Valvular Disorders PDF

Valvular Disorders Brittney Hulsey DMSc PA-C 1 Learning Objectives Identify the etiology of valvular disorders. Identify history and physical exam findings characteristic of these disorders and the accompanying characteristic murmurs. Formulate correct diagnostics...

Valvular Disorders Brittney Hulsey DMSc PA-C 1 Learning Objectives Identify the etiology of valvular disorders. Identify history and physical exam findings characteristic of these disorders and the accompanying characteristic murmurs. Formulate correct diagnostics and treatment options for the various types of valvular disorders. 2 Table of contents. 0 Heart 1 Sounds Cardiac 0 Auscultatio 0 Case 2 n 4 0 Murmurs 3 3 0 1 Heart Sounds 4 5 Heart Sounds S1= Lub ○ Systole ○ Mitral and tricuspid valve close ( this is the sound you are hearing) ○ Aortic and pulmonic valves open S2=dub ○ Diastole ○ Closing of the aortic and pulmonic valves ( this is what you are hearing) ○ Mitral and tricuspid valves open ○ Ventricles fill Lub Dub LubDub with Image 6 7 8  Split S2 A2P2 Explained S2 (Dub) The second heart sound can be split into segments ○ A2 P2 ○ The aortic valve will always shut slightly sooner then the pulmonic (THIS IS NORMAL) ○ Also known as Physiological split ○ Remember Erb's point? ○ Pathology can be identified with variations of this split 9  Fixed Splitting S2 Fixed split ○ A2 P2 split with a consistent interval that does not vary between breathing. ○ Causes Right ventricular failure Atrial septal defect Pulmonary hypertension Splitting S2 10  Wide Splitting S2 Wide split ○ Heard throughout the respiratory cycle and further widens during inspiration. ○ Causes ○ Pulmonic stenosis ○ Right bundle branch block 11  Paradoxical Splitting S2 Paradoxical split ○ Known as reverse split S2 ○ Usual order of S2 components are reverse: P2 A2 Causes Aortic stenosis Left bundle branch block Hypertrophic cardiomyopathy Severe Hypertension Pacemaker-induced rhythm 12  Other S3 Heart Sounds ○ “Ventricular gallop ○ Extra heart sound that occurs shortly after S2 ○ Produced during rapid filling phase of ventricles in early diastole when blood fills into a volume-overloaded or non- compliant ( stiff) ventricle. ○ Lub-dub-ta ○ S1, s2,s3 ○ Note: this can be a normal variance in young or pregnant ○ Causes Heart failure * Dilated Cardiomyopathy Mitral or Aortic regurgitation S3 13  Other S4 Heart Sounds ○ “Atrial gallop” ○ Occurs just before the first heart sound ( s1) ○ Produced by atria contracting forcefully to push blood into a stiff or non-compliant ventricle ○ Ta-lub-dub ○ Causes Left ventricular hypertrophy Hypertrophic Cardiomyopathy Ischemic heart disease S3 and S4 14  2 Auscultation 15 16  3 Murmur 18 Murmur A sound the heart makes when there is turbulence of blood flow through a ❏ Stenotic valve ❏ Leaky valve ❏ High blood flow “innocent” ❏ Structural heart defects 19 Grades of Murmurs 20  Murmur Timing Break murmurs up between systolic and diastolic Sounds made by forward flow are due to stenotic valves ○ Abnormal narrowing or stiffening of a heart valve Sounds made by backwards flow are due to leaky valves ○ Regurgitation occurs when a valve fails to close properly 21  Murmurs Change Breathing Position ○ Inspiration ○ Standing ( Valsalva ) Negative pressure in the Decreases venous return to chest increases venous the heart which reduces the return to the right side of intensity of most murmurs the heart due to decrease blood flow Right sided murmurs ○ Squatting ( release of valsalva) become louder Increases venous return Left sided murmurs and systemic vascular become quieter resistance, increasing left ○ Expiration ventricular volume and Increases venous return to makes most murmurs the left side of the heart louder Left