2. © Continuing Medical Implementation …...bridging the care gap Valvular Heart Disease Tulika Jain, MD Resident Teaching Conference December 5, 2008

3. Auscultation Use the diaphragm for high pitched sounds and murmurs Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs (diastolic rumble) Use the bell for low pitched sounds and murmurs (diastolic rumble) Sequence of auscultation Sequence of auscultation –upper right sternal border (URSB) –upper left sternal border (ULSB) –lower left sternal border (LLSB) –apex –apex - left lateral decubitus position –lower left sternal border (LLSB)- sitting, leaning forward, held expiration

4. Innocent Murmurs Common in asymptomatic adults Characterized by Characterized by –Grade I – II @ LSB –Systolic ejection pattern - no  with Valsalva –Normal precordium, apex, S1 –Normal intensity & splitting of second sound (S2) –No other abnormal sounds or murmurs –No evidence of LVH S1 S2

5. Characteristic of the NOT Innocent Murmur Diastolic murmur Diastolic murmur Loud murmur - grade III or above Loud murmur - grade III or above Regurgitant murmur Regurgitant murmur Murmurs associated with a click Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2 nd heart sound – fixed split, paradoxical split or single Abnormal 2 nd heart sound – fixed split, paradoxical split or single

6. Heart Sounds Pearls Right sided valves open earlier and close last due to lower pressure gradient Right sided valves open earlier and close last due to lower pressure gradient All right sided murmur and sounds tend to augment with inspiration: EXCEPTION: PULMONIC STENOSIS click DECREASES WITH INSPIRATION All right sided murmur and sounds tend to augment with inspiration: EXCEPTION: PULMONIC STENOSIS click DECREASES WITH INSPIRATION Valsalva releases increases murmur of HOCM and MVP Valsalva releases increases murmur of HOCM and MVP

7. Heart Sounds: Clicks

8. Valve Disorders Etiology Etiology Symptoms Symptoms Physical Exam Physical Exam Testing Testing Severity Severity Indications for Surgery Indications for Surgery

9. Common Clinical Scenarios Younger people Younger people –Functional murmur vs MVP vs bicuspid AV Older people Older people –Aortic sclerosis vs aortic stenosis

10. Aortic Stenosis - Etiology Young patient think congenital Young patient think congenital –Bicuspid AVD 2% population 2% population 3:1 male:female distribution 3:1 male:female distribution Co-existing coarctation 6% of patients Co-existing coarctation 6% of patients Rarely Rarely –Unicuspid valve –Sub-aortic stenosis Discrete Diffuse (Tunnel) Middle aged patient(4&5 th decades) think bicuspid or rheumatic disease Middle aged patient(4&5 th decades) think bicuspid or rheumatic disease Old patient think degenerative (6,7,8 th decades) Old patient think degenerative (6,7,8 th decades)

11. Aortic Stenosis: Etiology Valvular Valvular Subvalvular Subvalvular Supravalvular Supravalvular

13. Supravalvular Aortic Stenosis

14. Aortic Stenosis: Symptoms Cardinal Symptoms Cardinal Symptoms –Chest pain (angina) Reduced coronary flow reserve Reduced coronary flow reserve Increased demand-high afterload Increased demand-high afterload –Syncope (exertional pre-syncope) Fixed cardiac output Fixed cardiac output Vasodepressor response Vasodepressor response –Dyspnea on exertion & rest Other signs of LV failure Other signs of LV failure –Diastolic & systolic dysfunction

15. Severity of Stenosis Normal aortic valve area 2.5-3.5 cm 2 Normal aortic valve area 2.5-3.5 cm 2 Mild stenosis 1.5-2.5 cm 2 Mild stenosis 1.5-2.5 cm 2 Moderate stenosis 1.0-1.5 cm 2 Moderate stenosis 1.0-1.5 cm 2 Severe stenosis < 1.0 cm 2 Severe stenosis < 1.0 cm 2 Onset of symptoms Onset of symptoms ~0.9 cm 2 with CAD ~0.7 cm 2 without CAD

