Valvular Heart Disease

A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history of rheumatic fever as a child and has had a cardiac murmur since early adulthood. Her temperature is 36.7°C (98°F), pulse is 130/min and irregularly irregular, respirations are 20/min, and blood pressure is 98/60 mm Hg. Jugular venous pressure is not increased. Bilateral crackles are heard at the lung bases. There is an opening snap followed by a low-pitched diastolic murmur at the third left intercostal space. An x-ray of the chest shows left atrial enlargement, a straight left cardiac border, and pulmonary venous engorgement. Which of the following is the most likely explanation for these findings? (A) Aortic valve insufficiency (B) Aortic valve stenosis (C) Mitral valve insufficiency (D) Mitral valve stenosis (E) Tricuspid valve insufficiency

(D) Mitral valve stenosis Opening snap + diastolic murmur in 3rd LICS + atrial enlargement/straight left cardiac borer on CXR = MS

************************ file:///C:/Users/Tanvi/Downloads/2298.full.pdf A 55-year-old woman with systemic lupus erythematosus and antiphospholipid syndrome presents with worsening fatigue and dyspnea that prevents her from working or doing strenuous housework. Physical examination is remarkable for a holosystolic murmur and an S3 heart sound. Echocardiography demonstrates severe mitral regurgitation.Mitral valve replacement is recommended. If the surgery is successful, which of the following sets of changes in ventricular function will most likely occur? (A) Ejection fraction and left ventricular systolic pressure will both fall (B) Ejection fraction and left ventricular systolic pressure will both rise (C) Ejection fraction will fall, and left ventricular systolic pressure will rise (D) Ejection fraction will rise, and left ventricular systolic pressure will fall (E) Neither ejection fraction nor left ventricular systolic pressure will change

(C) Ejection fraction will fall, and left ventricular systolic pressure will rise Chronic mitral regurgitation produces volume overload hypertrophy of the left ventricle and enlargement of the left atrium (to accommodate the higher atrial volumes with little increase in atrial pressure). The dilatation of the left ventricle initially compensates for mitral regurgitation but has proceeded to left heart failure in this patient, as indicated by her fatigue and dyspnea on exertion. This indicates that the left ventricular muscle contractility is reduced and the muscle is unable to increase its contractility to compensate for increased afterload. Repair of the mitral valve forces all of the blood in the dilated heart to exit through the aorta, which has a higher resistance than the left atrium (which previously received the regurgitated blood). The increased resistance necessitates an increased left ventricular systolic pressure (compare with choices A and D) to eject the blood. The failing left heart cannot eject as much against this higher afterload, however, and thus the ejection fraction is reduced. (This eliminates B;D E)

Ventricular Septal Defect

* * * * * * *

Mitral Insufficiency/Regurgitation

* * *MCC = Mitral Valve Prolapse *High-pitched holosystolic murmur at the apex with radiation to the axilla * * * *Atrial fibrillation is common, as a consequence of atrial dilatation **Mitral Regurgitation is the MCC of large-v waves* *Wide physiological splitting of the 2nd Heart Sound (due to early closure of Aortic Valve)

Describe five hemodynamic consequences of Mitral Stenosis

*Decreased left ventricular filling can decrease SV *Increased LA pressure and volume can increase risk of fibrillation and mural thrombus formation *Increased LA pressure and volume can cause backflow into pulmonary vein and increase PCWP (results in pulmonary edema, congestion, and pulmonary hypertension) *Pulmonary hypertension can decrease pulmonary vascular complicance *Pulmonary hypertension can increase RV pressure and volume (hypertrophy) with eventual RHF or functional tricuspid regurgitation

Describe the changes that occur in the left ventricular pressure-volume (PV) loop when there is moderate to severe aortic stenosis

*Increased pressure gradient across LV/Aorta => Increased peak systolic LV pressure *Decreased SV (due to increased Afterload)

What are 3 causes of aortic valve stenosis? What is the MCC in patients < 30 What is the MCC in patients > 60

*MCC < 30: Congenital bicuspid aortic valve *MCC > 60: Degenerative age related calcified aortic valve *Chronic rheumatic fever

Tricuspid Regurgitation

*MCC in adults is functional TR due to RV dilation *MCC in IV drug users is infective endocarditis *Causes retrograde blood flow into the RA during systole *Causes RA dilatation and hypertrophy and backup of pressure into the venous system *A small, clinically insignificant amount of tricuspid regurgitation is present in about 70% of adults and can be considered a variant of normal anatomy *Physical exam may reveal palpably (and sometimes visibly) pulsatile liver on abdominal exam *Signs/symptoms of tricuspid insufficiency are generally those of right-sided heart failure, such as ascites and peripheral edema *A giant C-V waves occurs in TR as blood refluxes back into the RA during systole

