Valvular Heart Disease.docx

Aortic stenosis Pathogenesis LV pressure increase, causing pressure hypertrophy, angina, CCF, causes hypertension. Concentric hypertrophy, sustained heaving apex, area is the same Normal dia. 4cm2 symptoms at 1cm2 Stenosis can be valvular: subvalvular: supravalvular Etiology congenital congenital AS or bicuspid arotic valve rheumatic, degenerative, pagets disease, SLE, RA, post radiation. Symptoms: dyspnea (1st symptom with 5 year survival), syncope, angina, sudden death. Signs: tardeus and parveous pulse, high bp, soft and split 2nd heart sound, s4 gallop Systolic ejection murmur, crescendo-decrescendo, Sv1+ Rv5 > 35mm means LVH Severity of AS mild >1.5 moderate 1.5-1 severe <1

Aortic regurgitation Causes: bicuspid valve, RHD, syphilis, dissecting aneurysms, IE, SLE, traumatic aortic stenosis. Symptoms: mild to moderate- asymptomatic to palpitation, Severe AR – breathlessness, angina nocturnal angina. Signs: all peripheral signs of AR 

Head light sign: alternate blanching and de-blanching of forehead.

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Landolfi’s sign: Systolic contraction and diastolic dilation of the pupil.

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Becker’s sign: Visible pulsation of the retinal arterioles

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De Musset’s sign: Bobbing of the head with each heartbeat (like a bird walking)

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Muller’s sign: Visible pulsations of the uvula

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Quincke’s sign: Capillary pulsations seen on light compression of the nail bed.

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Corrigan’s pulse: A rapid and forceful distension of the arterial pulse with a quick collapse.

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Mayne’s sign: A decrease in diastolic blood pressure of 15 mmHg when the arm is held above the head (very non-specific)

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Shelly’s sign: Pulsation of the cervix

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Rosenbach’s sign: Hepatic pulsations

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Gerhardt’s sign (aka Sailer’s sign): Pulsation of the spleen in the presence of splenomegaly

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Traube’s sign: Systolic and diastolic sounds heard over the femoral artery (“pistol shots”)

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Duroziez’s sign: Gradual pressure over the femoral artery leads to a systolic and diastolic bruit

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Hill’s sign: Popliteal systolic blood pressure exceed brachial systolic blood pressure by ≥ 60 mmHg (most sensitive sign for aortic regurgitation)

Murmur: Austin flint a mid diastolic murmur heard paradoxically in AR.

Mitral stenosis: Valve size 4cm2, stenosis at 1.5cm2 Causes: RHD, mitral valve degeneration. LA pressure increases – LA hypertrophy – pulmonary venous HTN – hemoptysis Can cause winter bronchitis, streaks of blood Dyspnea and cough due to J cell exudates, pulmonary arterial HTN takes time, JVP increases, hepatomegaly, pedal edema, palpitation – atrial fibrillation Symptoms – dyspnea, palpitation, hemoptysis, cough, edema, syncope, embolism. Sign – low volume pulse, less mean arterial pressure, increase JVP a wave absent, tapping apex LOUD S1, mid diastolic murmur, opening snap, shift correlate the severity. Pre-systolic accentuation, s2 OS interval inversely relates with severity.

Mitral regurgitation: Causes: Mitral annulus Annular calcification Leaflets Myxomatous degeneration, Rheumatic disease, Endocarditis, SAM (hypertrophic cardiomyopathy) Chordae tendineae Rupture (idiopathic),Endocarditis Papillary muscles Dysfunction or rupture Left ventricle Cavity dilatation Symptoms: Dyspnea on exertion, Fatigue, Palpitation, RV failure symptoms Signs: soft s1, s3 gallop, murmur systolic. Severity of MR  Apical displacement and size  Palpable S3  Longer/louder MR murmur  S3 intensity  length of diastolic flow rumble  Wider split S2 (earlier A2)

Hypertrophic cardiomyopathy (great masquerder)  Myocardial hypertrophy  Non-dialated hyperdynamic chambers  Absence of any other cardiac disease  Independent of obstruction Description by teare, brock myomectomy, marrow popularized myomectomy, sigwart PTSMA Beta-myosin heavy mutation 14q12 MISSENCE MUTATION, Malignant mutation – associated with sudden cardiac death, B- MHC and tropomyosin mutation, cTnT mutation have only mild hypertrophy but worst prognosis and increase SCD. Other genetic disorder- Noonan, fredrechich ataxia, hunter-hurler, aceyl CoA def. Mitral vlave abnormalities – elongation of leaflet, anterior displacement of papillary muscle, very short choridae, Systolic anterior movement DIASTOLIC DYSFUNCTION- HALLMARK when systolic dysfunction occurs its called burned out HCM Nt- pr BNP increases in diastolic dysfunction Normal EF with less CO LVOT mainly occurs due to SAM which occurs due to 2 phenomenon Venturi effect and drag effect MR occurs with posterior jets 80% 20% intrinsic defect and jets directed anteriorly Autonomic dysfunction – very poor prognosis, 25% will have abnormal pressure. C/f – dyspnea, angina, presyncope, syncope, sudden death Risk list Conventional Family h/o of SCD Unexplained syncope Repetitive non-sustained VT Hypotensive Massive LV hypertrophy Late gadolinium enhancement

Potentially high risk End stage phase LV apical aneurysm with scar

Potential arbitrator Substantial LVOT Diffuse gadlolinium enchan. Transmural scar Multiple Sacrcomere mutation Intensive sports Athersosclerotic plaque

Examination –       

JVP with prominent a wave Pulses bigeminus Double apical impulse / triple apical impulse S2 paradoxical split S3 in decompensate LV S4 atrial systole Murmur – MR murmur is heard, LVOT murmur at apex and b/w apex and sternum increases on standing, valsalva, amyl nitrate.  Harsh crescendo- decrescendo murmur, ejection systolic murmur  Brockenbrough-Braunwald-Morrow sign decrease pulse pressure after ectopic beat