aortic and pulmonary valve disease
Post on 02-Jun-2018
226 Views
Preview:
TRANSCRIPT
-
8/11/2019 Aortic and Pulmonary Valve Disease
1/15
AORTICVALVEDISEASEObjectives:Aftercompletingthischapterthestudentshouldbeabletostatethecausesofleft
ventricularoutflowtractobstruction,theclinicalpresentationandphysicalfindingsinaorticstenosis,
thedifferentetiologiesandthepathophysiologyofthedisease,thenaturalhistory,investigativetools
andtherapyforaorticstenosis.
Thestudentshouldbeableaswelltodifferentiatebetweentheacuteandchronicformsofaortic
regurgitationasregardsthecausesandclinicalpresentation.Theetiology,pathophysiology,naturalhistory,investigativetoolsandtherapyforaorticregurgitationshouldbememorized.
1AORTICSTENOSIS
Valvularaorticstenosisisthemostcommoncauseofleftventricularoutflowtractobstruction.
Othercausesinclude
Subvalvularaorticstenosisbyafixedmembraneorafibromusculartunnel
Dynamicsubvalvularobstructioncausedbyhypertrophiccardiomyopathy
Supravalvularaorticstenosis
Etiology:1.CongenitalAorticStenosis:
Themostcommonisthebicuspidaorticvalve,whichleadstoprematuredegenerationand
calcificationofthecusps(fig.1.). Abnormaltrileafletvalvewithleafletfusion,unicuspidandcommissural
valveareothercongenitalcausesforstenosis.
Figure1.Normaltricuspidandabnormalbicuspidaorticvalve
2.AcquiredAorticStenosis:
i. DegenerativeCalcificAorticStenosis:
Thisoccursduetoabnormalcalcificationinatrileafletaorticvalveusuallyinthe7thor
8thdecades.Thecalcificationmayalsoinvolvethemitralannulusorextendintotheconduction
system,resultinginatrioventricularorintraventricularconductiondefects.Seniledegenerative
ASisnowtheleadingindicationforaorticvalvereplacement(AVR).
ii.
RheumaticAortic
stenosis: Itisusuallypresentwithcoexistingmitralvalvedisease,with
fibrosis,calcificationandcommissuralfusion
iii.
OtherinfrequentcausesofASincludeobstructivevegetations, homozygoustypeII
hypercholesteroemia,Pagetdisease,Fabrydisease, ochronosis,andirradiation.
Pathophysiology:
1. Theaorticvalveorificecontinuestogetnarrowerwithtime,andastheaorticvalvearea
decreasestheleftventriclefacesahigherafterload.
-
8/11/2019 Aortic and Pulmonary Valve Disease
2/15
2. Tomaintainthecardiacoutputtheleftventriclemustdevelophighersystolicpressureswhich
increasesthewallstress.Thisleadstocompensatoryleftventricularhypertrophywhichallows
theleftventricularwallstresstonormalize.
3. LVsystolicfunctionisusuallywellpreserved,andcardiacoutput(CO)ismaintainedformany
yearsdespitealargepressuregradientacrosstheAV.Duringthistime,thepatientdoesnot
experienceareductioninrestingCO,LVdilatation,ordevelopmentofsymptoms.
4. Theleftventricularcompliancedecreasesandwithalesscompliantleftventriclelessfilling
occurspassivelyintheearlyphaseofdiastole.Leftatrialcontractionbecomesmoreimportantin
maintaininganadequatepreload.
5. ASintensifiestheseverityofexistingmitralregurgitation(MR)byincreasingtheventricular
pressuregradientresponsiblefordrivingbloodfromtheleftventricletotheleftatrium.
Additionally,functionalMRasaconsequenceofLVdilatationinlatestagesofASmay
superimposethehemodynamicchangesassociatedwiththislesiononthoseproducedbyAS.
6. Themyocardialoxygendemandincreasesduetoanincreaseoftheleftventricularmass,
increasedsystolicpressureandprolongationofsystole.
7. Theelevationoftheleftventricularenddiastolicpressuredecreasestheperfusionpressure
across
the
coronary
vascular
bed
with
diminution
of
the
endocardial
O2
supply.
