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What is a common bioprosthetic valve's advantage in Aortic Valve Replacement (AVR)?
What is a common bioprosthetic valve's advantage in Aortic Valve Replacement (AVR)?
Trans Catheter Aortic Valve Replacement (TAVR) is a procedure that can be performed by general practitioners without special training.
Trans Catheter Aortic Valve Replacement (TAVR) is a procedure that can be performed by general practitioners without special training.
False
What is one indication for performing an Aortic Valve Replacement?
What is one indication for performing an Aortic Valve Replacement?
Severe symptomatic Aortic Stenosis
Match the following types of valves used in TAVR with their characteristics:
Match the following types of valves used in TAVR with their characteristics:
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Which of the following is a sign of wide pulse pressure?
Which of the following is a sign of wide pulse pressure?
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Aortic regurgitation leads to an increase in diastolic blood pressure.
Aortic regurgitation leads to an increase in diastolic blood pressure.
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What effect does resting or sleeping bradycardia have in patients with aortic regurgitation?
What effect does resting or sleeping bradycardia have in patients with aortic regurgitation?
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In aortic regurgitation, the left atrial pressure (LAP) is __________ due to increased left ventricular volume.
In aortic regurgitation, the left atrial pressure (LAP) is __________ due to increased left ventricular volume.
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Match the clinical findings with their relation to Aortic Stenosis (AS) or Aortic Regurgitation (AR):
Match the clinical findings with their relation to Aortic Stenosis (AS) or Aortic Regurgitation (AR):
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Which of the following conditions is the most common cause of root-related chronic aortic regurgitation?
Which of the following conditions is the most common cause of root-related chronic aortic regurgitation?
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Acute aortic regurgitation is characterized by gradual onset of symptoms over several months.
Acute aortic regurgitation is characterized by gradual onset of symptoms over several months.
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What is the primary hemodynamic change in the left ventricle due to chronic aortic regurgitation?
What is the primary hemodynamic change in the left ventricle due to chronic aortic regurgitation?
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Chronic aortic regurgitation can be classified as ____, which typically has no symptoms.
Chronic aortic regurgitation can be classified as ____, which typically has no symptoms.
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Match the following causes of chronic aortic regurgitation with their categories:
Match the following causes of chronic aortic regurgitation with their categories:
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What kind of murmur is associated with aortic stenosis?
What kind of murmur is associated with aortic stenosis?
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Aortic stenosis typically presents with a soft first heart sound (SI) in patients with aortic valve stenosis due to degenerative pathology.
Aortic stenosis typically presents with a soft first heart sound (SI) in patients with aortic valve stenosis due to degenerative pathology.
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What pattern on an ECG indicates left ventricular hypertrophy (LVH) associated with aortic stenosis?
What pattern on an ECG indicates left ventricular hypertrophy (LVH) associated with aortic stenosis?
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The _____ phenomenon describes the low pitch component of the murmur radiating to the apex in aortic stenosis.
The _____ phenomenon describes the low pitch component of the murmur radiating to the apex in aortic stenosis.
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Match the following heart sounds or characteristics with their associated conditions:
Match the following heart sounds or characteristics with their associated conditions:
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What does a collapsing pulse indicate?
What does a collapsing pulse indicate?
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A pseudocollapsing pulse has a sharp upstroke and is high volume.
A pseudocollapsing pulse has a sharp upstroke and is high volume.
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In which condition would you typically observe a pulsus bisferiens?
In which condition would you typically observe a pulsus bisferiens?
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The ______ pulse has a high volume and sharp downstroke.
The ______ pulse has a high volume and sharp downstroke.
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Match the following types of pulses with their characteristics:
Match the following types of pulses with their characteristics:
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Which of the following is a definitive treatment for acute aortic regurgitation?
Which of the following is a definitive treatment for acute aortic regurgitation?
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The SS-50 rule applies to symptomatic severe aortic regurgitation.
The SS-50 rule applies to symptomatic severe aortic regurgitation.
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What is the typical initial symptom of aortic dissection related to acute aortic regurgitation?
What is the typical initial symptom of aortic dissection related to acute aortic regurgitation?
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In acute aortic regurgitation, the left atrial pressure (LAP) can exceed __________ mmHg.
In acute aortic regurgitation, the left atrial pressure (LAP) can exceed __________ mmHg.
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Match the following features with their associated conditions related to aortic regurgitation:
Match the following features with their associated conditions related to aortic regurgitation:
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What is the classification for heart failure with reduced ejection fraction?
