital following an acute change in mental status. She has a mechanical heart valve. Her medications are carvedilol, lisinopril, atorvastatin, and warfarin. Coagulation studies show an INR of 3.1, which is within the target range set by her cardiologist. For which of the following comorbid medical conditions would this medical regimen and INR be most appropriate? Topic Review Topic

1. Mechanical aortic valve with hyperlipidemia
2. Mechanical aortic valve with atrial fibrillation
3. Mechanical aortic valve with diabetes mellitus
4. Mechanical aortic valve with hypertension
5. Mechanical aortic valve with history of systemic embolization

(M2.CV.43) A 72-year-old woman presents to her primary care doctor for a check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her physician notes an apical, rumbling diastolic murmur that occurs following an opening snap. The rumbling is loudest at the start of diastole. She has no other physical exam findings and has no other past medical history. What is the best course of action? Topic Review Topic

1. Observation, as this is likely a Still's murmur
2. Transthoracic echocardiogram
3. Transesophageal echocardiogram
4. Electrocardiogram
5. ASO titers

(M2.CV.61) A 53-year-old man from Guatemala presents with a 6-month history of progressively worsening dyspnea on exertion and cough, which has led to marked limitation of his physical activity. As a child, he had a febrile illness characterized by arthritis affecting multiple joints and abnormal movements. On cardiac exam, he has a low-pitched diastolic rumble that is most prominent at the apex. Subsequent workup with echocardiogram confirms the diagnosis of a valvular abnormality. What is the best treatment option? Topic Review Topic

1. Mitral valve repair
2. Medical management with diuretics
3. Closed mitral commissurotomy
4. Percutaneous mitral balloon valvotomy
5. Open mitral commissurotomy

(M2.CV.201) A 64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasalar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI holosystolic murmur at the apex that radiates to the axilla. Which of the following valvular abnormalities would you most likely find on emergent bedside echocardiogram? Topic Review Topic

1. Aortic stenosis
2. Aortic regurgitation
3. Mitral valve prolapse
4. Mitral stenosis
5. Mitral regurgitation

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