List 6 potential causes of Mitral Regurgitation

*Mitral valve prolapse (MVP = MCC) *Rupture/dysfunction of the posteromedial papillary muscle (e.g., posterior Acute MI; 2nd MCC *Diseases that cause dilation of the left ventricle (e.g. aortic stenosis, aortic regurgitation) can lead to mitral regurgitation by stretching the mitral valve annulus. (functional MR) *Infective Endocarditis/ RHF *Idiopathic rupture of the chordae tendineae or chordal rupture associated with mitral valve prolapse can also cause severe acute mitral regurgitation *Rarely, ergotamine, pergolide, and cabergoline can cause mitral regurgitation ****** ******Note that this is far less common than other etiologies, and should only be considered as a possibility after having ruled out others definitively--even if a patient is taking one of these drugs! *

Mitral Stenosis

*Narrowing of MV due to calcification or valvular damage *MCC is Rheumatic heart disease (60% of cases) *Leads to increased pressure gradient between LA & LV *Backup of blood in LA -> pulmonary venous congestion (increased PCWP) -> exertional dyspnea, orthopnea, and PND *Longstanding pulmonary venous congestion causes irreversible changes in the vessel wall, leading to chronic pulmonary hypertension. *Low-pitched diastolic rumble following an opening snap just after S2 *S1 is increased in intensity **The time between the opening snap and the second heart sound decreases as the stenosis becomes more severe* **Heard best at the fourth intercostal space, midclavicular line, with the patient in left lateral decubitus position. **Mitral Stenosis leads to left atrial dilation and hypertrophy. This can result in atrial fibrillation* *Atrial fibrillation is associated with stasis and thrombus formation leading to possible embolization **May be associated with Dysphagia, Hoarseness, and Hemoptysis due to LA dilation*

Mitral Valve Prolapse

*One or both mitral valve leaflets are "floppy" and prolapse, or balloon back, into the left atrium during systole *Female to male ratio = 7:1 *Affects 2-3% of adult population **Produces a mid-systolic click usually followed by a late systolic crescendo murmur *Best heard over apex *MCC = Myxomatous Degeneration (Thickening of spongiosa due to dermatan sulfate) *Connective tissue disorders such as Ehlers-Danlos, Marfan, or osteogenesis imperfecta predispose to mitral valve prolapse. *May also be associated with PCKD and Klinefelter **Leaflets are often enlarged, redundant, thick, and rubbery* *Increased incidence seen in patients with Grave's Disease *Can predispose to infective endocarditis *Majority of patients are asymptomatic **Anxiety and panic disorders have been associated* *Tx in sympomatic patients: B-Blocker (decreases HR and force of contraction => less stretch and trauma to the prolapsed leaflets)

A 61-year-old male dies in a motor vehicle accident. Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy. The structural changes in this patient's heart are most likely associated with which of the following? 1. Pulmonic stenosis 2. Mitral insufficiency 3. Chronic hypertension 4. Wolff-Parkinson-White syndrome 5. Congenital atrial septal defect

2. Mitral insufficiency ECCENTRIC hypertrophy of LV + Dilation of LA = Mitral Insufficiency

Where are both Mitral Valve Prolapse and Mitral Regurgitation best heard?

Apex of the heart

A 38-year-old man comes to the physician because of a 1-week history of shortness of breath with exertion. His respirations are 12/min. Light palpation of the carotid artery shows the upstroke to be abnormally brisk and the downstroke to fall precipitously. Which of the following is the most likely cause of these physical examination findings? A) Aortic coarctation B) Aortic regurgitation C) Aortic stenosis D) Mitral regurgitation E) Mitral stenosis F) Ventricular septal defect

B) Aortic regurgitation The water-hammer, or Corrigan's, pulse is characterized by a very brisk upstroke, large amplitude, and rapid collapse; it is an extreme form of the hyperkinetic pulse.

Based on the pressure tracings, which of the following is the most likely diagnosis? A) Aortic regurgitation B) Aortic stenosis C) Mitral regurgitation D) Mitral stenosis E) Tricuspid regurgitation

C) Mitral stenosis

Where is the murmur of Aortic Stenosis best heard?

Loudest at the base of the heart/ Aortic Area

What are the three holosystolic murmurs?