sided murmurs become louder 22 Murmurs Change 23  Murmurs Change Leaning forward ○ Aortic murmurs louder Left lateral decubitus ○ Mitral murmurs louder 25  Murmurs Changes Position/ Effect on Murmurs Examples Breathing Inspiration Increases right-sided murmurs Tricuspid regurgitation, Pulmonic stenosis Expiration Increases left-sided murmurs Mitral regurgitation, Aortic stenosis Standing Decreases most murmurs except HCM Hypertrophic cardiomyopathy, Mitral valve and MVP (increase) prolapse Squatting Increases most murmurs, decreases Aortic stenosis (increases), Hypertrophic HCM and MVP cardiomyopathy (decreases) Left Lateral Enhances mitral murmurs Mitral stenosis, Mitral regurgitation Sitting, Leaning Enhances aortic murmurs, especially Aortic regurgitation Forward diastolic 26 Systolic Murmurs Aortic Stenosis Mitral Valve Prolapse Mitral Regurgitation Pulmonic Stenosis Tricuspid regurgitation Hypertrophic cardiomyopathy Ventricular septal defect* 27 Most common murmur Aortic Stenosis Narrow aortic valve Cause ○ > 70 years old likely degenerative calcification ○ < 70 likely congenital ○ rheumatic heart disease S/S ○ SAD face Syncope Angina Dyspnea on exertion LVH Never give nitro to these patients What do you hear? ○ Paradoxical S2 ○ Systolic crescendo decrescendo murmur ○ RUSB ○ Increase with squatting and expiration ○ Louder with leaning forward Radiation ○ Carotids Treatment: valve replacement or balloon aortic valvuloplasty 28  Mitral Valve Prolapse One or both leaflets bulge into the left atrium during systole ○ Abnormally large, floppy leaflets or excess connective tissue Most common in women Causes ○ Connective tissue disorder Marfans Ehlers Danlos S/S ○ Chest pain ○ Palpitations ○ Dizziness ○ Fatigue What do I hear? ○ Midsystolic ejection click Due to tensing of leaflets and chordae tendineae ○ Inc with standing ( earlier click) Treatment ○ Beta blockers ○ Mitral valve repair or replacement 29  Mitral Valve Prolapse Everyone down for the party except MVP and HCM Squatting ○ Increase venous return and systemic vascular resistance ○ More blood flow back to the heart to increase left ventricular volume ○ THe leaflets of mitral valve are stretched tighter and don't prolapse as early with a large ventricular volume ○ This delays the click because they are helo more securely Standing ○ Reduces venous return and preload ○ Less blood filling the left ventricle ○ Small ventricular volume brings the leaflets closer together increasing prolapse earlier. 30  Mitral Regurgitation Mitral valve fails to fully close, allowing retrograde blood flow form LV into left atrium during systole 2nd most common murmur Causes ○ MVP ○ rheumatic heart disease ○ Endocarditis ○ Left ventricular dilation ○ Ischemic heart disease What do you hear? S/S ○ Holosystolic ( last through ○ Dyspnea the entire systole) ○ Pulmonary edema ○ Blowing (high pitched) ○ Fatigue ○ th 5 intercostal space, ○ Palpitations midclavicular line ○ Inc with squat,and LLD Radiation? ○ Axilla 31  Mitral Regurgitation Treatment: ○ Valve repair or replacement ○ Diuretics if pulmonary edema ○ ACE inhibitors/ ARBs- decrease workload on heart ○ Beta blockers 32  Pulmonic Stenosis Stenosis of outflow tract from right ventricle to pulmonary artery Causes ○ congenital-MC ○ Rheumatic fever ○ Radiation 33  Pulmonic Stenosis Causes ○ Congenital MC ○ Rheumatic S/S ○ Dyspnea on exertion ○ Syncope ○ Chest pain ○ Cyanosis ○ Syncope ○ RV failure What do I hear? ○ Crescendo -decrescendo murmur ○ S2 widely split ○ Left upper sternal border Radiation? ○ back 34  Pulmonic Stenosis Tx ○ Diuretics if heart failure ○ Percutaneous balloon valvuloplasty ○ Surgical repair 35  Tricuspid Regurgitation Tricuspid valve does not close properly leading to backflow of blood