Therefore,
the
subendocardiumissusceptibletolownutrientflow,andthisunderperfusionresultsin
myocardialischemia.
NaturalHistory
Patientswithpureaorticstenosisdonothavesymptomsuntilthe aorticvalveareaislessthan
1.0cm2.
Thereisalonglatentperiodorphaseduringwhichthepatienthasnosymptoms.
Therateofincreaseofthemeanaorticpressureisabout7mmHg/year.
Asymptomaticpatients,evenwith criticalAS,haveanexcellentprognosis regarding survival,
withanexpecteddeath rateof less than1%peryear;only4%of suddencardiacdeaths in
severeASoccurinasymptomaticpatients.
Withtheonsetofsymptomsthesurvivalratedecreasessignificantly:
Onsetofanginaisassociatedwithanaveragesurvivalof5years,
Onsetofsyncopeisassociatedwithanaveragesurvivalof3years,
Onsetofcongestiveheartfailureisassociatedwithanaveragesurvivalof2years.
More than 50% of deaths were sudden. Death in general, including sudden death, occurs
primarilyinsymptomaticpatients.
ClinicalPresentation:
Aortic
stenosis
should
by
suspected
when
any
patient
has
a
systolic
ejection
murmur
at
the
right
upper
sternalborderthatradiatestothecarotidarteries.Mostpatientsareasymptomaticatpresentation.
1.Symptoms:
o TheclassicsymptomtriadofASincludesanginapectoris,syncope,andheartfailure.
o Exertionaldyspneaisthemostcommoninitialcomplaint,evenwithnormalLVsystolicfunction,
anditrelatestoabnormalLVdiastolicfunction.Paroxysmalnocturnaldyspnea,orthopnea,and
pulmonaryedemausuallyarelateoccurringsymptomsofheartfailure.
o Becauseanginacommonlyisprecipitatedbyexertionandrelievedbyrest,itoftensimulates
symptomsofCAD.
-
8/11/2019 Aortic and Pulmonary Valve Disease
3/15
o Anginaresultsfromaconcomitantincreasedoxygenrequirementbythehypertrophic
myocardiumanddiminishedoxygendeliverysecondarytotheexcessivecompressionof
coronaryvesselsandrelativesubendocardialmyocardialischemia.Ofcourse,anginaalsocan
resultfromcoexistentCAD.
o Riskofinfectiveendocarditisishigherinyoungerpatientswithmildvalvulardeformitythanin
olderpatientswithdegeneratedcalcifiedAVs,butitcanoccurinboth.
o EmbolizationfromacalcifiedorinfectedAVthatresultsinunilateralvisionloss,focalneurologic
signs,andmyocardialinfarctioncanbethefirstsignsofAVpathology.
2.PhysicalFindings:
(a)Arterialpulse:
Pulsusparvusettardus(Diminishedamplitudeanddelayed),inelderlyindividuals,thismaynotbe
presentdespiteseverestenosisbecauseofmorerigidaortaandcarotidvessels.
PulsusalternanscanoccurwiththeonsetofLVfailure.
Asystolic"thrill"maybepresentatthesecondrightintercostalspaceoratthesuprasternalnotchand
usuallyindicatesameanAVgradienthigherthan50mmHg.Thethrillisbestfeltwhilethepatientis
leaningforward.Onoccasion,itcanbetransmittedtothecarotids.
(b)Palpation:Leftventricularhypertrophyisnotaccompaniedbyenlargementoftheleftventricle;thus
theapicalimpulseisnotdisplaced.Theimpulseissustainedduetotheprolongationofsystole.