What is the classification for heart failure with reduced ejection fraction?
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Angina is not considered a first-line symptom of NYHA classification.
Angina is not considered a first-line symptom of NYHA classification.
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What does the abbreviation ADHF stand for?
What does the abbreviation ADHF stand for?
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Heart failure classified as HFPEF has an ejection fraction of __________ or greater.
Heart failure classified as HFPEF has an ejection fraction of __________ or greater.
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Match the NYHA class with its criteria:
Match the NYHA class with its criteria:
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What stage of heart failure has no symptoms and only risk factors present?
What stage of heart failure has no symptoms and only risk factors present?
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Patients in Stage C heart failure are symptomatic, whether prior or present.
Patients in Stage C heart failure are symptomatic, whether prior or present.
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What does HFrEF stand for?
What does HFrEF stand for?
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The stage of heart failure that is also known as refractory heart failure is Stage ____.
The stage of heart failure that is also known as refractory heart failure is Stage ____.
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Match the following symptoms with their relevance to systolic failure:
Match the following symptoms with their relevance to systolic failure:
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Which of the following symptoms is predominantly associated with heart failure?
Which of the following symptoms is predominantly associated with heart failure?
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In patients with heart failure, orthopnea occurs immediately after lying down.
In patients with heart failure, orthopnea occurs immediately after lying down.
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What condition is characterized by an increase in left atrial pressure (LAP)?
What condition is characterized by an increase in left atrial pressure (LAP)?
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In diastolic failure, the primary issue is __________ which leads to increased left ventricular end-diastolic pressure (LVEDP).
In diastolic failure, the primary issue is __________ which leads to increased left ventricular end-diastolic pressure (LVEDP).
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Match the presentations of dyspnea with their descriptions:
Match the presentations of dyspnea with their descriptions:
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Where is the ejection systolic murmur typically located?
Where is the ejection systolic murmur typically located?
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The Austin Flint murmur is characterized by a high-pitched sound.
The Austin Flint murmur is characterized by a high-pitched sound.
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What presentation is associated with Corrigan sign?
What presentation is associated with Corrigan sign?
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The _____ de Musset sign is characterized by head nodding with heartbeat.
The _____ de Musset sign is characterized by head nodding with heartbeat.
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Match the signs to their descriptions:
Match the signs to their descriptions:
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Study Notes
Aortic Valve Replacement (AVR)
- Bioprosthetic valves are commonly used for AVR, offering less complications and eliminating need for anticoagulants.
- AVR is indicated for severe symptomatic aortic stenosis (AS) and for severe asymptomatic AS with LV ejection fraction < 50%, gradient > 60 mmHg, peak flow ≥ 5 m/s, rapid progression on yearly echocardiogram, undergoing other procedures, or symptomatic on dobutamine stress test.
- Dobutamine stress test helps differentiate severe AS from LVF with incidental AS.
- AVR has potential disadvantages including more complications and difficulty obtaining fitness for elderly patients.
Trans Catheter Aortic Valve Replacement (TAVR)
- Performed by cardiologists trained in TAVR.
- Costly procedure but considered an option when AVR is contraindicated.
- Two types of valves used in TAVR: balloon-expandable and self-expanding.
Severe/Decompensate Aortic Regurgitation (AR)
- Leads to LV failure with increased end-systolic volume, decreased ejection fraction, and increased left atrial pressure, resulting in dyspnea.
Effect on Circulatory Parameters
- Preload increases due to the backflow of blood from aorta to the LV.
- Afterload increases due to increased systolic blood pressure, stretching the heart and boosting contractility (Frank-Starling Law).
- Diastolic Blood Pressure (DBP) significantly decreases as the blood regurgitates into the LV, potentially reaching zero.
- Pulse Pressure (PP) widens due to the significant difference between systolic and diastolic blood pressure.
Signs of Wide Pulse Pressure
- Hill's sign: Lower limb BP - upper limb BP > 20 mmHg, considered the surest sign.
- Lincoln's sign: Prominent popliteal pulsations.
Nocturnal Angina
- Resting bradycardia during sleep prolongs diastole, worsening AR and leading to increased blood stealing from coronary arteries, causing angina.
- Vasoconstriction increases aortic pressure, further worsening AR by increasing the gradient between the aorta and LV.
- Strict blood pressure control is crucial.
