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 mid–diastolic rumble | Cardiac apex in the left lateral position | Expiration | Loud S1, opening snap (following S2) |
Tricuspid Stenosis | High pitched mid–diastolic 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 | Mid–systolic click + late systolic murmur | Cardiac apex | Valsalva or standing | |
Aortic Stenosis | Mid–systolic ejection murmur | Aortic area -> radiating to carotids | Expiration | Paroxical split of S2, S4, carotid bruit |
Pulmonary Stenosis | Mid–systolic 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