(c)Auscultation:
o S1isusuallynormalorsoft.
o Theaorticcomponentofthesecondheartsound,A2,isusuallydiminishedorabsentbecausethe
AViscalcifiedandimmobileand/oraorticejectionisprolongedorburiedintheprolonged
systolicejectionmurmur.ThepresenceofanormalorA2speaksagainstthepresenceofsevere
AS.
o ParadoxicalsplittingoftheS2alsooccursbecauseoflateclosureofA2.
o
P2may
also
be
accentuated
when
LV
failure
leads
to
secondary
pulmonary
hypertension.
o Thepresenceofanejectionclickisdependentonthemobilityofthevalvecuspsanddisappears
whentheybecomeimmobileandseverelycalcified.Thus,itiscommoninchildrenandyoung
adultswithcongenitalASbutrareinelderlyindividualswithacquiredcalcificASwithrigidvalves.
o AprominentS4isusuallypresentduetoforcefulatrialcontractionintoahypertrophiedleft
ventricle.
o TheclassiccrescendodecrescendosystolicmurmurofASisbestheardatthesecondintercostal
spaceintherightuppersternalborder;itisharshatthebaseandradiatestobothcarotid
arteries.
o However,themurmurmaybemoreprominentattheapexinelderlypersonswithcalcificAS
duetoradiationofthehighfrequencycomponentsofthemurmurtotheapex(Gallavardin
phenomenon)leadingtoitsmisinterpretationasamurmurofMR.
o Themoreseverethestenosis,thelongerthedurationofthemurmurandthemorelikelyit
peaksatmidtolatesystole.Whentheleftventriclefailsandcardiacoutputfalls,theAS
murmurbecomessofterandmaybebarelyperceptible.
DifferentialDiagnosis:
o Supravalvularaorticstenosis
o Congenitalsubvalvularaorticstenosis
o Hypertrophicobstructivecardiomyopathy
-
8/11/2019 Aortic and Pulmonary Valve Disease
4/15
o Mitralregurgitationduetoposteriormitralleafletdysfunction
Complications
o Suddencardiacdeath
o Heartfailure
o Conductiondefects
o Infectiveendocarditis
o Calcificembolization
LaboratoryExamination:
1. ECG:
o AlthoughtheECGfindingsmaybeentirelynormal,theprincipalfindingisleftventricular
hypertrophy(LVH),whichisfoundin85%ofpatientswithsevereAS;however,its
absencedoesnotprecludecriticalAS.
o TwaveinversionandSTsegmentdepressioninleadswithpredominantlypositiveQRS
complexesarecommon.STdepressionexceeding0.3mVinpatientswithASindicatesLV
strainandsuggeststhatsevereLVHispresent(fig.2).
Fig.2.ECGinapatientwithsevereaorticstenosisshowingLVHwithstrain
2. ChestXray:Maybeentirelynormal(Notuseful).Ifcardiomegalyispresentitusuallydenotes
leftventriculardysfunctionorassociatedaorticregurgitation.Poststenoticdilatationofthe
ascendingaortamaybeevident.Onlateralview,AVcalcificationisfoundinalmostalladults
withhemodynamicallysignificantAS.
DiagnosticTesting:
1) Echocardiography:(fig.3&4)
o Thisisthemethodofchoiceforestablishingthediagnosisandassessingitsseverity.It
measuresthetransvalvulargradientandtheaorticvalvearea.Thenormalvalveareais2
4cm2.Avalveareaof1.5cm
2ismild,1.01.5cm
2ismoderatewhilelessthan1.0cm
2is
severeaorticstenosis(table1).
o InvalvularAS,theetiology(bicuspid,rheumatic,orseniledegenerative)maybe
assessed.LVsize,mass,andfunctionshouldbeevaluatedineachpatient.
-
8/11/2019 Aortic and Pulmonary Valve Disease
5/15
-
8/11/2019 Aortic and Pulmonary Valve Disease
6/15
Cardiaccatheterization:Whenthereisdoubtaboutthediagnosisandinpatientswithangina
cardiaccatheterizationisindicated;inadditionmalesabovetheageof40yearsandfemales
abovetheageof50yearsarecandidatesforcoronaryangiography(fig.5).
Treatment:
1) PriorityofTherapy:Themainstayoftherapyforsevereaorticstenosisissurgicalreplacementof
theaorticvalve.
Thisisrestrictedtopatientswithsymptomsbecausesurvivalbenefitisapparentonly
aftersymptomsoccur.
Olderpatientswithcriticalstenosisandyoungpatientswithveryhighgradientsmay
benefitfromelectivesurgery.
2) MedicalTreatment:
Antibioticprophylaxisbeforeproceduresismandatory.