16. Aortic Stenosis: Physical Findings Intensity DOES NOT predict severity Intensity DOES NOT predict severity Presence of thrill DOES NOT predict severity Presence of thrill DOES NOT predict severity “Diamond” shaped, systolic crescendo- decrescendo “Diamond” shaped, systolic crescendo- decrescendo Decreased, delay & prolongation of pulse amplitude: “pulsus parvus and tardus” Decreased, delay & prolongation of pulse amplitude: “pulsus parvus and tardus” Paradoxical S2 Paradoxical S2 S4 (with left ventricular hypertrophy) S4 (with left ventricular hypertrophy) S3 (with left ventricular failure) S3 (with left ventricular failure)

17. Aortic Stenosis: Physical Findings S1 S2 Mild-Moderate Severe

18. Heart Sounds: Splitting AS

19. Aortic Stenosis : Lab EKG: LVH EKG: LVH CXR: Intially have concentric LVH so unremarkable; Critical AS may show post stenotic dilation of the aorta, hypertrophy, congestion CXR: Intially have concentric LVH so unremarkable; Critical AS may show post stenotic dilation of the aorta, hypertrophy, congestion

20. CXR: AS with Post Stenotic Dilatation of Aorta

22. Aortic Stenosis: Treatment Indications for surgery: Symptomatic Symptomatic Asymptomatic but EF < 50% Asymptomatic but EF < 50% Poor performance on ETT Poor performance on ETT Reasonable if asymptomatic true AS and operative mortality is low Reasonable if asymptomatic true AS and operative mortality is low If low output, low gradient AS then need dobutamine stress echo If low output, low gradient AS then need dobutamine stress echo

23. Aortic Stenosis: Treatment Aortic stenosis is a surgical disease Aortic stenosis is a surgical disease Treatment is valve replacement Treatment is valve replacement Aortic valve balloon valvuloplasty rarely done due to stroke risk and other complications Aortic valve balloon valvuloplasty rarely done due to stroke risk and other complications Current trials using catheter based aortic valve replacement Current trials using catheter based aortic valve replacement

24. Aortic Regurgitation: Etiology Any conditions resulting in incompetent aortic leaflets Any conditions resulting in incompetent aortic leaflets Congenital Congenital –Bicuspid valve Aortopathy Aortopathy –Cystic medial necrosis –Collagen disorders (e.g. Marfan’s) –Ehler-Danlos –Osteogenesis imperfecta –Pseudoxanthoma elasticum Acquired Acquired –Rheumatic heart disease –Dilated aorta (e.g. hypertension..) –Degenerative –Connective tissue disorders E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis ) –Syphilis (chronic aortitis) Acute AI: aortic dissection, infective endocarditis, trauma Acute AI: aortic dissection, infective endocarditis, trauma

25. Aortic Regurgitation: Symptoms Dyspnea, orthopnea, PND Dyspnea, orthopnea, PND With extreme reductions in diastolic pressures (e.g. < 40) may see angina With extreme reductions in diastolic pressures (e.g. < 40) may see angina

26. Aortic Regurgitation: Physical Exam Widened pulse pressure Widened pulse pressure –Systolic – diastolic = pulse pressure High pitched, blowing, decrescendo diastolic murmur at LSB High pitched, blowing, decrescendo diastolic murmur at LSB Best heard at end- expiration & leaning forward Best heard at end- expiration & leaning forward Hands & Knee position Hands & Knee position S1 S2 S1

27. Peripheral Signs of Severe Aortic Regurgitation Quincke’s sign: capillary pulsation Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula Mueller’s sign: systolic pulsation of uvula Durosier’s sign: femoral retrograde bruits (bell) Durosier’s sign: femoral retrograde bruits (bell) Traube’s sign: pistol shot femorals Traube’s sign: pistol shot femorals Hill’s sign:BP Lower extremity >BP Upper extremity by Hill’s sign:BP Lower extremity >BP Upper extremity by –> 20 mm Hg - mild AR –> 40 mm Hg – mod AR –> 60 mm Hg – severe AR

28. Central Signs of Severe Aortic Regurgitation Apex: Apex: –Enlarged –Displaced –Hyper-dynamic –Palpable S3 –Austin-Flint murmur Aortic diastolic murmur Aortic diastolic murmur –length correlates with severity (chronic AR) –in acute AR murmur shortens as Aortic DP=LVEDP –in acute AR - mitral pre-closure

