Lecture 20 November 24th-cv Valves

1DDX: LECTURE 20 – NOVEMBER 24th, 2006 CARDIAC VALVULAR DISEASES Page 4 AORTIC STENOSIS • Valve separates left ventricle from aorta • Narrowing of aortic valve: obstruction of blood flow. Decreased cardiac output. More blood remains in left ventricle. • More severe stenosis, smaller opening of valve, more severe symptoms. Page 5 May be congenital, may be degenerative (causes scarring over time) or may be caused by rheumatic fever (RF) If rheumatic fever is cause, it never occurs alone, it is always accompanied by mitral valve stenosis. (the mitral valve is most commonly affected by RF) Effects: Stronger contraction of left ventricle,  hypertrophy of LV. Myocardium may grow inward, decreasing volume of LV. Characteristic Syncope: • Not enough blood supply to aorta, main cerebral arteries originate from aorta, not enough blood to cerebral vascular tree. • Episodes of syncope happens during exercise: greater demands on heart. Episodes may also follow arrhythmias (awareness of heart beat, palpitations). Angina: Coronary arteries originate from arch of aorta as well: decreased blood supply. Dyspnea on exertion: Congestion of pulmonary veins due to extra blood in the left ventricle. Increased pressure in left ventricle  left atrium  pulmonary veins. Increased pressure in pulmonary tree  SOB on exertion. (SOB: early sign of left-sided heart failure.) DDX: Fainting may be cerebral insufficiency due to Aortic Stenosis (esp. in older patients) Physical examination: • Fatigue (D/T low cardiac output) • Dyspnea on exertion • Palpitation • Dizziness • Fainting • Anginal pain • Pallor (low CO) • Decreased amplitude of pulse (weak pulse) • Apical impulse: displaced laterally due to hypertrophy of left ventricle • S1 is normal on auscultation • Displaced left border of heart detected on percussion. DDX LECTURE 20, NOVEMBER 24th – PAGE 1

•

Murmur? Systolic, blood goes through this valve during systole, and the murmur occurs because the valve won’t open fully. Murmur radiates widely to right side of neck and down left sternal border, possibly to apex (heard best in 2nd intercostal space, to right of sternum). Can’t diagnose aortic stenosis based on murmur alone.

Diagnosis: LV hypertrophy (takes years to develop) CXR: cardiomegaly Heart Catheterization will help rule out CAD. Prognosis: Fulmanant: deteriorates quickly. Without valve replacement, survival is 2-3 years following first episode of syncope. AORTIC REGURGITATION / INSUFFICIENCY / INCOMPETENCE Diameter of orifice is normal, but valves do not close properly. Blood regurgitates into left ventricle from aorta. Page 6 Causes: Rheumatic heart disease and infective endocarditis are the most common causes of aortic regurgitation. No problem during systole. During diastole, the aortic valve should close, but it doesn’t, there is blood flowing backwards against resistance, creates sound of murmur. Signs and symptoms • Angina: Portion of blood flows backwards, reduced blood flow in aorta, same as above for stenosis • Orthopnea may be PND: paroxysmal nocturnal dyspnea • Water-hammer pulse: High initial amplitude, then it collapses. Bounding pulse: see Bates. • PMI: apical impulse: displaced laterally • Blood pressure: Increased systolic, very low diastolic pressure. Wide pulse pressure. Characteristic. • S1 will be normal (closure of mitral and tricuspid valves). These valves are not involved. • Diastolic murmur will be heard best at Erb’s point (left 3rd interspace). High-pitched, blowing, diastolic, decrescendo (Decreases in amplitude). (use diaphragm of stethoscope) • Patient should be sitting up and leaning forward to hear this best. • Radiation of murmur down left sternal border towards apex. • How to distinguish from other murmurs? Echocardiography. (ECG) Special Signs: • Duroziez’s sign: maybe, maybe not • Corrigan’s pulse: large, rapid, rapid full in diastole, check Bates • De mussett’s sign: Bobbing movement of the head caused by increased stroke volume (DDx with Parkinson’s). Also d/t increased pulse pressure • Quincke’s sign: nail bed capillary refill: blanching and reddening of nails on gentle pressure (d/t wide pulse pressure) • Muller’s sign: patient opens mouth, observe uvula. Will see systolic pulsations of uvula due to DDX LECTURE 20, NOVEMBER 24th – PAGE 2

wide pulse pressure. Diagnosis: Page 7 ECG: very diagnostic MITRAL VALVE PROLAPSE See other names in notes. Occurs during SYSTOLE. Usually in healthy young women. Asymptomatic for years. Other patients may have arrhythmias Chest pain: • Not related to physical exertion, • Pain is variable in character, • Pain may be migratory, • May take more than ½ hour to relieve pain. • (these features distinguish it from angina) Due to arrhythmias, may be small increased risk of embolism (increased BP and turbulence, predisposition of thrombus formation) and stroke, infective endocarditis. Mid-systolic click: this is diagnostic, along with ECG. In general, MVP has benign course Wide pulse pressure: may also see this in patients with isolated systolic Ht. Systolic high, diastolic normal. Advancing stages of dyspnea Dyspnea on exertion  orthopnea (d in supine position)  paroxysmal noctural dyspnea. Case 1: A 50-year-old woman who had an “innocent” murmur diagnosed in childhood, presents with dyspnea on exertion, orthopnea and paroxysmal noctural dyspnea of several month’s duration. On questioning, she describes a 1-year history of fatigue and exhaustion that has limited her daily activities. She has not seen a physician in years. On physical examination, her blood pressure is 110/70mm her jugular venous pressure is 8cm H2O and she exhibits 1+ pulses with normal arterial upstrokes and bibasilar rales. There is a laterally displace apex but with a palpable S3, soft S1, a widely split S2 a loud S3 grade II/IV blowing, a highpitched systolic murmur heart best at the apex and radiating to axilla, left infrascapular area. She has trace edema, no clubbing/cyanosis. Analysis: What valve is involved? • • •

