EKG with LVH - tall qrs

EKG with LAE - lead 1 - p is bifid or inverted

Echo doppler used in AoS measures: - the peak instantaneous gradient to determine stenosis
severity

Cath used in AoS measures: - peak to peak gradient to determine stenosis severity - USUALLY
SMALLER

valve area vs gradient: which is better to determine severity - valve area

Ao valve area of mild stenosis - 1.5-2

Ao valve area of moderate stenosis - 1.1-1.5

Ao valve area of surgical stenosis - <1

Ao valve area of critical stenosis - <.75

3 cardinal s/s for corrective intervention of AoS - 1) chest pain - 5 yr

2) syncope - 3 yr
3) CHF (dyspnea) - 2 yr

Medical therapy in AoS - what helps what hurts? - LIMITED - may be harmful
digoxin and other positive inotropes help temp
AVOID nitrates and other vasodilators (syncope)

What should the pt be advised to do with AoS - reduce activities

limit exposure to stress
reduce salt

surgical therapy for AoS - VALVE REPLACEMENT - esp in pt that are symptomatic, in pt that are
aysmptomatic, valve area should be <.75

AoS valve repalacement options - homograph

bioprosthesis
mechanical

Etiology of AoR(7) - HTN

deg valve dz
bicuspid Ao
rhematic fever
anyklosing spondylitis
disseaction of Ao
ao root dilation - MARFANS

hemodynamics of AoR - as regurg increases, LVE, then LVH, then inc LVEDP, inc LA-P, Then inc
PCWP, then pulm congestion leading to LV failure and dec LV systolic fxn

Clinical presentation of AoR - aymptomatic

non-specific s/s - chest pain, CHF

Dx/PE of AoR(4) - WIDE PULSE PRESSURE

bounding carotid and peripheral pulses
Diastolic Decresecndo murmur at base radiating to apex
displaced PMI

CXR of AoR - Lve and pulm edema

EKG of AoR - LVE, LVH, LAE

Echo of AoR - TEST OF CHOICE

asses LV size and contractility
assess LA size
morph of Ao valve
determine severity or Ao insufficiency by size of REGURGITANT Jet

Dopper on mild AoR - gradient bw Ao and LV in diastole, thus slope is shallow as a high velocity
is maintained

Dopple in Sever AoR - LVEDP increases sharply, narrowing the diastolc P gradient, making the
slope STEEP - quicker drop in flow velocity

CAth in AoR - asses LV size and contractility

calculate the regurg fraction
ao root injection - no dye should go into LV therefore the severity of the regurg is determined
by the amount that leaks back into the LV
ALSO - can determine pressure gradient

MGMT of AoR - Difficult to determine when to intervene

DANGER of sustaining irreversible LV damage and operating too late

LVE >5.5 by echo is when they should have REPLACEMENT

KNOW AORTIC REGURG ALGORITHM - KNOW AORTIC REGURG ALGORITHM

Valve REplacement options of AoR - homograph
xenograph bioprosthesis
mechanical valve

Medical tx of AoR - AFTERLOAD REDUCTION - ae/arb

diuretics, dig, and nitrates also
reduce activities and salt

etiology of TS - RARE
rheumatic verver
carcinoid tumors

Hemodynamics of TS - increase TV gradient with RAE and engorgement of the vena cavas and
then Right HF

Clinical presentation of TS - when severe, Right HF, JVD, Hepatomegalu, Ascites, Edema

Dx/PE of TS - hard to hear, diastolic low pitch rumble

possible opening snap
prominent a waves on venous wave form
Right hF findings

CXR TS - may show righ heart border enlargement

EKG TS - RAE

Echo TS - restricted TV excursion with increased gradient from RA to RV

RAE
TV area

Cath TS - RIGHT Heart Cath - may show pressure gradient

MEdical MGMT TS - diuretics

Intervention is Ts - balloon valvuloplasty

No Sx
No mech valves (thrombosis)
Tissue valves preferred

etiology TR - pulmonary HTN***

degenerative dz
CHF
carcinoid tumors
hemodynamics of TR - increased RA size -> increase RV size _> Rv failure

clinical presentation of TR - as/s

may have right HF

CXR TR - Righ heart enlargement

EKG TR - RIGHT HEART enlargement

ECHO TR - RAE
RVE
TV morphology and fxn
doppler will show regurg and estimate severity

