Transcript Valvular Heart Disease

Valvular Heart Disease
Eric J Milie, D.O.
Goals and Objectives
Recognize which cardiac murmurs warrant
further evaluation
Understand three cardinal signs of aortic
stenosis and indications for surgical intervention
Outline treatment plans for specific valvular heart
lesions
Grading Heart Murmurs
Out of VI
I.
Only heard with careful listening
II.
Audible when stethoscope applied to chest
III. Louder than 2/6
IV. Accompanied by a palpable thrill
V.
Audible when stethoscope partially off of chest
VI. Audible to naked ear
Findings Murmur S1
S2
Other
Maneuvers
Findings
Aortic
Stenosis
Mid to late
systolic; may be
soft or absent if
severe
Normal
Single or
paradoxically
split
Carotid upstrokes
diminished and
delayed; S3 or S4
may be present
Murmur softer with
Valsalva maneuver
Mitral
Stenosis
Diastolic rumble
Loud
Normal
Opening snap may
be present
Murmur increased
during brief exercise
Aortic
Regurgitation
Blowing diastolic
Soft
Normal
Wide pulse
pressure, systolic
hypertension,
hyperdynamic
circulation
Murmur increased with
handgrip or squatting
Mitral
Regurgitation
Holosystolic
Soft
Normal or
split
S3 may be present;
cartoid upstrokes
brisk
Murmur louder with
Valsalva maneuver
MVP
Mid to late
systolic
Normal
Normal
Mid-systolic click
Murmur increased with
standing
Recommendations by Class
Class I: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and
effective.
Class II:Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a
procedure or treatment.
IIa. Weight of evidence/opinion is in favor of usefulness/efficacy
IIb. Usefulness/efficacy is less well established by
evidence/opinion.
Class III:Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective,
and in some cases may be harmful.
Aortic Stenosis: Etiology
Often congenital
Rheumatic AS associated with previous
rheumatic disease
Idiopathic, calcific As associated with elderly,
generally milder
AS: Symptoms
Dyspnea
Angina
Syncope
These are cardinal symptoms, occur late in
disease, and are associated with mortality
(usually 2-3 year survival after onset of
symptoms)
AS: Physical Exam
Weak and delayed arterial pulses with carotid
thrill (pulsus parvus et tardus)
Double apical impulse
S4 common
Diamond shaped systolic murmur
Usually >3/6
AS: Echo
LV thickening
Thickening and calcification of aortic valve cusps
Dilatation, reduced LVEF poor prognosis
Aortic stenosis with turbulent flow (green
pixels), as seen in the five-chamber view
AS: Classification of Severity
Mild: Valve Area >1.5cm²
Moderate: Valve area 1.0cm² to 1.5cm²
Severe: Valve area <1.0cm²
AS: Treatment
Avoid strenuous exercise in severe AS
Treat CHF in standard fashion, but avoid afterload
reduction
Statin therapy to slow progression of leaflet calcification
Balloon valvotomy to reduce symptoms in patients who
aren’t surgical candidates
Valve replacement in adults who are symptomatic or
with evidence of outflow obstruction
Surgery optimally performed before frank heart failure
develops
Aortic Regurgitation: Etiology
Rheumatic etiology common
Hypertension
Infective endocarditis
Dilitation due to cystic medial necrosis
Myxomatous infiltration
Marfan syndrome
Patients ¾ male
AR: Manifestations
Exertional dyspnea
Cardiac awareness
Angina
LV failure
Wide pulse pressure
Capillary pulsations (Quincke’s sign)
S3
Blowing, decrescendo diastolic murmur heard best
along left sternal border
AR: Lab
CXR- LV enlargement
EKG- LV hypertrophy
Echo: LA and LV enlarged, increased excursion
of LV posterior wall
AR: Treatment
Standard therapy for LV failure
Vasodilators to delay need for surgical
intervention
Surgical intervention indicated in symptomatic
patients with severe AR or in asymptomatic
patients with LV dysfunction on echo (LVEF
<55%)
Mitral Stenosis: Etiology
Most commonly rheumatic (up to 40% of patients
with rheumatic fever develop mitral stenosis,
99% of surgically removed mitral valves with
rheumatic infiltration)
Congenital MS rare
MS: History
Symptoms commonly begin in 4th decade
Can cause severe debility by age 20 in
economically deprived areas
Principal symptoms are dyspnea and pulmonary
edema precipitated by exertion, anemia, fever,
excitement pregnancy, sexual intercourse, etc.