Managementofpatientswithoutsymptomsisdirectedtowardsprimaryprevention
ofcoronaryarterydisease,maintenanceofsinusrhythmandproperbloodpressure
control.Patientsareinstructedtoreportsymptoms.
Therapyforheartfailureisdirectedatvolumecontroltoreliefpulmonarycongestion.
Diureticsshouldbeusedwithcaution.Vasodilatorsincludingnitratesshouldbe
avoidedinpatientswithsevereaorticstenosisandheartfailure.
Atrialfibrillationispoorlytolerated,sincetheatrialcomponentisimportantforLV
filling;thecadiacoutputdecreasesandpulmonarycongestionrapidlyensues.Thus
rhythmcontrolshouldbeattemptedifpossible.
3) PercutaneousTherapy: PercutaneousAorticBalloonValvuloplasty(PABV)hassomeroleonlyinpediatric
congenitalaorticstenosishoweverwithanearlyrestenosisrate.
Itisausefultechniqueforpatientswhoarenotcandidatesforsurgicaltreatment
becauseofcomorbiditiesoradvancedage,orperhapsasabridgetononelective
surgicaltreatment.
Transcatheteraorticvalveimplantation(TAVI):thisisanovelandexcitingtechnique
whereby anartificialaorticheartvalveattachedtoawireframeisguidedbycatheter
totheheart.Onceintheproperpositionintheheart,thewireframeexpands,
Fig.5.
-
8/11/2019 Aortic and Pulmonary Valve Disease
7/15
allowingthenewaorticvalvetoopenand functioninposition.TAVIisrecommended
intheveryelderlypatientswithseveresymptomaticASwhoareconsidered
unsuitableforconventionalsurgerybecauseofseverecomorbiditiesandhighriskof
preioperativemortality.
4) SurgicalTherapy:
Replacementoftheaorticvalveisthestandardmethodfortreatmentofvalvularaortic
stenosis
AORTICREGURGITATIONBackground:
Aorticregurgitationcanbeclassifiedasbeingtheresultofanacuteorchronicprocess.
Chronicaorticregurgitationistheresultoffailureofcoaptationoftheaorticvalveleaflets
causedbydiseasedvalvecusps,dilatationoftheaorticrootorboth.
Acuteaorticregurgitationisusuallyassociatedwithbluntchesttrauma,endocarditisoraortic
dissectionandisasurgicalemergencyinmostsituations.
A.Clininal
Presentation
1.Signsand
Symptoms:
a)
Chronic
Aortic
Regurgitation:
Patientsareusuallyasymptomaticforalongtimeandwhensymptomsdeveloptheyare
usuallyrelatedtopulmonarycongestion;firsteffortdyspnea,orthopneaandparoxysmal
nocturnaldyspneaandlatersignsofrightheartfailure.
Anginabaybepresentduetodiminishedpressuregradientacrossthecoronarybed.
b)
Acute
Aortic
Regurgitation:
TheLVdoesnothavesufficienttimetodilateinresponsetothesuddenincreasein
volume.
Asaresult,LVenddiastolicpressureincreasesrapidly,causinganincreaseinpulmonary
venouspressure.
Aspressureincreasesthroughoutthepulmonarycircuit,thepatientdevelopsdyspnea
andpulmonaryedema.
Earlysurgicalinterventionshouldbeconsidered(particularlyifARisduetoaortic
dissection,inwhichcasesurgeryshouldbeperformedimmediately).
2.PhysicalFindings:
GeneralExamination:
ExamineforMarfanoidcharacteristicsamongyoungpatientswithaorticregurge.(Ectopialentis;
higharchedpalate;pectusandarachnodactly)
Signsof
bacterial
endocarditis.
Prominentapicalimpulse.
Bloodpressure:Wideningofthepulsepressurecausinghyperdynamiccirculationwithan
elevatedsystolicandanabnormallylowdiastolicpressure.
ArterialExamination:Water Hammerpulse. Pulsepressureiswidened,associatedwithalow
diastolicpressure,oftenlessthan60mmHg.
Palpation:Forceful hyperdynamicapicalimpulse.
