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Valvular Heart Disease Internal Medicine Board Review
Niels Engberding, MD, FACC, FESC
Assistant Professor of Medicine
Division of Cardiology
Emory University of School of Medicine
Case #1
• 78 y/o female is admitted to hospital with pulmonary edema
• She has had 3 months of progressive dyspnea
• On exam she has a late-peaking systolic murmur with a single heart sound
• An echocardiogram reveals a heavily calcified/stenotic aortic valve (area of 0.8 cm2)
Which of the following is appropriate? • 1) ACE inhibitor therapy for heart failure
• 2) Coronary angiography followed by aortic valve replacement
• 3) Exercise thallium to evaluate for ischemia
• 4) Balloon valvuloplasty
Major types of aortic valve stenosis
Baumgartner et al. JASE 2009; 22(1):1 Braunwald’s Heart Disease, 10th ed. 2015; Elsevier
Aortic Stenosis
• Congenital – Bicuspid Aortic Valve • Associated with dilation of the aorta
• Can present with aortic regurgitation
• Typically presents in 40’s-50’s
• Acquired • Rheumatic – usually with coexisting mitral disease
• “Senile” – age-related calcific degeneration
• Typically presents > 65 years
Senile Aortic Stenosis
• Most common cause of Aortic Valve replacement in the U.S.
• Incidence is 2% among people over the age of 65 – true AS not Aortic sclerosis.
• Pathophysiology may be related to atherosclerosis.
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Pathophysiology
Lilliy’s Pathophysiology of Heart Disease, 4th ed. 2007; Lippincott W &W
AS - History
• Asymptomatic – Small increased risk of sudden cardiac death
• Symptoms • Angina
• Syncope
• Heart Failure
Physical Examination
• Narrow Pulse Pressure
• Delayed Carotid Pulses
• Pulses (Parvus et Tardus)
• S4
• Late-peaking crescendo-decrescendo murmur
• Single second heart sound
Ross et al. Circulation 1968; 38:61
Outcomes of aortic stenosis
Management for Severe AS
• Asymptomatic • Consider exercise restriction
• Avoid vasodilators
• Caution with non-cardiac surgery
• Symptomatic - Surgery
Nishimura et al. JACC 2014; 63(22):2438
Main indications for aortic valve replacement
Severe AS
symptomatic asymptomatic
LVEF < 50%
Other cardiac surgery
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Signs of Severe AS
• EKG – LVH
• Echo • Calcified Leaflets with reduced valve opening
• LVH
• Mean gradient of greater than 40mmHg
• Calculated valve area of less than 1.0 cm2
• Cath • Confirm gradient
• Assess coronaries in patients at risk for CAD
Which of the following is appropriate? • 1) ACE inhibitor therapy for heart failure
• 2) Coronary angiography followed by aortic valve replacement
• 3) Exercise thallium to evaluate for ischemia
• 4) Balloon valvuloplasty
CASE #2
• A 42 y/o man with a history of a bicuspid aortic valve and a history of treated endocarditis.
• Echocardiography reveals severe aortic regurgitation
• He is asymptomatic.
Which of the following is not appropriate • 1) Nifedipine if left ventricular function is normal
• 2) Aortic valve replacement if the left ventricular end-diastolic diameter is >75 mm
• 3) All patients with severe chronic aortic regurgitation regardless of symptoms should undergo aortic valve replacement
Chronic Aortic Regurgitation - Etiology • Rheumatic
• Dilated Aortic Root
• Bicuspid Aortic Valve
• HTN
• Previous Endocarditis
Chronic Aortic Regurgitation - other etiologies
Ankylosing spondylitis
Reiter’s syndrome
Syphilis
Ehlers – Danlos
Osteogenesis imperfecta
Pseudoxanthoma elasticum
Marfan’s
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AR - Pathophysiology
Braunwald’s Heart Disease, 10th ed. 2015; Elsevier
AR – Hemodynamics
Braunwald’s Heart Disease, 10th ed. 2015; Elsevier
Normal Severe acute AR
Chronic compensated AR Chronic decompensated AR After AVR
Chronic AR – Physical Exam
• Widened Pulse Pressure
• Bounding pulses
• Austin-Flint murmur - a soft mid-diastolic murmur heard at the apex
• Displaced apical pulse
Timing of Surgery – the importance of symptoms
Braunwald’s Heart Disease, 10th ed. 2015; Elsevier from: Dujardin et al. Circulation 1999;99:1851
Chronic AR - Indications for surgery
Severe AR
Nishimura et al. JACC 2014; 63(22):2438
Chronic AR- Medical Therapy
• Asymptomatic patient – Vasodilator therapy.
• ACE-I or Nifedipine – Nifedipine is the only vasodilator proven in a clinical trial to slow progression of AR. A recent long-term trial did not show benefit in preventing surgery.
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Acute AR
• Usually a medical and surgical emergency
• Etiologies • Aortic dissection
• Endocarditis
• Trauma
Which of the following is not appropriate • 1) Nifedipine if left ventricular function is normal
• 2) Aortic valve replacement if the left ventricular end-diastolic diameter is >75 mm
• 3) All patients with severe chronic aortic regurgitation regardless of symptoms should undergo aortic valve replacement
CASE #3
• A 48 y/o recent immigrant from the Philippines presents with dyspnea and hemoptysis.
• No significant past medical history.