MS: Physical
Right ventricular lift
Palpable S1
Opening snap follows A2 by 0.06 to 0.12
seconds
OS-A interval inversely proportional to severity of
disease
Diastolic rumbling murmur
MS: Complications
Hemoptysis
Pulmonary embolism
Pulmonary infection
Systemic embolization
Endocarditis uncommon in pure MS
MS: Labs
EKG: Typically A. Fib or LA enlargement when
sinus rhythm present
CXR: LA and RV enlargement, Kerley B lines
Echo: calcification and thickening of valve
leaflets and LA enlargement
MS: Treatment
Prophylaxis for rheumatic fever
Heart failure treatment if present
Dig, beta blockers to control ventricular rate
Valvotomy in presence of symptoms and mitral
orifice <1.7cm²
Anticoagulation if indicated
Mitral Regurgitation: Causes
Rheumatic heart disease in 33% of cases
MVP
Ischemic heart disease with papillary muscle
dysfunction
LV dilitation
Mitral annular calcification
Hypertrophic cardiomyopathy
Infective endocarditis
congenital
MR: Clinical Manifestations
Fatigue
Weakness
Exertional dyspnea
MR: Physical Exam
Sharp upstoke of arterial pulse
LV lift
S1 diminished
Wide splitting of S2
Loud holosystolic murmur
MR: Echo
Enlarged LA
Hyperdynamic LV
Doppler echocardiogram useful in diagnosing
and assessing severity of MR
MR: Treatment
For severe/ decompensated MR, treat as heart
failure
Endocarditis prophylaxis is indicated
Surgical intervention warranted in symptomatic
individuals or in evidence of progressive LV
dysfunction
Surgery before decompensated heart failure
Anticoagulation in face of atrial fibrillation
Mitral Valve Prolapse: Etiology
Most commonly idiopathic
? Familial
Ischemic heart disease
Atrial septal defect
Marfan syndrome
More common female>male
Normal mitral
valve
MVP
MVP: Clinical Manifestations
Most patients asymptomatic and remain so
Chest pain (atypical)
Supraventricular and ventricular arrhythmias
Most important complication of severe MR is LV
failure
Sudden death is very rare
MVP: PE
Mid or late systolic click followed by late systolic
murmur
Murmur exaggerated by valsalva, reduced with
squatting
Echo shows displacement of one or both leaflets
late in systole
MVP: Treatment
Asymptomatic patient: reassurance
Prophylaxis for endocarditis indicated
Valve repair for patients with severe MR
ASA or anticoagulation for patients with TIA or
embolization
Question 1
A new patient comes to you for evaluation. He’s a
45 year old male whose only complaint is that of
some dyspnea on exertion, which he attributes
to old age. He doesn’t smoke or drink alcohol.
He does admit to being “very ill as a child,” but
has been relatively healthy since. On physical
exam, a diastolic murmur is noted, but the
remainder of the exam is within normal limits.
Question 1 continued
Which of the following is the next best step in this
patient’s management?
a) Only routine preventative care
b) Trial of beta blocker therapy to see if his shortness of
breath resolves
c) Echocardiogram for assessment of the diastolic
murmur, with further recommendations to follow
d) Cranial OMT for assessment of his CRI
Question 2
A 73 year old white male presents to the
emergency department after a syncopal episode.
He’s dyspnic, with air hunger at the bedside, and
is complaining of chest discomfort radiating to
his jaw and down his left arm. On exam, a III/VI
crescendo-decrescendo murmur is appreciated.
Question 2 continued
Which of the following valvular pathologies is most
likely responsible for this man’s presentation?
a) Aortic Stenosis
b) Aortic Regurgitation
c) Mitral Stenosis
d) Mitral Regurgitation
e) Mitral valve prolapse
Question 3
The most common cause of mitral stenosis is:
a) Familial
b) Idiopathic
c) Sauerkraut ingestion
d) Rheumatic
e) Alcohol induced