- AR patients generally experience better outcomes when exercising due to tachycardia, which shortens diastole.
Aortic Stenosis vs Aortic Regurgitation
| AS | AR | |
|---|---|---|
| Angina | +++ (First symptom) | + (Nocturnal only) |
| Syncope | + | - |
| Dyspnea | ++ (Increased Left Ventricular End Diastolic Pressure) | + (Left Ventricular Failure → Increased Left Ventricular End Diastolic Pressure) |
| Palpitations | - (Pressure overload) | + (Volume overload) |
Aortic Stenosis
Clinical Findings
- Pulse: High volume pulse due to increased blood in the left ventricle and increased ejection fraction.
Heart Sounds
- S1: Ejection click may be present in bicuspid aortic valve (BAV).
- A2: Soft in degenerative pathology, loud in BAV pathology, and reverse split (late A2) in severe AS.
- S3: Present due to LVH & LVF.
- S4: Present.
Murmur
- Harsh, mixed frequency ejection systolic murmur with late systolic accentuation.
- Low pitch component radiating to carotids.
- High pitch component radiating to apex (Gallavardin phenomenon).
- Best heard in the aortic area.
Management
- Management largely depends on symptom severity and echocardiogram findings.
Investigations
- ECG: LV strain pattern (LVH) with Sokolov-Lyon criteria (V5/V6 R wave + VI/V5 S wave > 35 mm), minimal ST depression and asymmetric T inversion.
- X-ray: Dilated aortic arch in AS.
- ECHO: Definitive diagnosis and assessment of AS severity.
Aortic Regurgitation
Classification
- Acute AR: Usually a sudden onset due to trauma, infection, or aortic dissection.
- Chronic AR: Generally develops over time due to various valvular or root-related causes.
Chronic AR Causes
-
Valvular (Leaflet) Causes:
- Rheumatic: May be associated with mitral stenosis (MS) or aortic stenosis (AS).
- Congenital: Quadricuspid valves.
- Takayasu arteritis.
- Ankylosing spondylitis.
-
Root Related Causes:
- Syphilis (most common).
- Marfan's syndrome.
- Ehlers-Danlos syndrome.
- Rheumatological conditions including Takayasu arteritis, Behcet's disease, Cogan's syndrome (aortitis + interstitial keratitis + vestibulitis), and IgG4 related disease (large vessel vasculitis).
Chronic AR Classification
- Mild to moderate: No or minimal symptoms, possibly palpitations.
- Severe: Symptomatic due to left ventricular failure.
Chronic AR Pathology
- Core: Diastolic regurgitation.
- Diastolic Pressure: Significant pressure gradient between LV (around 10 mmHg) and aorta (around 80 mmHg) due to backflow.
Chronic AR Circulatory Changes
- Mild to Moderate: Incompetent leaflets lead to incomplete closure, allowing blood to leak back from aorta to LV.
- Ejection Fraction (EF): Normal or slightly increased.
- EDV (End Diastolic Volume): May be increased.
- LVEDP (Left Ventricular End Diastolic Pressure): Usually normal but may slightly increase in severe cases.
Collapsing Pulse
- Also observed in regurgitation, aorta-pulmonary window, or patent ductus arteriosus.
Collapsing vs. Pseudocollapsing Pulse
| Collapsing pulse | Pseudocollapsing pulse | |
|---|---|---|
| Sharp upstroke, sharp downstroke | Ill-sustained apex | |
| High volume | (N) volume | |
| Seen in AR | Seen in MR |
Pulsus Bisferiens
- Two peaks in systole:
- P: Percussion wave
- T: Tidal wave
- Normally: P > T.
- But in Hypertrophic cardiomyopathy (HCM): P < T.
Aortic Regurgitation: Management
- Symptomatic AR: Aortic valve replacement surgery required.
-
Asymptomatic Severe AR: LV failure is present but patient is asymptomatic. The "SS-50 rule" is applied:
- EF ≤ 55%
- LVEDD ≥ 50%
Acute AR
-
Causes:
- Aortic Dissection: Chest pain.
- Infective Endocarditis: Potential complication of infection.
- Rupture of Sinus of Valsalva: Right heart failure.
- Trauma: May cause damage to the valve or aorta.
-
Pathology:
- Acute Regurgitation: No time for the heart to adapt, leading to increased LVEDP, and elevated LAP (above 25 mmHg), causing acute pulmonary edema and LV failure.