29. Assessing Severity of AR Assess severity by impact on peripheral signs and LV Assess severity by impact on peripheral signs and LV –  peripheral signs =  severity –  LV =  severity –S3 –Austin -Flint –LVH –radiological cardiomegaly

30. Aortic Regurgitation

31. Aortic Regurgitation: Natural History Asymptomatic %/Y Normal LV function (~good prognosis) Normal LV function (~good prognosis) –Progression to symptoms or LV dysfunction < 6 –Progression to asymptomatic LV dysfunction < 3.5 –75% 5-year survival –Sudden death < 0.2 Abnormal LV function Abnormal LV function –Progression to cardiac symptoms 25 Symptomatic (Poor prognosis) –Mortality > 10 Bonow RO, et al, JACC. 1998;32:1486.

32. Aortic Regurgitation: Treatment Before development of heart failure, AI can be treated with vasodilators (ACE Inhibitors), diuretics, salt restriction Goal: Surgery BEFORE LV dysfunction !!!! “Rule of 55”

33. Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation Type of Regurgitation LVESD mm EF % Aortic > 55 < 55 < 55 Mitral > 40 < 60 < 60

34. A 75 year old woman with Recent orthopnea/PND Chronic dyspnea Class 2/4 Chronic dyspnea Class 2/4 Fatigue Fatigue Recent orthopnea/PND Recent orthopnea/PND Nocturnal palpitation Nocturnal palpitation Pedal edema Pedal edema

35. Mitral Stenosis: Etiology #1 Rheumatic

36. Mitral Stenosis: Etiology #1 Rheumatic #2 ?

37. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic

38. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic

39. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic... #99 ?

40. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic

41. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic #100 ?

42. Mitral Stenosis: Etiology #1 Rheumatic #2 Rheumatic #3 Rheumatic #99 Rheumatic #100 Congenital, endocarditis, Carcinoid, Fabray, Hurler, Whipple, Atrial Myxoma

43. Mitral Stenosis Etiology Primarily a result of rheumatic fever Primarily a result of rheumatic fever –~ 99% of MV’s @ surgery show rheumatic damage) Scarring & fusion of valve apparatus Scarring & fusion of valve apparatus Rarely congenital Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female. Two-thirds of all patients with MS are female.

44. Mitral Stenosis Pathophysiology Normal valve area: 4-6 cm 2 Normal valve area: 4-6 cm 2 Mild mitral stenosis: Mild mitral stenosis: –MVA 1.5-2.5 cm 2 –Minimal symptoms Mod mitral stenosis Mod mitral stenosis –MVA 1.0-1.5 cm 2 usually does not produce symptoms at rest Severe mitral stenosis Severe mitral stenosis –MVA < 1.0 cm2

45. Right Heart Failure: Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement  Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi  LA Pressure RV Pressure Overload RV Pressure OverloadRVH RV Failure LV Filling Mitral Valve Stenosis Pathophysiology

46. Mitral Stenosis: Symptoms Dyspnea, PND, orthopnea Dyspnea, PND, orthopnea –Slow progressive course –May not admit to symptoms Hemoptysis Hemoptysis Palpitations Palpitations Emboli Emboli

47. Mitral Stenosis Examination

48. Mitral Stenosis Physical Exam First heart sound (S1) is accentuated and snapping First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm) Pre-systolic accentuation (esp. if in sinus rhythm) S1 S2 OS S1

49. Auscultation-Timing of A2 to OS Interval Width of A2-OS inversely correlates with severity Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens Shorter A2-OS=more severe mitral stenosis Shorter A2-OS=more severe mitral stenosis

50. Mitral Stenosis: ECG LAE LAE With pulm HTN: RAD, RVH With pulm HTN: RAD, RVH AFIB AFIB

52. Mitral Stenosis: CXR

54. Mitral Stenosis: Treatment

58. An 80 year old woman with increasing dyspnea Longstanding heart murmur Longstanding heart murmur Increasing dyspnea & fatigue Increasing dyspnea & fatigue Recent ER visit Dx CHF Recent ER visit Dx CHF

