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 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