Valvular Diseases

Valve Pathophysiology Symptoms Signs ECG Medical Tx Surgery
Mitral Stenosis Rheumatic fever. Pregnancy

Impedes LV filling:

1.  ↑ LA pressure -> pulmonary congestion

2. ↓ CO

– Dyspnea, orthopnea, PND

– Hemoptysis (rupture of pulmn vessels)

– Systemic embolism (blood stasis in enlarged LA) “more in stenosis, less in regurg”

– Hoarsness (enlarged LA) “more in stenosis, less in regurg”

– Rt HF (hepatomegaly, ascites, edema)

– A fib

– ↓ pulse pressure

– Pulmn rales

– Sternal lift (enlarged LV)

– LAE: P mitrale (broad, notched P waves)

– RVH: tall R waves, Rt axis deviation

– A fib

↓ Preload:

Na restriction + furosemide

 

× Abx

If class III and failure of medical tx
Mitral Regurgitation Ischemia, systolic HF, HTN

– Some of the LV SV -> pumped backward into the LA instead of the aorta:

1. 1.  ↑ LA pressure -> pulmonary congestion

2. ↓ CO

– Forceful displaced LV impulse

– Distended neck veins

 

– LAE: P mitrale (broad, notched P waves)

– LVH: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm, Lt axis deviation

 

↓ Afterload: ACEI ± nitrates

 

× Abx

LVEF < 60%

Or

LVESD <45mm

Mitral Valve Prolapse MC congenital valvular abnormality. Young women.

More in EDS, PKD, Marfan’s

Most are asx. If sx, usually due to arrythmias:

Lightheadedness, palpitations, syncope, chest pain

B-blockers for chest pain and palpitations

 

Abx only if + MR

Rarely
Aortic Stenosis Calcification + degeneration -> elderly

– Outflow obstruction -> ↑ EDP -> LVH

Angina, syncope, dyspnea from CHF – Weak + delayed pulse “Pulsus parvus et tardus”

– Carotid thrill

– LVH: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm, Lt axis deviation Straight to surgery if Sx

 

√ Abx

 

Replace if severe (valve area < 0.8 cm2, [normal = 2.5-3 cm])
Aortic Regurgitation HTN and ischemia, CTD

– Leads to volume overload of the LV -> the ventricle compensates by increasing its EDV -> LVH (↓ dBP -> ↓ coronary perfusion)

– If acute (IE, aortic dissection) -> no compensation -> ↓ CO

Angina, syncope, dyspnea from CHF – Many pripheral signs -> check pic at the end – LVH: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm, Lt axis deviation ↓ Preload:

Na restriction + furosemide

 

√  Abx

 

LVEF <55%

Or

LVESD >55mm

 


 

Murmurs

Valve Murmur Best heard at? Accentuated by? Others
Mitral Stenosis Low pitched middiastolic rumble Cardiac apex in the left lateral position Expiration Loud S1, opening snap (following S2)
Tricuspid Stenosis High pitched middiastolic rumble Tricupsid area Inspiration
Mitral Regurgitation Holosystolic murmur Cardiac apex -> radiating to left axilla Expiration Soft S1, wide split of S2, S3
Tricuspid Regurgitation Holosystolic murmur Tricuspid area Inspiration
Mitral Valve Prolapse Midsystolic click + late systolic murmur Cardiac apex Valsalva or standing
Aortic Stenosis Midsystolic ejection murmur Aortic area -> radiating to carotids Expiration Paroxical split of S2, S4, carotid bruit
Pulmonary Stenosis Midsystolic ejection murmur Pulmonary area -> radiating to the back Inspiration
Aortic Regurgitation Early diastolic decrescendo murmur Aortic area -> ask pt to bend forward Expiration Soft S1, absent S2, S3, femoral A. murmur\thrill
Systolic flow murmur
Austin-Flint murmur
Pulmonary Regurgitation Early diastolic decrescendo murmur Pulmonary area Inspiration

 

  • Diastolic murmurs: mitral\tricuspid stenosis + aortic\pulmonary regurgitation
  • Systolic murmurs: aortic\pulmonary stenosis + mitral\tricuspid regurgitation + MVP

 


 


Download the PDF version: here


References:

  • Kaplan step 2 lecture notes
  • Paul Bolin’s videos
  • Toronto notes
  • Lifeinthefastlane.com

 

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