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Valvular diseases
best initial test for all valvular diseases: Echocardiogram
most accurate test for all valvular diseases: catherization
Normal Heart Sounds
S2 physiologic split:
During normal breathing, the timing between the aortic and pulmonic
components of the S2 varies
...
Maximum splitting occurs at peak
inspiration
Generic File
Innocent murmur:
This type of murmur is seen with non-cardiac conditions such as pregnancy,
hyperthyroidism, exercise and anemia
...
The short duration and mid-range frequency
characterize an innocent murmur
...

S4 gallop
due to left ventricular hypertrophy (LV stiffness)
paradoxic S2 splitting that can’t be distinguished

MILD:
In early systole there is an aortic ejection click followed by a diamond
shaped systolic murmur which ends mid-way through systole
...
As the condition worsens the murmur
frequency increases
...

S2 is physiologically split
...


Generic File
SEVERE:
diamond shaped systolic murmur which is loud and higher than the mild
S1 normal
S2 louder than normal
we can only hear the P2 due to left heart failure
aortic ejection click is gone
S4 gallop heard just before the S1
caused by increased LV wall thickness and stiffness
Generic File
EKG + CXR:
LV hypertrophy and cardiomegaly like all the others
Medical therapy:
no medical treatment
we can give diuretics to decrease preload before operating
ACE- Inhibitors, nitroglycerin & vasodilators are absolutely contraindicated
due to risk of profound hypotension
If asymptomatic then observe the patient
Reschedule for echocardiography after 1 year
Surgical therapy:
if symptomatic
valve replacement
balloons don’t really work here since it’s a calcification and we can’t
balloon calcium
TAVI (Transthoracic Aortic Valve Implantation)
when the patient can’t undergo surgery

Mitral Regurgitation
Failure in closure of mitral valve result in back flow of blood into left atrium
during systole
...

As the eccentric hypertrophy progresses there will be decrease in stroke volume

and increase in backward pressure that results pulmonary edema and later on
right heart failure
causes: (things that make the heart dilate
...
here LVESD (left
ventricular end systolic diameter) increases >4cm (ventricle is dilated too much)
...

Causes:
HTN most common cause
dilation = regurgitation
Infective endocarditis, Chronic rheumatic fever
Aortic dissection
Coarctation of aorta
Tertiary syphilis
Ankylosing spondylitis
Symptoms:
dyspnea
LHF
Early diastolic Decrescendo murmur
Widened pulse pressure due to hyperdynamic circulation
Bounding pulse (aka water-hammer pulse)
Bobbing & popping head with systole, Pulsation in nail beds
In later stages, symptoms of CHF will be present
Duroziez sign: systolic/diastolic thrill or murmur over the femoral arteries

Auscultation:

S1 is diminished due to premature closure of the mitral valve leaflets
An aortic ejection click follows the first heart sound by 75
milliseconds
...

A high pitched decrescendo murmur occupying the first half of diastole
can be heard starting immediately after the second heart sound
...

Generic File

Diagnosis:
ekg and CXR show LV hypertrophy and aortic dilation
Echocardio:
best test shows dilated LV with LV volume overload + fluttering of
anterior mitral leaflet
Medical therapy:
all regurgitant lesions are treated with

endocarditis prophylaxis
amoxicillin or clindamycin
salt restriction
diuretics
ACE inhibitors
digoxin
Afterload reduction by vasodilators
best therapy since it delays progression the most
Surgical therapy:
aortic valve replacement
when EF <55% and LVESD >5
...
Narrowing
of mitral valve orifice less than 2
...

Dilation & work hypertrophy of left atrium occurs
Causes:
Rheumatic fever
it can cause any valvular lesion however most commonly mitral
stenosis
genetic defect
2/3 are females (pregnancy increases plasma volume)
symptoms:
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
fatigue
wasting
hemoptysis (ruptured vessels)
systemic embolism
due to stagnation of left atrial blood
we have a large left atrium so we have a large chance of Afib hence
biggest chances of stroke
hoarseness
since the big left atrium presses on the recurrent laryngeal nerve
right heart failure:
hepatomegaly
ascites
peripheral edema
Dysphagia
since the big left atrium is pressing on the esophagus
Signs:
rales
atrial fibrillation
decreased pulse pressure
Loud S1
opening snap following S2
its the sound of the mitral valve opening

as it becomes worse the opening snap happens earlier
diastolic rumble (low pitched, apical murmur)

Mild Mitral Stenosis:

Generic File

S1 is increased in intensity due to mild thickening of the the
mitral valve leaflets
...

There is an opening snap 100 milliseconds into diastole
...

right ventricle hypertrophy
due to pulmonary HTN caused by backing up of blood from left
atrium to lungs
right and left atrial abnormalities with left atrial hypertrophy
+/- Afib

enlarged left atrium
straightening of the left heart border
double density behind heart
left mainstem bronchus gets pushed up
Echocardio:
thickened mitral valve leaflets
medical therapy:
no real therapy to dissolve the stenosis
preload reduction:
sodium restriction
diuretics
side effect -> can cause intrauterine growth retardation
ACE inhibitors won’t work here since they help reduce ventricular
emptying and here our problem is with ventricular filling
digoxin also doesn’t work here since it helps with ventricular empyting
we use it here only if there is Afib
surgical therapy:
balloon valvuloplasty

it is contraindicated in mitral regurgitation
it works since this stenosis is caused by fibrosis unlike the aortic
which is caused by calcium
if balloon fails then mitral valve replacement

all left sided heart murmurs increase with increase of blood in the heart and decrease with the
decrease of blood
except hypertrophic cardiomyopathy and mitral valve prolapse which decrease with increase
of blood and become worse with the decrease of blood
valsalva and standing are equivalent to diuretics:
they are good for all lesions
they are bad for mitral valve prolapse and hypertrophic cardiomyopathy
treatment:
regurgitants (MR, AR)
Vasodilators (ACEi)
stenosis (MS, AS)
no beta blockers bad
balloon the mitral
replace the aortic
hypertrophic cardiomyopathy + mitral valve prolapse
ACE is bad

Beta blockers are good
handgrip is the opposite of ACE inhibitors (which decrease afterload)
they increase the afterload
so handgrip makes regurgitant lesions worse
they compress the arteries of the arm



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