59. Mitral Regurgitation: Etiology Valvular-leaflets Valvular-leaflets –Myxomatous MV Disease –Rheumatic –Endocarditis –Congenital-clefts Chordae Chordae –Fused/inflammatory –Torn/trauma –Degenerative –IE Annulus Annulus –Calcification, IE (abcess) Papillary Muscles Papillary Muscles –CAD (Ischemia, Infarction, Rupture) –HCM –Infiltrative disorders LV dilatation & functional regurgitation LV dilatation & functional regurgitation Trauma Trauma

60. MR Etiology:Surgical series MVP(20-70%) MVP(20-70%) Ischemia (13-40%) Ischemia (13-40%) RHD (3-40%) RHD (3-40%) Infectious endocarditis(10-12%) Infectious endocarditis(10-12%)

61. MR Pathophysiology Chronic LV volume overload -» compensatory LVE initially maintaining cardiac output Chronic LV volume overload -» compensatory LVE initially maintaining cardiac output Decompensation (increased LV wall tension) -»CHF Decompensation (increased LV wall tension) -»CHF LVE – » annulus dilation – » increased MR LVE – » annulus dilation – » increased MR Backflow – » LAE, Afib, Pulmonary HTN Backflow – » LAE, Afib, Pulmonary HTN

62. MR Symptoms Similar to MS Similar to MS Dyspnea, Orthopnea, PND Dyspnea, Orthopnea, PND Fatigue Fatigue Pulmonary HTN, right sided failure Pulmonary HTN, right sided failure Hemoptysis Hemoptysis Systemic embolization in A Fib Systemic embolization in A Fib

63. Recognizing Chronic Mitral Regurgitation Pulse: Pulse: – brisk, low volume Apex: Apex: –hyperdynamic –laterally displaced –palpable S3 +/- thrill –late parasternal lift 2  to LA filling S 1 soft or normal S 1 soft or normal S 2 wide split (early A2) unless LBBB S 2 wide split (early A2) unless LBBB Murmur-Fixed MR: Murmur-Fixed MR: –pansystolic –loudest apex to axilla –no post extra-systolic accentuation Murmur-Dynamic MR(MVP) Murmur-Dynamic MR(MVP) –mid systolic –+/- click –  upright S 3 / flow rumble if severe S 3 / flow rumble if severe

64. Recognizing Acute Severe Mitral Regurgitation Acute severe dyspnea, CHF & hypotension Acute severe dyspnea, CHF & hypotension LV size normal LV size normal LV may/may not be hyperdynamic LV may/may not be hyperdynamic Loud S1 Loud S1 Systolic murmur may/may not be pan- systolic Systolic murmur may/may not be pan- systolic Inflow/rumble Inflow/rumble S3 present-may be only abnormality S3 present-may be only abnormality RV lift RV lift TTE/TEE for diagnosis TTE/TEE for diagnosis –Chordal or papilllary muscle rupture/tear –Infarction with papillary muscle ischaemia or tear –Infectious endocarditis with leaflet perforation or disruption or chordal tear –Flail MV segment

65. Recognizing Mitral Regurgitation ECG: ECG: –LA enlargement –Afib –LVH (50% pts. With severe MR) –RVH (15%) –Combined hypertrophy (5%) CXR: CXR: –  LV –  LA –  pulmonary vascularity –CHF –Ca++ MV/MAC

66. Mitral Regurgitation

67. CXR: MS vs MR

68. CXR: Mitral stenosis with MR and TR

69. Chronic MR Echocardiography Baseline evaluation to identify etiology, quantify severity of MR Baseline evaluation to identify etiology, quantify severity of MR Assess and quantify LV function and dimensions Assess and quantify LV function and dimensions Annual or semi-annual surveillance of LV function, estimated EF and LVESD in asymptomatic severe MR Annual or semi-annual surveillance of LV function, estimated EF and LVESD in asymptomatic severe MR To establish cardiac status after change in symptoms To establish cardiac status after change in symptoms Baseline study post MVR or repair Baseline study post MVR or repair

70. Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation Type of Regurgitation LVESD mm EF % Aortic > 55 < 55 < 55 Mitral > 40 < 60 < 60