• On examination, there is a loud S1 and a low pitched sound in diastole
Which is true about the opening snap of mitral stenosis 1) A short aortic closure sound (A2) to opening snap interval indicates severe stenosis
2) It cannot be appreciated if you own an iPhone
3) It is best appreciated in early systole
Physical Exam of MS
• History – Dyspnea, PND, Fatigue, Hemoptysis.
• Exam – Loud S1, Opening snap, Diastolic rumble, Loud P2.
• Severe MS – Short A2-opening snap interval.
Pathophysiology
Lilliy’s Pathophysiology of Heart Disease, 4th ed. 2007; Lippincott W &W
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Braunwald’s Heart Disease, 10th ed. 2015; Elsevier
Diastolic LA – LV pressure gradient Mitral Stenosis - EKG
• Atrial fibrillation is common
• Left atrial abnormality
• Rightward Axis/ RVH
Management of Mitral Stenosis
• Atrial fibrillation – anticoagulation, Rate Control with digoxin, B-blockers, diltiazem, verapamil
• Surgical intervention if symptoms with heavy exertion (NYHA Class II) and moderate to severe stenosis
Balloon valvuloplasty is alternative for pliable, noncalcified valve with minimal MR and no atrial clot
Which is true about the opening snap of mitral stenosis • 1) A short aortic closure sound (A2) to opening
snap interval indicates severe stenosis
• 2) It cannot be appreciated if you own an iPhone
• 3) It is best appreciated in early systole
In chronic mitral regurgitation which is not true? • 1) ACE inhibitor therapy can decrease the degree of
valve regurgitation acutely
• 2) Severe mitral regurgitation requires surgery if the LVESD is greater than 45mm
• 3) The operative approach for MR should always be valve replacement
• 4) Patients with mitral valve prolapse without regurgitation do not need SBE prophylaxis
Pathophysiology
Acute MR Chronic MR
Lilliy’s Pathophysiology of Heart Disease, 4th ed. 2007; Lippincott W &W
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Chronic MR - Etiologies
Lilliy’s Pathophysiology of Heart Disease, 4th ed. 2007; Lippincott W &W
Chronic MR
History – fatigue and dyspnea
Exam – hyperdynamic PMI, systolic murmur (late, holo, or early).
Diastolic rumble can be heard in severe MR.
EKG – left atrial enlargement, LVH
MITRAL REGURGITATION - THERAPY
• Severe • surgery prior to decline in LVEF • repair or replacement if
LVESD > 40 mm or LVEF < 60%
•Repair is preferred over MVR when possible
•Acute afterload reduction may decrease severity of MR
MITRAL VALVE PROLAPSE
Generally benign – women (20-50 y.o.) – mild regurgitation
Often progressive – men (40 – 70 y.o.) – myxomatous mitral disease, chordal rupture
Midsystolic click in MVP
Braunwald. Essential Atlas of Heart Diseases, 1997; Current Medicine
• Standing • Valsalva • Amyl nitrate
• Squatting • Handgrip
In chronic mitral regurgitation which is not true? • 1) ACE inhibitor therapy can decrease the degree of
valve regurgitation acutely
• 2) Severe mitral regurgitation requires surgery if the LVESD is greater than 45mm
• 3) The operative approach for MR should always be valve replacement
• 4) Patients with mitral valve prolapse without regurgitation do not need SBE prophylaxis
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New Guidelines for Endocarditis Prophylaxis
• Dental Procedures
• Procedures of respiratory tract that involve biopsy or incision of mucosa
• Not for GU or GI procedures unless active infection
• Prosthetic heart valves
• Prior endocarditis
• Heart Transplant patients
• Congenital Heart Disease
Procedures Patients
Hard Question #1
During a patient exam, you hear a mid-diastolic rumble at the apex and a diastolic decrescendo-blowing murmur at the LLSB. He has mild dyspnea on effort. The murmurs have been present for years.
Which of the following features on examination suggests the apical diastolic murmur is Austin Flint and not Mitral Stenosis?
Answers
• A) Increased S1
• B) Atrial Fibrillation
• C) Presystolic accentuation of rumble
• D) BP 160/50
• E) Opening Snap
Answers
• A) Increased S1
• B) Atrial Fibrillation
• C) Presystolic accentuation of rumble
• D) BP 160/50
• E) Opening Snap
Hard Question #2
• Which of the following is the most reliable finding on physical examination to indicate that a severe degree of Aortic Regurgitation is present?
• A) Wide arterial pulse pressure
• B) Lateral displacement of PMI
• C) Grade 2 mid-to-late diastolic apical murmur
• D) Absent A2
• E) Loud AR murmur
Hard Question #2
• Which of the following is the most reliable finding on physical examination to indicate that a severe degree of Aortic Regurgitation is present?
• A) Wide arterial pulse pressure
• B) Lateral displacement of PMI
• C) Grade 2 mid-to-late diastolic apical murmur
• D) Absent A2
• E) Loud AR murmur
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Hard Question #3
• A 52 y/o male comes to clinic with moderate dyspnea on exertion. On examination he has n S3 and II/VI systolic ejection murmur.
• An echo shows and LVEF of 15% and aortic stenosis. The mean aortic valve gradient is 10mmHg and the calculated aortic valve area is 0.7
Answers
• A) Refer for emergent aortic valve replacement
• B) Refer for coronary angiography and valvuloplasty
• C) Order a dobutamine stress echocardiogram
• D) Order a transesophageal echocardiogram to review
Answers
• A) Refer for emergent aortic valve replacement
• B) Refer for coronary angiography and valvuloplasty
• C) Order a dobutamine stress echocardiogram
• D) Order a transesophageal echocardiogram to review