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Mitral Stenosis

Etiology
-Rheumatic fever (immigrants)
-Pregnancy ( Plasma Vol. by 50%)
-Females > Males
Pathogenesis
LV filling LA dilation
LA pressure > Pulm. congestion
CO 2 pulm. Congestion RV failure
Sx: (Chronic)
Dyspnea/Orthopnea/
Paroxysmal Nocturnal dyspnea
Fatigue/Wasting
Pulm. Vessel rupturehemoptysis
Blood stasis in enlarged LA systemic
emboli

Signs:
Afib
Pulm Rales
Pulse Pressure
Loud S1
Opening snap after S2
Diastolic rumble (low pitched apical
murmur)
RV enlargement Sternal lift

Enlarged LARecurrent laryngeal n.


impingement hoarseness/dysphagia
Right Heart failure
EKG

CXR

Echo

-Pulm. HTN RVH


-Afib

Large LA:
-Double dense right
heart border (double
bubble)
-Post. Displacement of
esophagus
-Elevated left mainstem
bronchus
-Straightened left heart
border

Thickened mitral valve


leaflets
Mitral valve area
LA enlargement

Rx (Medical)
Diuretics
Diet (salt restriction)

Pulm. HTN:
-Kerley B Lines
- vascular markings
-Large pulm. Artery
Rx (Surgical)
Ballon Valvulotomy / PMBV (esp. if
pregnant or symptomatic or Pulm. Art P.

Digitalis ( Afib control)


Anticoagulants (Afib control)
ACE inhibitors useless
Mitral Regurgitation/Dilation
Acute Causes

> 50-60)
+ Anticoagulation with INR of 2.5-3.5
Valve replacement if PMBV fails

-Ruptured chordae tendinae (progress


to MVP)
-Papillary muscle rupture
-Endocarditis (also chronic)
-Trauma

-MVP
-Papillary muscle dysfunction
-Rheumatic Heart Disease
-Calcification
-HCCM (Constrictive)
-Congential endocardial cushion defect /
Corrected transposition of great vessels
-Endocardial fibroelastosis
-Severe LV dilation (lateral dilation)

Chronic causes

Pathogenesis
-LV backflow into LA LA pressure + CO
-Preload / Afterload
-Augmented Ejection fraction
-Prolonged compensation LV fail Right heart failure Late Pulm. HTN
Signs
-Left Ventricular impulse: Hyperdynamic + displaced (down and left)
-Carotid upstroke brisk + diminished volume
-Holosystolic murmur radiating to axilla with thrill
- Soft S1 + Wide split S2 + S3
- Soft S1 = Prolonged PR interval
- JVD Present
EKG

CXR

Echo

Catheter

-LVH
-LA enlargement
(+LV enlargement if
chronic)
Rx (Medical)

-Cardiac enlargement
-Vascular congestion w/
CHF

-MVP

-Large V wave
(LA systolic vol.
overload)

-ACE Inhibitors
-Digitalis
-Diuretics
-Anticoagulation (esp. Warfarin) if
thrombus or Afib.

Surgical
-Mitral Valve Replacement
-Deferred if Asx. Or few Sx.
-Indicated if Sx severe or persist even
w/ medical rx.
-Basically, if EF < 60% OR LVES
diameter > 40 mm, replace even if ASx
to prevent irreversible ventricular
dilation.

Mitral Valve Prolapse


Young females
Connective tissue disorders (Marfans/Idiopathic)
Asx > Sx of Arrhythmia (Ps)
Auscultation
If Sx.:
Pre-syncope
Palpitations
Pain (chest)
Panic attacks (resp. alkalosis)

-Mid to late systolic click


-Late systolic murmur at apex
-Murmur worsens with Valsalva but
improves with squatting

Dx with 2D/Doppler Echo


Marked Systolic displacement and coaptation of mitral valve leaflets to left side
+/- MR
Rx.
Mostly no Rx needed since ASx.
-If Sx:
-Beta blockers for chest pain
-Beta blockers + anti-arrhythmic for arrhythmias
-Mitral Valve replacement rarely needed.