71. Mitral Valve Prolapse: Epidemiology Affects 5-10% of population Affects 5-10% of population Most common cause of isolated severe MR Most common cause of isolated severe MR Females >> males; Ages of 14 and 30years Females >> males; Ages of 14 and 30years Strong hereditary component (? autosomal dominant) Strong hereditary component (? autosomal dominant) 2º to failure of apposition/coaptation of the anterior and posterior mitral valve leaflets. 2º to failure of apposition/coaptation of the anterior and posterior mitral valve leaflets. Results form diverse pathologic conditions, but cause is unknown in a majority of pts Results form diverse pathologic conditions, but cause is unknown in a majority of pts

72. Mitral Valve Prolapse: Symptoms Majority are asymptomatic for entire life Majority are asymptomatic for entire life Palpitations Palpitations Chest pain (atypical). Chest pain (atypical). –Often substernal, prolonged, poorly related to exertion, and rarely resembles typical angina Syncope Syncope

73. Fixed mitral regurgitation Fixed mitral regurgitation Mitral valve prolapse Mitral valve prolapse Mitral Insufficiency: Physical Exam S1 S2 S1 S1 C S2

74. MVP Physical Exam: Click Murmur Standing broadens murmur Squatting squishes murmur

75. Mitral Valve Prolapse: Complications Arrhythmias (Usually PVC, PSVT>>VT) Arrhythmias (Usually PVC, PSVT>>VT) Transient cerebral ischemic (embolic – rare) Transient cerebral ischemic (embolic – rare) Infective endocarditis (if assoc w/ MR) Infective endocarditis (if assoc w/ MR) Sudden death (rare) Sudden death (rare)

76. MVP Treatment Watch for mitral regurgitation Watch for mitral regurgitation As with MR, surgery when LVESD>40 mm or EF 40 mm or EF <60%.

77. © Continuing Medical Implementation …...bridging the care gap Thanks!

78. PS

82. Recognizing Aortic Stenosis

83. Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation Type of Regurgitation LVESD mm EF % FS Aortic > 55 < 55 < 55 < 0.27 < 0.27 Mitral > 45 < 60 < 60 < 0.32

84. Auscultation-Timing of A2 to OS Interval Width of A2-OS inversely correlates with severity Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens

85. Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation Type of Regurgitatio n LVESD mm EF % FS Aortic > 55 < 55 < 55 < 0.27 < 0.27 Mitral > 45 < 60 < 60 < 0.32

86. Recognizing Mitral Stenosis Palpation: Small volume pulse Small volume pulse Tapping apex-palpable S1 Tapping apex-palpable S1 +/- palpable opening snap (OS) +/- palpable opening snap (OS) RV lift RV lift Palpable S2 Palpable S2ECG: LAE, AFIB, RVH, RAD LAE, AFIB, RVH, RADAuscultation: Loud S1- as loud as S2 in aortic area Loud S1- as loud as S2 in aortic area A2 to OS interval inversely proportional to severity A2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS & rumble may be inaudible In severe MS with low flow- S1, OS & rumble may be inaudible

87. Mitral Stenosis: Symptoms

88. Assessing Murmurs Assessing Murmurs Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

89. Heart Sounds: Murmur Systolic murmur Systolic murmur –Right sided vs left sided: Effect of respiration (RIGHT SIDED INCREASE WITH INSPIRATION)!!!!!!!! Except PS decreases Effect of respiration (RIGHT SIDED INCREASE WITH INSPIRATION)!!!!!!!! Except PS decreases Valsalva release– two systolic murmurs that increase are HOCM and MVP Valsalva release– two systolic murmurs that increase are HOCM and MVP Diastolic murmur: Diastolic murmur: –Early diastolic (Great vessel origin): Semilunar: AI or PR –Mid diastolic: AV valve flow, MS, TS, increased cardiac output, severe MR/TR with rumble from increased flow Continuous Murmur Continuous Murmur –PDA – infraclavicular and peaks at S2 –AV fistula –Venous Hum –To and Fro is AS and AI