Surgical therapy TR - Not that helpful

prosthetic valves thrombose

PULMONIC stenosis/regug - well tolerated no problems

Etiologies of AoS - degenerative valve dz

congenital bicuspid ao valve
rheumatic fever

Pathology AoS - scarring and fibrosis interferes with leaflet opening

Hemodynamic effect of AoS - scarred valve-> dec CO-> LVH ->LVE->inc LVEDP -> inc PWCP-
>Pulm Edema - > dec EF - > cardsiogenic shock

clinical presentation of AoS - asymptomatic until severe -

arrythmia,
endocariditis
chest pain
dyspnes
heart failure
snycope

PE of AOS - EASIEST murmur to hear

harsh ejection radiating to carotids
S2 not aidible
CArotid upstroke - tardus et parvus

CXR AoS - AoV calcification

LVE
Pulm congestion
MS pathology - scarring and fusion of commisures - fish mouth

etiology of MS - rheumatic fever

degenerative vale dz

hemodynamic effect of MS - inc LA-P -> inc PCWP->pulm congestion and edema->right HF

Pressure gradient in MS - increase pressure gradient across mitral valve - LA P is greater than LV
diastolic pressure to maintain foward flow
Tachycardia and Afib increase pressire gradient therefore increasing decompensation

2 things that make MS worse - Tachycardia and Afib

SEverity of MS is based on - the symptoms

the pressure gradient
**mitral valve area

Stages of Mitral Stenosis - look at chart in book

clinical presentation MS MILD - asymptomatic until severe - decompensate in times of stress

infection and increased hr
a fib, thromboembolism, EVA and endocardidtis may develop in mild stage

clinical presentation MS SEvere - dyspnea

hemoptysis
hoarseness
fatigue
right HF

Complications of MS - afib
embolism
endocardidtis

s.s of reactive pulm HTN in MS - decreased exercise tolerance

edema
hepatomegaly
cardiac cirrhosis
cardiac cachexia
hoarseness

DX of MS - diastolic low freq rumbling at apex in left lateral position

HARD to HEAR
CXR MS - MV calcifications
Pulm vascular congestion
LAE

EKG MS - LAE - p mitrale

Right ventricle hypertrophy

Echo MS - DIAGNOSTIC TOOL OF CHOICE

restriction in valve
doming
LAE
MVA
Determies candidacy of valvuloplasty ot commissurotomy

CATH MS - confirm Echo

suspiscion of MS but echo suboptimal
MUST want to intervene
Pressure gradient = PCWP - LVEDP
MVA
pressure of CAD

Prognosis MS - influenced by s/s

MEdical therapy of MS - dec heart rate

maintain sinus rhythm
improve flow across valve
Diuretics and Nitrates - caution in hypotension
NEED surgical intervention - med mgmt will fail

Surgical intervention MS - Do prior to irreversible pulm HTN and Right HF

do when <1 MVA
Balloon valvuloplasty
commisurotomy
^^ best if no MR, atrial thrombus, or calcification
MV replacment

Etiology MR (6) - rheumatic fever

degenerative valve dz
cardiomyopathy
ischemic papillary mm dysfxn
prolapse
endocardidits

hemodynamics of MR - depends on amount regurg

LVH, LVE, muscle failure, pulm htn, right heart failure

clinical presentation MR - as/s

dsypnea
fatigue
malaise
a fib may occur

Dx of MR - EASIER THAN MS
holosystic apical murmur that radiates to left axilla

CXR of MR - LVE
LAE
Pulm congestion

EKG MR - LVE
LAE

ECHO MR - TEST OF CHOICE

LA and LV size
MRA
shows velocity
pressure gradient

2 main criteia obtained by ECHO - flow reversal demonstrated in systome in pulm veins
incerase LV size
(some centers have exercise capacity and and ETT)

CATH MR - measures right sided pressure

calculates regurg fration
assess CAD - pre op**

Criteria to decide MR - LV dimension

LA Size
Size of REgurg jet
Right sided pressures

WHy is timing of Sx important in MR - LV failure can become irreversible despite valve

replacement

Why is the LV failure not noticiable sometimes on Echo - the EF doesnt measure the LV failure
truly because everything out of the LV also goes into LA not just Ao therefore after repair, it will
just measure the EF going out the Ao and will show that it isnt much improved because that is
the true EF
MEdical therapy for MR - Afterload reduce - Ace/ArBs/hydralazine
nitrates
Diuretices
control HR/NSR

Surgery of MR - RAPAIR - better in prolapse and better overall

Replacement - bio or mechanical