Leads to volume overload of right atrium 36  Tricuspid Regurgitation Causes ○ Rheumatic heart disease ○ Endocarditis ○ Right ventricular dilation ○ Pulmonary hypertension ○ Valve calcification S/S ○ Fatigue ○ Edema ○ JVD ○ palpitations What do I hear? ○ Blowing holosystolic ○ Lower left sternal border Tx ○ Diuretics ○ Valve repair or valvuloplasty 37  Hypertrophic Cardiomyopath y Genetic heart condition with abnormal thickening of interventricular septum S/S ○ Dyspnea ○ Chest pain ○ Dizziness ○ Fatigue What do I hear? ○ Crescendo-decrescendo ○ Left lower sternal border ○ Lower left sternal border Tx ○ Beta blocker ○ Myomectomy ○ Implantable cardioverter-defibrillator 38  Hypertrophic Everyone down for the party except MVP and HCM Squatting Cardiomyopathy ○ Increase venous return and systemic vascular resistance ○ More blood flow back to the heart to increase left ventricular volume ○ A more filled left ventricle moves the obstruction out of the way and reduces the pressure gradient Standing ○ Reduces venous return and preload ○ Less blood filling the left ventricle ○ Small ventricular volume which allows obstruction to block blood flow 39  Diastolic Murmurs Aortic regurgitation Mitral Stenosis Tricuspid stenosis Pulmonic regurgitation 40  Aortic Regurgitation Backflow of blood from aorta to the left ventricle during diastole Leads to volume overload in left ventricle Causes ○ Endocarditis ○ Bicuspid aortic valve ○ Rheumatic heart disease ○ Connective tissue disease S/S ○ Left sided heart failure symptoms What do you hear? ○ Fatigue ○ Blowing Decrescendo ○ Dyspnea ○ LUSB ○ Palpitations Radiation ○ Chest pain ○ LLSB Tx ○ Diuretics ○ ACE/ARB ○ Valve repair 41  Aortic Regurgitation Other characteristics observed ○ Hill- Systolic blood pressure in lower extremities > systolic blood pressure in upper extremities ○ DeMussets- Head bobbing with each heartbeat. ○ Quincke- capillary pulsations on nail bed with each beat ○ Pistol Shot ( traube)-sharp bounding pulse of femoral artery ○ Corrigan ( water hammer)- rapid and forceful pulse with strong upstroke with quick drop-off ○ Muller- pulsation of uvula with each beat 42  Mitral Stenosis Narrowing of the mitral valve opening 2x more common in females Causes ○ Rheumatic heart disease MC ○ Calcification ○ Congenital heart defects S/S ○ Left atrial enlargement ○ Dyspnea on exertion What do you hear? ○ Pulmonary congestion ○ Opening snap after S2 ○ palpitations ○ Low-pitched rumbling ○ Atrial fibrillation ○ 5th intercostal space, midclavicular line 43  Mitral Stenosis Treatment ○ Diuretics for pulmonary congestion ○ Anticoag if atrial fibrillation ○ Beta blocker ○ Balloon valvotomy/valvuloplasty, valve repair, valve replacement 44  Tricuspid Stenosis Rare Narrowing of tricuspid valve Causes ○ Rheumatic fever ○ Endocarditis ○ Calcification S/S ○ JVD ○ Peripheral edema ○ Ascites ○ Hepatomegaly ○ Right sided heart failure What do I hear? ○ Low pitched rumbling ○ LLSB 45  Tricuspid Stenosis Tx ○ Diuretics ○ Beta blockers ○ Anticoagulation if atrial fibrillation ○ Valve repair and replacement 46  Pulmonic Regurgitation Backflow of blood from the pulmonary artery into the right ventricle during diastole 47  Pulmonic Regurgitation Causes ○ Secondary pulmonary HTN MCC ○ Infective endocarditis ○ Valve stenosis ○ Congenital heart defects ○ Rheumatic fever S/S ○ Right ventricular dilation ○ Fatigue ○ Dyspnea ○ Palpitations ○ Edema ○ Chest pain ○ Right sided heart failure Tx What do I hear? ○ Diuretics ○ high pitched murmur ○ Phosphodiesterase-5 inhibitors ○ Valve repair or replacement ○ Left upper sternal border ○ Widely split S2 48  Systolic + Diastolic Murmur Patent Ductus Arteriosus ○ Congenital heart defect with open ductus arteriosus ○ Continuous machine like murmur 49