90. Mitral Stenosis Symptoms Fatigue Fatigue Palpitations Palpitations Cough Cough SOB SOB Left sided failure Left sided failure –Orthopnea –PND Palpitation Palpitation AFib AFib Systemic embolism Systemic embolism Pulmonary infection Pulmonary infection Hemoptysis Hemoptysis Right sided failure Right sided failure –Hepatic Congestion –Edema Worsened by conditions that  cardiac output. Worsened by conditions that  cardiac output. –Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy, thyrotoxicosis

91. Aortic Regurgitation: Symptoms Dyspnea, orthopnea, PND Dyspnea, orthopnea, PND With extreme reductions in diastolic pressures (e.g. < 40) may see angina With extreme reductions in diastolic pressures (e.g. < 40) may see angina

92. Percutaneous AVR

93. Aortic Regurgitation: Symptoms Dyspnea, orthopnea, PND Dyspnea, orthopnea, PND Chest pain. Chest pain. –Nocturnal angina >> exertional angina –(  diastolic aortic pressure and increased LVEDP thus  coronary artery diastolic flow) With extreme reductions in diastolic pressures (e.g. < 40) may see angina With extreme reductions in diastolic pressures (e.g. < 40) may see angina

94. Common Murmurs and Timing Systolic Murmurs Aortic stenosis Aortic stenosis Mitral insufficiency Mitral insufficiency Mitral valve prolapse Mitral valve prolapse Tricuspid insufficiency Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Aortic insufficiency Mitral stenosis Mitral stenosis S1 S2 S1

95. Comparing AS and MR Systolic Murmurs Aortic stenosis Aortic stenosis Mitral insufficiency Mitral insufficiency Mitral valve prolapse Mitral valve prolapse Tricuspid insufficiency Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Aortic insufficiency Mitral stenosis Mitral stenosis S1 S2 S1

96. Assessing Severity of Chronic Mitral Regurgitation Measure the Impact on the LV: Apical displacement and size Apical displacement and size Palpable S3 Palpable S3 Longer/louder MR murmer (chronic MR) Longer/louder MR murmer (chronic MR) S3 intensity/ length of diastolic flow rumble S3 intensity/ length of diastolic flow rumble Wider split S2 (earlier A2) unless HPT narrows the split Wider split S2 (earlier A2) unless HPT narrows the split

97. Mitral Valve Prolapse: Physical Exam Most important finding: mid  late systolic click. Most important finding: mid  late systolic click. –Acute tensing of the mitral valve chordae Variable murmurs: Variable murmurs: –high pitched late systolic crescendo-decrescendo murmur, –Occasionally “whooping” or “honking” at the apex S1 C S2

98. MR Echocardiography Etiology: Etiology: –flail leaflets (chord/pap rupture) –thick (RHD) – post mvt of leaflets (MVP) – vegetations(IE) Severity: Severity: –regurgitant volume/fraction/orifice area –LV systolic function –increased LV/LA size, EF

99. MR Stages LV size and function defined by echo Stage 1-compensated: Stage 1-compensated: –End-diastolic dimension less 63mm, ESD less 42mm –EF more than 60 Stage 2-transitional Stage 2-transitional –EDD 65-68mm, ESD 44-45mm, EF 53-57 Stage 3-decompensated Stage 3-decompensated –EDD more than 70mm, ESD more than 45mm, EF less than 50

100. RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHY IN PATIENTS WITH CHRONIC MITRAL REGURGITATION AND PRIMARY MITRAL-VALVE DISEASE. SEVERITY OF MITRALREGURGITATION LEFT VENTRICULAR FUNCTION* FREQUENCY OF ECHOCARDIOGRA- PHIC FOLLOW-UP Mild Normal ESD and EF Every 5 yr Moderate Normal ESD and EF Every 1 – 2 yr Moderate ESD >40 mm or EF 40 mm or EF <0.65Annually Severe Normal ESD and EF Annually Severe ESD >40 mm or EF 40 mm or EF <0.65 Every 6 mo *ESD denotes end-systolic dimension and EF ejection fraction. Otto C.M. NEJM 345:10.

101. Mitral Valve Prolapse: Physical Exam Most important finding: mid  late systolic click. Most important finding: mid  late systolic click. –Acute tensing of the mitral valve chordae Variable murmurs: Variable murmurs: –high pitched late systolic crescendo-decrescendo murmur, –Occasionally “whooping” or “honking” at the apex S1 C S2