Valvular heart

Advanced AS can cause:

- Angina - Syncope - Heart failure

TV has 3 main pap muscles named:

- Anterior - Posterior - Medial (conal)

TV made up of 3 leaflets named:

- Anterior - Posterior ( Inferior ) - Spetal (medial )

PV consists of 3 cusps named:

- Anterior - Right - Left

In older Pt's (>65) AS typically due to:

- Calcification of once normal trileaflet valve. - Called a degenerative dz - most comomon cause of AS.

Is there normal Mitral Regurgitation?

-Yes, little regurg after MV closure.

Where is a double pulse commonly felt?

At the brachical/ femoral pulse points

What are the two categories for cardiac valves?

Atrioventricular ( AV) Semilunar

Tricuspid stenosis is usually associated with what heart disease?

Rheumatic heart dz Carcinoid heart dz

What are the Treatment for Mitral Stenosis?

- Diuretics to control volume status. - Beta Blockers to control HR - Vulvuloplasty - balloon ( like angioplasty) passed through stenosed MV, expanded to crack valve open - MV replacement

Side effects/ symptoms of MR?

- Dysapnea ( labored breathing) - Systolic murmur (turbulent flow) due to high pressure LV discharging high velocity flow into low pressure LA. *Increase LV preload*

Cusps have 2 layers of material named:

- Fibrosa: structural backbone _spongiosa: shock absorber (ventricular surface)

Symptoms of AS ( AO stenosis ):

- Murmur ( systolic) is often the first recognition of AO stenosis ( AS )

Define Sinus of Valsalva ( or ' Sinus' ):

- Out pouching of arterial root behind each cusp - R / L coronary artereies arise from R / L sinuses

Aortic valve consists of 3 cusps named:

- RCC (RIght Coronary Cusp) - LCC ( Left coronary cusp) - NCC ( non coronary cusp - no associated artery)

What are the treatments for chronic MR?

- Vasodilator medications to reduce afterload/ promote forward flow - Sx MV repair - SX MV replacement

What is considered part of the subvalvular aparatus?

- chordae tendonae - Papillary muscles

What structures are considered subvalvular apparatus?

- chordae tendonae - Papillary Muscles

QhR re the 2 wdges of teh semilunar valves:

- leadinf edge ( freee edge) - closing edge (ridge of tissue slightly below free edge

What happens to Pt's with severe AR/ AI:

- wide pulse pressure - high SV due to large blood vol in LV - results in high systolic pressure

whar year was there a dramatic decline in rheumatic carditis ( and subsequent mitral stenosis )?

1950s

How many categories do the Atrioventricular valve structures fall under, and what are they?

2 Valvular and Subvalvular

Define Bicuspid AO valve:

2 AO leaflets instead of 3

What how many layers are in a leaflet and what are they called?

3 - Fibrosa: fibrous skeleton - Spongiosa: Mid portion, myxomatous connective tissue - Atrialis: thin layer of collegen/ elastic tissue

normal area for mv:

4-6 cm^2

How many components make up the atrioventricular valves?

5

Pressure values and meansing: what do A - D represent?

A - MV open B - MV closed C - AO open D - AO closed ^- everyother, MV first AO second. * opens/ closed diagnal from each other on graph*

- Fibrosa - Spongiosa - Atrialis - Blood flow - chordae tendonae - Papillary muscles

A) Fibrosa B) Spongiosa C) Atrialis D) Blood flow E) chordae tendonae F) Papillary muscles

What are the anterior leaflet scallops named?

A1 (lateral) A2 (middle/ biggest) A3 (medial) Anatomy correlates with posterior scallops

What is Bicuspid AV typically associated with?

AO coarctation or AO aneurysm

What are the names of the semilunar valves?

AO valve ( aortic ) PV ( Pulmonary valve)

what valves are open in systole?

AV/ PV

*In AS, LV hypertrophy due to increased:*

Afterload

Natural Hx of AS, Prognostic Indicators of: Angina: Syncope: Failure:

Angina: 5 yrs Syncope: 3 yrs Failure: 2 yrs

What is considered part of the valvular apparatus?

Annulus Valve leaflets Commissures

what are the 2 leaflets of the Mitral valve?

Anterior leaflet Posterior leaflet

AR ( aortic regurgitation ) is also known as:

Aortic Insuficiency

Aortic valve located:

Below PV and above MV/TV

BP =

CO x TPF

WHat is the support structure of the leaflets?

Choardae tendonae

In AR/ AI Pt often have what kind of murmur?

Diastolic

In MS ehat happens on exersion?

Dysapnea

Rheumatic heart disease can result in :

Dysfucntion of the MV or possibly other valves

How common is the development of AS/AI in Bicuspid AV?

Fairly common, occurs earlier in life, than degenerative AV dz.

Define MV ( mitral valve) prolapse:

Fibrosa of the leaflet if fragmented and replaced by myxomatous connective tissue of the spongiosa (middle) leaflet layer. affected portions of leaflet become redundant/ billoe or prolapse back into LA

MV prolapse is also known as:

Floppy MV Myxomatous MV Barlows MV

When do the pap muscles contract?

