1. Valvular Heart Disease Robert Nash, D.O. Internal Medicine Resident Lecture Series

2. Goals and Objectives Recognize which cardiac murmurs warrant further evaluation Understand three cardinal signs of aortic stenosis and indications for surgical intervention Outline treatment plans for specific valvular heart lesions

5. Grading Heart Murmurs Out of VI I.Only heard with careful listening II.Audible when stethoscope applied to chest III.Louder than 2/6 IV.Accompanied by a palpable thrill V.Audible when stethoscope partially off of chest VI.Audible to naked ear

8. FindingsMurmurS1S2Other Findings Maneuvers Aortic Stenosis Mid to late systolic; may be soft or absent if severe NormalSingle or paradoxically split Carotid upstrokes diminished and delayed; S 3 or S 4 may be present Murmur softer with Valsalva maneuver Mitral Stenosis Diastolic rumble LoudNormal Opening snap may be present Murmur increased during brief exercise Aortic Regurgitation Blowing diastolic SoftNormal Wide pulse pressure, systolic hypertension, hyperdynamic circulation Murmur increased with handgrip or squatting Mitral Regurgitation Holosystolic SoftNormal or split S 3 may be present; cartoid upstrokes brisk Murmur louder with Valsalva maneuver MVP Mid to late systolic Normal Mid-systolic click Murmur increased with standing

11. Recommendations by Class Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II:Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb. Usefulness/efficacy is less well established by evidence/opinion. Class III:Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

13. Aortic Stenosis: Etiology Often congenital Rheumatic AS associated with previous rheumatic disease Idiopathic, calcific AS associated with elderly, generally milder

14. AS: Symptoms Dyspnea Angina Syncope These are cardinal symptoms, occur late in disease, and are associated with mortality (usually 2-3 year survival after onset of symptoms)

16. AS: Physical Exam Weak and delayed arterial pulses with carotid thrill (pulsus parvus et tardus) Double apical impulse S4 common Diamond shaped systolic murmur Usually >3/6

18. AS: Echo LV thickening Thickening and calcification of aortic valve cusps Dilatation, reduced LVEF poor prognosis

20. Aortic stenosis with turbulent flow (green pixels), as seen in the five-chamber view

21. AS: Classification of Severity Mild: Valve Area >1.5cm² Moderate: Valve area 1.0cm² to 1.5cm² Severe: Valve area <1.0cm²

22. AS: Treatment Avoid strenuous exercise in severe AS Treat CHF in standard fashion, but avoid afterload reduction Statin therapy to slow progression of leaflet calcification Balloon valvotomy to reduce symptoms in patients who aren’t surgical candidates Valve replacement in adults who are symptomatic or with evidence of outflow obstruction Surgery optimally performed before frank heart failure develops

26. Aortic Regurgitation: Etiology Rheumatic etiology common Hypertension Infective endocarditis Dilitation due to cystic medial necrosis Myxomatous infiltration Marfan syndrome Patients ¾ male

27. AR: Manifestations Exertional dyspnea Cardiac awareness Angina LV failure Wide pulse pressure Capillary pulsations (Quincke’s sign) S3 Blowing, decrescendo diastolic murmur heard best along left sternal border

29. AR: Lab CXR- LV enlargement EKG- LV hypertrophy Echo: LA and LV enlarged, increased excursion of LV posterior wall

32. AR: Treatment Standard therapy for LV failure Vasodilators to delay need for surgical intervention Surgical intervention indicated in symptomatic patients with severe AR or in asymptomatic patients with LV dysfunction on echo (LVEF <55%)

37. Mitral Stenosis: Etiology Most commonly rheumatic (up to 40% of patients with rheumatic fever develop mitral stenosis, 99% of surgically removed mitral valves with rheumatic infiltration) Congenital MS rare

39. MS: History Symptoms commonly begin in 4 th decade Can cause severe debility by age 20 in economically deprived areas Principal symptoms are dyspnea and pulmonary edema precipitated by exertion, anemia, fever, excitement, pregnancy, sexual intercourse, etc.