-
8/11/2019 Aortic and Pulmonary Valve Disease
8/15
Auscultation:
Blowingearlydiastolicdecrescendomurmur,bestheardintheleftuppersternal border,sitting
leaningforwardatexpiration.
AconcomitantsystolicejectionmurmuriscommoninmoderatetosevereARduetothe
increasedvolumeofbloodflowingacrosstheaorticvalve.
AntegradeflowacrossapartiallyclosedmitralvalveisthoughttocauseanAustinFlintmurmur,
whichisamid andlatediastolicapicallowfrequencymurmurorrumble.
S4:OftenpresentduetoLVHandpoorLVcompliance.S1:ItsintensitydecreasesasLVfunction
worsens.TheappearanceofS3impliesleftventricularfailure.
Physical
findings
related
to
widening
of
the
pulse
pressure
(table
2)
SIGN PHYSICALFINDING
Musset'sSign Headbobbingwitheachbeat
Muller'sSign SystolicpulsationoftheUvula
Hill'sSign Poplitealcuffpressure>40mmHgabovebrachial
WaterHammerPulse
(Corriganspulse)
Rapiddistensionandcollapseofarterial
pulse
Quincke'sPulse Capillarypulsationsvisibleinthe
fingernailbedsandlips
Duroziez'sSign Toandfromurmuroverthefemoral
arterywiththearterycompressed
Pistolshotsounds Prominentsystolicanddiastolicsounds
overthefemorals
B.Etiology
of
Aortic
Regurgitation
(table
3)
TypeofAbnormalityAcuteAortic
Regurgitation
ChronicAortic
Regurgitation
Abnormalities
in
the
aortic
root
resulting
in
distortedcuspsuspension
1.Aorticdissection
2.Traumaticdissection
1.Marfan'sSyndrome
2.Aorticaneurysm
3.Annuloaorticectasia
4.SyphiliticAortitis
5.SystemicLupus
erythematosis
6.Ankylosing
Spoddylitis
-
8/11/2019 Aortic and Pulmonary Valve Disease
9/15
C.Pathophysiology
1.ChronicAorticRegurgitation:
ChronicARproducesleftventricular(LV)volumeoverloadthatleadstoaseriesofcompensatory
changes,includingleftventricularenlargementandeccentricleftventricularhypertrophy,as
opposedtoconcentrichypertrophyobservedinapressureoverloadstate(ie,aorticstenosis).
Withincreasedleftventricularenddiastolicvolumethestrokevolumewillincrease.
Theleftventricleaccommodatesfortheregurgitantvolumewithoutincreaseoftheenddiastolic
pressure.
Leftventricularsystolicdysfunctioneventuallydevelops,leadingtoprogressivedilatationand
impairedemptyingoftheleftventricle.ThustheEjectionfractionwilldecreasewithanincrease
oftheenddiastolicvolumeandenddiastolicpressure.
2.AcuteAorticRegurgitation:
Thereisarapidincreaseoftheleftventricularenddiastolicvolume,withnotimefor
hypertrophyorabilityoftheLVtoaccommodate.
Theleftventricularenddiastolicpressure(LVEDP)increasesrapidly,prematurelyclosingthe
mitralvalveandcausingdiastolicmitralregurgitation.
TherapidincreaseoftheLVEDPleadstopulmonaryedema.
NaturalHistory:
TheprognosisofsevereARinasymptomaticpatientswithnormalLVfunctionremainsexcellent,
butextravigilanceisrequiredinmonitoringthesepatientstoensurethattheoptimaltimefor
surgicalinterventionisnotoverlooked.
Oncesymptomsdevelopinchronicaorticregurgitationthereisrapidprogressionanddeclinein
thepatient'sfunctionalstatus.
Theleftventricularejectionfraction(LVEF)isthemostimportantdeterminantofsurvival.
Inmedicallytreatedpatientswithmildtomoderateaorticregurgitationthe10yearsurvivalis
8595%;whileinthosewithmoderatetosevereaorticregurgitationthe10yearsurvivalis50%
only.
Inchronicaorticregurgitationsurvivalratesimprovedwithaggressiveuseofvasodilator
therapy(Nifedipine/AngiotensinConvertingEnzymeInhibitors).However,medicaltherapydoes
notreplacesurgerywhenindicated.