Patient: Female, 50 year old woman. She was diagnosed with an “innocent” murmur (one that is physiological, will disappear with growth) in childhood. Dyspnea on exertion, orthopnea, PND: shows involvement of pulmonary vascular tree, left cardiac DDX LECTURE 20, NOVEMBER 24th – PAGE 3

•

failure. More severe case because the SOB is at rest (orthopnea) and PND. These 3 signs are indicative of left cardiac involvement. This is a complication of something else. What’s going on?

• • • • •

Now she has fatigue and exhaustion that is limiting her daily activities. Normal blood pressure. JVP is very high (8, normal is 2) Right heart is likely involved now. Rales: crackles. Basilar: at the base of the lungs. Auscultate the lower portion of lungs from posterior.

• • •

We still want to know the origin of the problem… Laterally displaced apex: LV enlargement. Heard best at apex: mitral valve.

•

Is it mitral valve stenosis or mitral valve regurgitation?

•

It is a systolic murmur, so it is mitral valve regurgitation.

Case 2: A 36 yr old man with a history of bilateral lens dislocations is seen because of progressive fatigue, dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. At physical examination, he is noted to be quite tall with a height of 6ft 6 inches (195cm). His blood pressure is 160/60. There is no jugular venous distension, but systolic pulsations of the uvula are noted, as is quick collapse of the arterial pulses, which is seen in the fingertips with transillumination. There are bibasilar rales, together with a diffuses and hyperdynamic apex beat that is displaced laterally and inferiorly, a soft s1 and s2 a loud s3, and grade iii/vi high-pitched nearly holodiastolic murmur heard best at the cardiac base particularly the right upper sternal border. A late diastolic rumble is heard at the apex. • • • •

What valve is involved? Aortic. Bilateral lens dislocations: could be due to high blood pressure or WIDE pulse pressure. He has signs of pulmonary involvement Wide pulse pressure: 100 (normal is 40)

• • • • • • •

No jugular distention (no right heart involvement yet) Uvula? Systolic pulse S3: sign of CHF. Apex is displaced due to enlarged heart (cardiomegaly) Loud S3 Holodiastolic murmur: found throughout systole. Aortic involvement: regurgitation.

Case 3: A 44-year-old Mexican man complains of a progressively worsening cough over the past 5 months. His cough is associated with shortness of breath on exertion over past year. He must sleep propped up on 2-3 pillows to breathe (he has two- to three-pillow orthopnea). He notes PND intermittently. DDX LECTURE 20, NOVEMBER 24th – PAGE 4

The patient has lived in a very rural area of Mexico for most of his life. His medical history is significant for several episodes of sore throat as a child. Physical Examination Examination of the lungs reveals bilateral basilar crackles but is otherwise clear to percussion and auscultation. A cardiac exam reveals a prominent first heart sound S1 . A soft I/VI holosystolic (throughout systole) murmur is heard at the apex. 2nd heart sound S2 is normal. There is loud opening snap. Soft diastolic murmur is heard best at apex, left axilla. There is no jugular venous distension and no peripheral edema. Remainder of physical exam is within normal limits. An ECG shows notched P waves, but is otherwise normal. A chest radiograph shows bilateral costodiaphragmatic angle blunting (accumulation of fluid). The left atrium appears slightly enlarged. The lung fields are otherwise clear. What would be on DDX list? • Mitral stenosis • Rheumatic fever • Lung infection (eg. TB) • Congestive heart failure due to… • Mitral regurgitation Who is the patient? 44-year-old male • What is his major complaint? Worsening cough over past 5 months, accompanied with shortness of breath on exertion, 2-3 pillow orthnopnea, intermittent PND. • In a rural area, he may not have had as much medical attention. He had several episodes of sore throat, but he might not have been diagnosed with a Strep infection. • • • • • • •

Cough may be sign of cardiac or of respiratory problem. Signs of left-sided heart failure, pulmonary congestion Blunting of costo- diaphragmatic angle = pleural effusion Bilateral: very important. With pneumonia, you will listen over area involved and hear rales. If it is bilateral, this is a sign that the heart may be involved. Diastolic murmur at apex suggests involvement of mitral valve. Stenosis may be suspected. Notched or high P wave means left atrial enlargement. P wave will have high amplitude because it is dilated. Sore throats: may be indication of multiple Strep infections as a child. Probably didn’t receive treatment, he is now experiencing complications from this condition many years later. Mitral valve is most often involved, and he is demonstrating signs of congestive heart failure.

•

Cough was presentation of CHF, pulmonary congestion that happened as a result of mitral stenosis from rheumatic fever.

•

In this case, there may be a few things going on: soft S3 may not result from our diagnosis.

DDX LECTURE 20, NOVEMBER 24th – PAGE 5