40. MS: Physical Right ventricular lift Palpable S1 Opening snap follows A2 by 0.06 to 0.12 seconds OS-A interval inversely proportional to severity of disease Diastolic rumbling murmur

42. MS: Complications Hemoptysis Pulmonary embolism Pulmonary infection Systemic embolization Endocarditis uncommon in pure MS

43. MS: Labs EKG: Typically A. Fib or LA enlargement when sinus rhythm present CXR: LA and RV enlargement, Kerley B lines Echo: calcification and thickening of valve leaflets and LA enlargement

44. MS: Treatment Prophylaxis for rheumatic fever Heart failure treatment if present Dig, beta blockers to control ventricular rate Valvotomy in presence of symptoms and mitral orifice <1.7cm² Anticoagulation if indicated

50. Mitral Regurgitation: Causes Rheumatic heart disease in 33% of cases MVP Ischemic heart disease with papillary muscle dysfunction LV dilitation Mitral annular calcification Hypertrophic cardiomyopathy Infective endocarditis congenital

51. MR: Clinical Manifestations Fatigue Weakness Exertional dyspnea

52. MR: Physical Exam Sharp upstoke of arterial pulse LV lift S1 diminished Wide splitting of S2 Loud holosystolic murmur

54. MR: Echo Enlarged LA Hyperdynamic LV Doppler echocardiogram useful in diagnosing and assessing severity of MR

57. MR: Treatment For severe/ decompensated MR, treat as heart failure Endocarditis prophylaxis is indicated Surgical intervention warranted in symptomatic individuals or in evidence of progressive LV dysfunction Surgery before decompensated heart failure Anticoagulation in face of atrial fibrillation

61. Mitral Valve Prolapse: Etiology Most commonly idiopathic ? Familial Ischemic heart disease Atrial septal defect Marfan syndrome More common female>male

62. Normal mitral valve MVP

64. MVP: Clinical Manifestations Most patients asymptomatic and remain so Chest pain (atypical) Supraventricular and ventricular arrhythmias Most important complication of severe MR is LV failure Sudden death is very rare

65. MVP: PE Mid or late systolic click followed by late systolic murmur Murmur exaggerated by valsalva, reduced with squatting Echo shows displacement of one or both leaflets late in systole

68. MVP: Treatment Asymptomatic patient: reassurance Prophylaxis for endocarditis is no longer indicated Valve repair for patients with severe MR ASA or anticoagulation for patients with TIA or embolization

69. Endocarditis Prophylaxis Indications for prophylaxis — Prophylaxis was recommended only in those settings associated with the highest risk of developing an adverse outcome if IE were to occur [1]. The following cardiac conditions were considered to meet this criterion:1 Prosthetic heart valves, including bioprosthetic and homograft valves. A prior history of IE. Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits. Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure. Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device. Cardiac valvulopathy in a transplanted heart. No longer indicated — Common valvular lesions for which antimicrobial prophylaxis is no longer recommended include bicuspid aortic valve, acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation and those who have undergone prior valve repair), and hypertrophic cardiomyopathy with latent or resting obstruction. Procedures that may result in transient bacteremia — The 2007 AHA guidelines recommend that antimicrobial prophylaxis be given to patients with the cardiac lesions cited above when they undergo procedures likely to result in bacteremia with a microorganism that has the potential ability to cause endocarditis.

72. Question 1 A new patient comes to you for evaluation. He’s a 45 year old male whose only complaint is that of some dyspnea on exertion, which he attributes to old age. He doesn’t smoke or drink alcohol. He does admit to being “very ill as a child,” but has been relatively healthy since. On physical exam, a diastolic murmur is noted, but the remainder of the exam is within normal limits.

73. Question 1 continued Which of the following is the next best step in this patient’s management? a)Only routine preventative care b)Trial of beta blocker therapy to see if his shortness of breath resolves c)Echocardiogram for assessment of the diastolic murmur, with further recommendations to follow d)Cranial OMT for assessment of his CRI

74. Question 2 A 73 year old white male presents to the emergency department after a syncopal episode. He’s dyspnic, with air hunger at the bedside, and is complaining of chest discomfort radiating to his jaw and down his left arm. On exam, a III/VI crescendo-decrescendo murmur is appreciated.

75. Question 2 continued Which of the following valvular pathologies is most likely responsible for this man’s presentation? a)Aortic Stenosis b)Aortic Regurgitation c)Mitral Stenosis d)Mitral Regurgitation e)Mitral valve prolapse

76. Question 3 The most common cause of mitral stenosis is: a)Familial b)Idiopathic c)Sauerkraut ingestion d)Rheumatic e)Alcohol induced