Suddendeathmayoccuramongpatientswithseveresymptomaticaorticregurgitation.
Abnormalities
of
the
aorticvalvecusps
1.Infectious
Endocarditis
2.Traumaticleaflet
Inversionorprolapse
1.Bicuspidvalve
2.Rheumaticheart
disease
3.Calcificdegeneration
4.SinusofValsalva
aneurysm.
5.Myxomatous
degeneration.
-
8/11/2019 Aortic and Pulmonary Valve Disease
10/15
LaboratoryTesting
ECG:TypicallyshowsLVHwithupright"t"wavesandleftatrialabnormality.Atrialfibrillationif
associatedmitralvalvediseaseispresent.
ChestRadiography:
DramaticCardiomegaly(CorBovinum)
Ascendingaortadilatation.
Leftatrialdilatation.
Echocardiography:Estimatesseverityofaorticregurgitation,leftventricularsizeandsystolic
function(fig.6).
Fig.6.Themosaiccolorrepresentssevereaorticregurgitation
onthis2dimensionalechopicture
CardiacCatheterization:Malesabove40yearsandfemalesabove50yearsgoingforaorticvalve
replacementneedtheircoronariesvisualizedbyangiography.Itisalsoofvaluetoconfirmthe
hemodymamicfindingsanddegreeofregurgitationbyaortographywhencontradictorydata
fromotherinvestigationsarepresent.
Treatment
PrioritiesofTherapyaretoestablishthecause,ensurethatthepatient'sconditionis
hemodynamicallystableanddeterminetheneedforandtimingofsurgicalintervension.
MedicalTherapy:
Considerantibioticprophylaxisforpatientswithendocarditiswhenperformingprocedures
likelytoresultinbacteremia
InseverechronicAR,vasodilatortherapymaybeusedinselectconditionstoreduce
afterloadinpatientswithsystolichypertension,inordertominimizewallstressandoptimize
LVfunction.
SurgicalTherapy:SurgicaltreatmentofARusuallyrequiresreplacementofthediseasedvalvewitha
prostheticvalve.Itisindicatedin
AllsymptomaticpatientswithsevereARregardlessoftheLVfunction.
AsymptomaticpatientswithsevereARwithLVdysfunctionasevidencedbyan EF70
mmor LVESDis>50mm(byechocardiography)
-
8/11/2019 Aortic and Pulmonary Valve Disease
11/15
PulmonicStenosisPulmonicstenosis(PS)referstoadynamicorfixedanatomicobstructiontoflowfromthe right
ventricle(RV)tothepulmonaryarterialvasculature.
Etiology
Congenitaleitherinisolationorinassociationwithothercongenitalcardiacdefects
Rarelyrheumaticheartdisease
Carcinoidsyndrome
RVoutflowtractmassesandtumours
Pathophysiology
PScanbeduetoisolatedvalvular(90%),subvalvular,orperipheral(supravalvular)obstruction,oritmay
befoundinassociationwithmorecomplicatedcongenitalheartdisorders.
Valvularpulmonicstenosis
IsolatedvalvularPScomprisesapproximately10%ofallcongenitalheartdisease.Typically,the
valvecommisuresarepartiallyfusedandthe3leafletsarethinandpliant,resultinginaconical
ordomeshapedstructurewithanarrowedcentralorifice.Poststenoticpulmonaryartery
dilatationmayoccurowingto"jeteffect"hemodynamics.
WithseverevalvularPS,subvalvularrightventricularhypertrophycancauseinfundibular
narrowingandcontributetotherightventricularoutflowobstruction.Thisoftenregressesafter
correctionofvalvularstenosis.
SubvalvularPSoccursasanarrowingoftheinfundibularorsubinfundibularregion,oftenwitha
normalpulmonicvalve.ThisconditionispresentinindividualswithtetralogyofFallotandcanalso
beassociatedwithaventricularseptaldefect.
ClinicalPicture
History:
Mostchildrenandadultswithmildtomoderatelyseverepulmonicstenosis(PS)are
asymptomatic.
ThosewithseverePSmayexperienceexertionaldyspneaandfatigue.