-
Features:
- Short, low-pitched ejection systolic murmur (ESM) with a soft S1.
- LV Failure: Cardiovascular shock and hypotension.
-
Treatment:
- Definitive: Immediate surgery.
-
Awaiting Surgery:
- Nitroglycerin (NTG).
- Nitroprusside.
- Inotropes.
Heart Failure
- ACC/AHA 2017 Definition: A complex clinical syndrome caused by any structural or functional cardiac disorder (e.g., LVH, arrhythmia) that impairs the ventricle's ability to fill with or eject blood.
- Note:* ACC: American College of Clinical Cardiology; AHA: American Heart Association
Heart Failure Classification
Types of Heart Failure:
- HFrEF (Reduced EF < 40%): Characterized by reduced left ventricular ejection fraction.
- HFPEF/HFNEF (Preserved/Normal EF ≥ 50%): Preserved or normal left ventricular ejection fraction but impaired diastolic filling.
- HFMEF (Mid-range EF 40-50%): Left ventricular ejection fraction in the mid-range.
- ADHF (Acute Decompensated Heart Failure): Sudden deterioration of heart function resulting in fluid overload and reduced cardiac output.
NYHA Classification
- First Line Symptoms: Angina, dyspnea, palpitations.
- Syncope: Not considered a NYHA symptom.
| Class | Criteria | Reason for Mortality |
|---|---|---|
| I | Symptoms with more than ordinary activity | Negligible mortality |
| II | Symptoms with ordinary physical activity | Sudden cardiac death |
| III | Symptoms with less than ordinary activity | |
| IV | Symptoms with rest | LV failure symptoms |
Stages of Heart Failure
| Stages | Characteristics |
|---|---|
| A | - No symptoms.- No structural heart disease.- Only has risk factors: - HTN.- Atherosclerosis.- DM.- OSA. |
| B | - No symptoms.- Structural heart disease present.- E.g: 1.HTN patient → LVH. 2.Previous MI → Cardiac remodelling. |
| C | - m/c.- Patient is symptomatic (Prior/present). |
| D | - AKA refractory heart failure.- No response to any medical therapy. |
- Note: Most common presentation of heart failure: HFrEF, NYHA 2/3, Stage C.
HFrEF
Clinical Features
-
Systolic Failure Symptoms (LV Forward Symptoms):
- Due to decreased cardiac output, indicating left-sided heart failure.
- Fatigue: Can lead to cachexia (extreme weight loss) due to TNF-α.
- Decreased Urine Output.
- Cool Extremities.
- Cyanosis.
- Altered Mentation.
- S3 Heart Sound.
- Cardiomegaly (Dilated LV).
- Displaced Apex.
- Pulsus Alternans.
- Narrow Pulse Pressure.
Diastolic Failure Symptoms
-
Concentric LVH (Left ventricular hypertrophy):
- Cavity size decreases.
- Volume decreases.
-
Systolic Failure:
- Insufficient dilation.
- Increased end systolic volume (ESV).
- Increased LVEDP (Left ventricular end diastolic pressure).
- Increased LAP (left atrium pressure).
- Increased PCVP (Pulmonary capillary venous pressure).
- Pulmonary exudation.
Dyspnea
- Crackles: Typically present in acute presentation.
- Pleural Effusion: More common on the right side, patients may prefer to lie on their right side.
Presentations of Dyspnea
- Orthopnea: Dyspnea that arises immediately after lying down.
- Paroxysmal Nocturnal Dyspnea (PND): Dyspnea occurring 2-3 hours after lying down.
- When the patient lies supine, fluid shifts from interstitial to intravascular space.
- This fluid increase is not accommodated by the failing heart, leading to backflow into the pulmonary circulation and symptoms of air hunger.
Associated Murmurs
- Ejection Systolic Murmurs: Heard at the base of the heart.
-
Austin Flint Murmur:
- Low-pitched, mid-diastolic murmur.
- Caused by displacement of the anterior mitral leaflet by the regurgitant jet.
Peripheral Signs
| Sign | Presentation |
|---|---|
| Corrigan sign | Prominent carotid and supraclavicular pulsations |
| Alfred de musset sign | Head nodding with each heartbeat |
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Description
This quiz covers key concepts related to aortic valve replacement (AVR) and transcatheter aortic valve replacement (TAVR). Learn about indications for AVR, the significance of the dobutamine stress test, and the types of valves used in TAVR. Explore complications and patient considerations in valve replacement procedures.