Aortic Stenosis
Etiology
Elderly calcification and degeneration
Congenital bicuspid valve + calcification and fibrosis
Rheumatic fever
-Elevated LV systolic pressure compensatory LVH to maintain CO without
ventricle dilation
(Stroke volume normal until late stages)
-Forceful atrial contractions against thick noncompliant ventricles filling + S4
gallop LVEDP
-LVH + high intramyocardial wall tension O2 demand + diastolic coronary
flow Angina
LVEDP + Myocardial failure Pulmonary congestion
-Angina + Syncope + CHF (dyspnea) ASC in AS
-Pulsus tardus et parvus
-Carotid thrill
- Harsh systolic ejection aortic murmur with thrill radiating to carotids
-S4 gallop + decreased A2 + Paradoxical split of S2
-Aortic ejection click
Dx
-EKG: LVH
-CXR: Calcification / Cardiomegaly / Congestion (pulm.) ( 3 Cs)
-Echo: Thick aortic valve leaflets + excursion of leaflets
Rx
-Limit physical activity + exercise stress test CONTRA
-Asx has excellent prognosis so no intervention
-If Sx develop: impending sudden cardiac death (aortic valve area < 0.8 cm3)
(Normally, 2.5-3)
--Surgery for valve replacement + Anticoag with target INR of 2-3
-PVBM useless on calcified valves.
Differential
Aortic sclerosis w/o HOCM
MR
PS
stenosis
-Brisk but
-Holosystolic murmur
-No radiation into
-NO late peaking
bifid carotid
neck
of systolic murmur upstroke
-Radiates to axilla, NOT
-NO delayed
carotids
-Murmur loudest
carotid upstroke
-No carotid
along left sternal
radiation
-Normal carotid
border

-NO LVH
-Echo NORMAL for
valves or mildly
affected only
-Catheterization:
NO significant
gradient across
aortic valve

upstroke
-DECREASE
with Valsalva
and Leg Raise

-Dilated LV, NOT


hypertrophy

-Increases with
inspiration
-Enlarged RV

-Echo and
EKG :
Pseudoinfarct
pattern with
large Q waves

-Normal aortic valve (if


no assoc. Aortic valve
disease)

-Echo confirms RV
enlargement

Aortic Regurgitation
Etiology
-Systemic HTN
-Aortic diseases : Syphilis / Ankylosing Spondylitis / Marfan / Rheumatic fever /
Aortic dissection or trauma
Pathophysiology
Chronic AR Vol. Overload of LV Compensatory LVEDV Dilated / less
contractile LV
Acute Severe AR No time for compensatory dilation LVEDP but Normal
LVEDV
If MR complication LVEDP reflects back into pulm. Vasculature Acute
Pulm. Edema
Acute Severe
Chronic
CO
Even Narrower Aortic pulse
Pressure
Even smaller LV

CO
Narrow Aortic Pulse Pressure ( aortic diastolic
P)
Small LV
Large SV Systolic / Diastolic P Pulse P
Regurg/backflow INTO LV compensatory SVR
decrease
-Aortic Diastolic P to maintain peripheral blood
flow

Sx:
-Dyspnea (MC)
3 murmurs:
-Diastolic decrescendo systolic murmur
-Austin Flint murmur (water hammer pulses)
-Duroziez sign: Systolic +/- diastolic thrill and murmur over femoral arteries
S3 in early stages of LV decompensation
EKG

CXR

Echo

LVH with vol. overload


pattern
(Narrow but deep Q
waves in left precordial
leads)
Rx

LV + Aortic root dilation

LV + Aortic root dilation


+ LV vol. overload
+Ant. Mitral valve leaflet
flutters

Diet (salt restriction)


Diuretics
ACE inhibitors / ARBs / CCB (Nifedipine) Vasodilators to Reduce afterload!
Aortic valve replacement if EF < 55% OR LV systolic diameter > 55mm