Inextremelyrarecases,patientspresentwithexertionalangina,syncope,orsuddendeath.
Peripheraledemaandothertypicalsymptomsoccurwithrightheartfailure.
Cyanosisispresentinthosewithsignificantrighttoleftshuntviaapatentforamenovale,atrial
septaldefect,orventricularseptaldefect
Physicalexam
precordialheaveorapalpableimpulsefromtheRValongtheleftparasternalbordermaysuggestseverePS.Intheleftuppersternalborder,asystolicthrillmaybepalpableatthelevelof
thesecondintercostalspace.
InvalvularPS,auscultationrevealsanormalS1andawidelysplitS2,withasoftanddelayedP2.
ValvularPStypicallycausesasystoliccrescendodecrescendoejectionmurmurintheleftupper
sternalborderthatincreaseswithinspirationandradiatesdiffusely.Asystolicejectionclickmay
precedethemurmur.
-
8/11/2019 Aortic and Pulmonary Valve Disease
12/15
Diagnosis
EchocardiographyEchocardiographyprovidesadefinitiveconfirmationofthediagnosisofPS.Both
2dimension.alandDopplertechniquesshouldbeusedtocomprehensivelyevaluatethepulmonic
valve.Thepulmonaryvalveareaofahealthyadultis2.0cm2/m
2ofbodysurfacearea.
MildvalvularPSisdefinedbyavalvearealargerthan1cm2andatransvalvularpressuregradient
oflessthan50mmHg.
ModeratelyseverePSoccursifthevalveareais0.51.0cm2,withatransvalvularpressure
gradientbetween50and75mmHg.
SeverePSisdefinedbyavalveareasmallerthan0.5cm2andatransvalvularpressuregradient
greaterthan75mmHg.
Treatment
Percutaneousballoonvalvuloplastyhasbecometheinitialinterventioninchildren,adolescents,and
adultswithcongenitalvalvarPS.Balloonvalvuloplastyshouldbeconsideredinanypatientwitha
transvalvularpressuregradientgreaterthan50mmHg.
PulmonaryRegurgitation
Etiology
Primarypulmonaryhypertension(idiopathic)
Secondarypulmonaryhypertension.Thisisthemostcommoncauseinadults
Rheumaticheartdisease(rare)
Infectiveendocarditis
Carcinoiddisease
Medicationsthatactviaserotoninergicpathways(eg,methysergide,pergolide,fenfluramine)
Pathphsiology
Incompetenceofthepulmonicvalveoccursinanyoneof3basicpathologicprocesses:
Dilatationofthepulmonicvalvering
Acquiredalterationofpulmonicvalveleafletmorphology Congenitalabsenceormalformationofthevalve
History
Symptomsofrightsidedheartfailurecanoccurwhentheseverityanddurationoftheregurgitation
resultinrightventricularenlargementanddecompensation.Dyspneaonexertionisthemostcommon
complaint.Easyfatigability,lightheadedness,peripheraledema,chestpain,palpitations,andfrank
syncopemayoccur.
Physicalexam
Jugularvenouspressure(JVP)isusuallyincreased.Whenrightventricularenlargementispresent,a
palpableimpulse(liftorheave)isusuallypresentattheleftlowersternalborder.Palpablepulmonary
arterypulsationattheleftuppersternalbordermaybepresentinthesettingofsignificantpulmonary
arterydilatation.
TheGrahamSteellmurmurofpulmonaryhypertensionisahighpitched,earlydiastolicdecrescendo
murmurnotedovertheleftuppertoleftmidsternalareaandisaresultofhighvelocityregurgitantflow
acrossanincompetentpulmonicvalve.
-
8/11/2019 Aortic and Pulmonary Valve Disease
13/15
Diagnosis
Echocardiography.ColorflowDopplerechocardiographyisthemainstayforrecognizing
pulmonicregurgitation.
Treatment
1.
Inprimarypulmonaryvalveregurgitationtheprognosisisverygood,rarelyiscorrectionofthe
defectnecessary.
2.
Insecondarypulmonaryvalveregurgitationtheprognosisdependsonthecauseandisdirected
towardstheprimarydisease.