In systole

What is the Annulus?

Ring of fibrous tissue, attached to cardiac skeleton, saddle shaped, electrically insulates aatria from ventricles ( allow atria/ vents to contract independantly)

SIgnificant MR leads to:

Increased preload, and filling pressures

During ventricular contaction ( systole) what are the Hemodynamics of MR:

LA ejects blook back to LA as well as AO, increases LAP.

Chronic MR ( aka Mitral Insufficiency) makes the heart look like:

Large LV, large LA

How do you define abnormal mitral regurgitation?

Leaks due to primary leaflet problem. Prolapse or flail segment, or secondary problem that alters sub valvular apparatus.

What are the names of the Atrioventricular valves?

MV ( Mitral valve) TV ( Tricuspid valve)

TV annulus >

MV annulus

What valves are open in diastole?

MV/ TV

MV prolaps can result in:

Mitral Insufficiency

AS pressure - volume loop

Orange pv loop - est. normal for Pt EDV of 140 ml ; ESV of 60 ml SV of 80 ml EF of 575 Blue PV loop is avtual * First ptoblem with AS is INCREASED AFTER LOAD * - this is an example of Advanced AS - this person now has heart failure resulting in increased preload/ reduced contractility EDV : 160ml ESV: 115ml SV: 45 ml EF: 28% All caradiac parameters are normalized after AV replacement

as MS advances it can lead to;

Orthopnea/ pulmonary edema

POsterior cusp is separated into 3 semi circle scallops named? which one is the biggest?

P1 ( Lateral ) P2 ( Middle, biggest ) P3 ( Medial )

MS ( Mitral Stenosis ) has reduced what?

Preload and SV *protected LV MS, LA enlargement - ultimately RV gets affected due to PHTN.

WHat is increased in AR/AI?

Preload and afterload SV and EF are usually high too

What shape does the posterior mitral valve cusp appear in?

Rectangular

AS case in echo A4C:

Reduced lv func normal right heart function mild LA enlargment

What do the semilunar valves separate from the ventricles?

THe great arteries

Define what makes the chordae tendonae?

Tendons attaching to valve/ pap muscles helps ventricle retain correct geometry

Define mitral stenosis:

Thickened calcified mitral leaflets obstruct flow from left atrium into left ventricle

TV spetal leaflets have what kind of leaflets:

short/ oblique

How common is Tricuspid stenosis?

Uncommon

What direction to the atrioventricular valves flow in?

Unidirectional from atria to ventricles

AR hemodynamic - During ventricular relaxing:

Ventricular Diastole ( relaxing) : BF backwards from AO to LV. -ASP increases - ADP decreases PP increases

Hemodynamics of AS:

Ventricular ejection, LVP exceeds AP

Significant tricuspid stenosis will result in back up of:

Volume ( edema) behind RA, can lead to enlarged liver/spleen/ ascites

In younger Pt;s AS is often due to:

a bicuspid ( 2 leaflet ) valve. Considered a common congenital abnormality

Pulmonary valve located:

above AV/ MV/ TV

What are the treatments for acute MR?

almost always an Sx emergency.

Define rheumatic fever:

an inflammatory condition occuring after strep pharyngitis

In valvular disease regurgitation the valve doesn't:

close all the way, blood leaks backwards

in the leaflet the atrialis is made of:

collegen/ elastic tissue

diastolic rummble on auscultation, echocardiogram extremely helpful for diagnosis and determining the:

degree of stenosis

In the leaflet, the fibrous layer is made of:

fibrous skeleton

Cusps form pocket like:

flaps

What are commisures?

site of union, cleft like split, site of separation from one leaflet to another. associated with pap muscle

in the leaflet, the spongiosa is made of:

myxomatous connective tissue

Acute MR ( aka Mitral insufficiency) makes the heart look like:

normal LV, large LA

In the peripheral pulse, a delayed pulse is due to slow ejection of blood through:

obstructed AV, aka narrow pulse pressure

In valvular disease stenosis, the valve doesn't:

open all the way, not enough blood passes through

heart valve case in echo PLAX:

reduced function, LVH, thickened AC, Trivial pericardial effusion

Define AR/ AI ( Aotric regurgitation/ Aortic Insufficiency):

retrograde flwo through AV and back to LV can be due to valve problems of AO root dz.

a consequence ( sequela ) after acute rheumatic fever is:

rheumatic heart disease

MS can be exacerbated by other factors such a:

tachycardia, volume expansion, pregnancy, heart faillure ect.

Semilunar valves have no:

tensor apparatus

In the hemodynamics of MS ( mitral stenosis), high left atrial pressure is transmitted back to:

the lungs

define mitral stenosis/ mitral leaflet doming:

thickened ridgid MV, usually domes during diasrole, as the elevated LA pressures push against to restrictiev vlve orifice

Basal portion of the anterior cusp contains myocardial cells that help facilitate:

valve closure

does the chotdae tendonaee prevent prolapse into atria?

yes

AS case in echo PSAX:

zoom on AV appears trileaflet heavily calcified poor leaflet excursion ( mobility)

WHat % of population has a Bicuspid valve?

~ 2%