MCQ
1.Inaorticvalvedisease,markastrue orfalseX
a) Severeaorticstenosiswithleftventricularfailureisassociatedwithamediansurvivalofapprox.
2 years
b) Mildaorticstenosisinyoungpeopleisassociatedwithanegligibleriskofendocarditis
c) Longtermtreatmentwithnifedipineinaorticregurgitationisassociatedwithimprovedoutcome
d) Systolicbloodpressuremaybenormalorelevatedinpatientswithsevereaorticstenosis
1. A72yearoldgentlemanisreferredtoyoubecauseofaprecordialsystolicmurmur.On
examination,thereisaharshmidsystoliccrescendodecescendomurmurattherightparasternal
ICS,radiatingtothecarotids.Thepatientisasymptomatic.Echocardiographyrevealsanaortic
valveareaof 1.2cm2andameansystolicgradientof 30mmHgandanormalLVsystolic
function.
Whatisthemostappropriateinterventionforthispatientatthepresenttime?
a.Percutaneous balloonaorticvalvuloplasty
b.Aorticvalvereplacement
c.Conserveandfollowup
3.Matchthefollowingvalvelesionswiththeir associatedmurmur
a.Aorticstenosis 1.decrescendodiastolicblowingmurmurheardbestalongleftsternal border
b.Mitralregurgitation 2.holosystolic murmurattheapexradiatingtoleftaxilla
c Aorticregurgitation 3.crescendodecrescendosystolicmurmuralongtheleftsternalborder
d.Mitralvalveprolapse 4.midorlatesystolicmurmurattheapexthatmaybeprecededbyaclick
4.Hillssignmeansthat
a. Brachialandpoplitealarterialbloodpressuresareequal
b. Brachialarterialbloodpressureishigherthanpoplitealpressure
c. Poplitealarterialbloodpressureishigherthanbrachialby30mmHg
d. Popliteal arterialpulsationsarenotpalpable
-
8/11/2019 Aortic and Pulmonary Valve Disease
14/15
5Adiamondshapedmurmurrefersto
a. Crescendo
b. Decrescendo
c. Crescendodecrescendo
d. Noneoftheabove
6Murmurofaorticstenosisradiatesto
a. Axilla
b. Neck
c. Back
d. Rightshoulder
7 Aorticstenosisisalwaysofrheumaticoriginwhenassociatedwith
a. aorticregurgitation
b. mitralregurgitation
c. mitralstenosis
d. carotidbruit
8Themostcommonformofcongenitalvalvularaorticstenosisis
a. Unicommmisural
b. Bicuspid
c. Homozygoushypercholesterolemia
d. Ochronsis
9Themostcommonformofcompensatoryhypertrophyinaorticstenosisis
a. Eccentric
b. Concentric
c. Asymmetric
d. Alloftheabove
10 Onsetofsyncopeisassociatedwithanaveragesurvivalof
a. 1year
b. 3years
c. 5yearsd. 8years
11TheclassicsymptomtriadofASincludesallofthefollowingexcept
a. Angina
b. Syncope
c. Cyanosis
d. Heartfailure
12 Anejectionclickheardinapatientwithvalvularaorticstenosisimpliesanimmobileandcalcificvalve
a. True
b. False
13 Thesimplestandmostfeasibletoolforassessmentofseverityofaorticstenosisis
a. Cardiaccatheterization
b. Magneticresonanceimaging
c. Electrocardiography
d. Dopplerechocardiography
-
8/11/2019 Aortic and Pulmonary Valve Disease
15/15
14 Apatientwithnewlydiscoveredaorticregurgitationandseverechestpainshouldbeconsideredtohave
a. Myocardialinfarction
b. Acutepericarditis
c. Aorticdissection
d. Syphyliticaortitis
15 Acuteaorticregurgitationmaybecausedby
a. Bluntchesttrauma
b. Infective
endocarditis
c. Aortic dissection
d. Alloftheabove
16 Preoperativepredictorsofpoorpostoperativesurvival inpatientswithsevereaorticregurgitationainclude
allofthefollowingexcept:
a. LVESDgreaterthan55mm
b. LVEFlessthan50%
c. NYHACHFclassIII,IV
d. Waterhammerpulse
top related