MR TR VSD

Describe the typical presentation of the murmur in Mitral Stenosis

Mitral stenosis is heard as an opening snap followed by mid- to late-diastolic rumbling

What is the effect of standing and valsalva on the characteristic auscultatory finding of mitral valve prolapse?

Standing and valsalva decrease preload, reducing the LVEDV and relieving the chordae tendineae of some tension. This makes the click occur earlier in systole and increases the length of the murmur

Aortic Regurgitation

* * * * * * * *

HOCM

* * * * * * *Bifid carotid pulse with brisk upstroke (spike and dome)

__________________ is the ventricular pressure at the end of systole (End Systolic Pressure/ESP)

Afterload ****** is this true?

What is the treatment for asymptomatic, uncomplicated mitral valve prolapse?

Asymptomatic patients should be reassured that their condition is benign.

What role does the atrial kick/contraction play in Atrial Stenosis?

Responsible for LV Filling In patients with chronic aortic stenosis and concentric left ventricular hypertrophy, atrial contraction contributes significantly to left ventricular filling. This increase in preload is one of the compensatory mechanisms in AS, used to overcome the outflow obstruction/increased afterload and maintain SV. Overtime, as AS worsens, neither the increase in preload or LV concentric hypertrophy will be able to compensate and SV will decrease

Aortic Stenosis

*Most common valvular disease in the western world *Impairs ventricular emptying due to outflow obstruction/resistance *A large pressure gradient is required to push blood through the valve => increased end systolic pressure/afterload *AS Involves a prolonged latent period during which the patient is asymptomatic as the heart compensates for the outflow obstruction *Increased afterload -> concentric ventricular hypertrophy as well as a decreased stroke volume *Concentric ventricular hypertrophy may lead to diastolic dysfunction/ impaired filling due to reduced compliance (Associated with S4) *Decreased stroke volume -> Decreased arterial pressure *At rest cardiac output is normal however with exercise/severe stenosis, it may be decreased **Paradoxical splitting of 2nd heart sound* **Crescendo-decrescendo systolic ejection murmur (ejection click may be present)* *Often radiates to the carotid arteries or can be auscultated at the clavicles. *Common presenting symptoms: Syncope, Angina, and Dyspnea on Exertion (SAD) *Loudest at the base of the heart/Aortic area **May cause macroangiopathic hemolytic anemia secondary to mechanical destruction* *Aortic valve replacement is the only definitive treatment for aortic stenosis. **Physical exam may reveal pulsus parvus et tardus (aka anacrotic pulse)*

Aortic Insufficiency

*Retrograde flow of blood from the aorta into the left ventricle during diastole *Results from either damage to aortic valve or dilation of aortic root *High-pitched "blowing" early diastolic decrescendo murmur *Enhanced by the patient leaning forward and holding his breath at end-expiration *Heard best at the 3rd intercostal space on the left (Erb's point) *In the developing world, the MCC is rheumatic fever. *Connective tissue diseases, syphilitic aortitis, and aging can lead to chronic dilation of the aortic root, resulting in aortic regurgitation. * * *As the disease progresses, symptoms of congestive heart failure eventually occur.

Describe the prognosis of Aortic Stenosis

*Survival rate is normal for asymptomatic aortic stenosis *Survival rate is 2-3 years for symptomatic aortic stenosis w/o valve replacement *Survival rate is normal for symptomatic aortic stenosis w/ valve replacement

A 64-year-old woman with a history of rheumatic fever presents to her primary care clinician complaining of excessive fatigue with walking and difficulty lying flat. She had no prior physical limitations, but recently has been unable to walk more than 3 blocks without needing to stop and rest. Her cardiac exam is notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. What is the most likely diagnosis? 1. Mitral Regurgitation 2. Aortic Stenosis 3. MItral Stenosis 4. Aortic Regurgitation 5. Tricuspid Regurgitation

3. MItral Stenosis

A 50-year-old female presents with a holosystolic murmur heard best over the apex, radiating to the axilla. She has no signs of pulmonary hypertension or edema. What best explains her lack of symptoms? 1. The right ventricle is compensating with decreased compliance 2. The left atrium is compensating with increased compliance 3. The aorta is compensating with increased compliance 4. As long as preload in the left ventricle is maintained there would be no symptoms 5. There is only a ballooning of the valve which would not result in any hemodynamic changes in the heart

3. The aorta is compensating with increased compliance The patient in this vignette most likely has chronic mitral regurgitation, based on her lack of symptoms and characteristic murmur. Chronic mitral regurgitation is characterized by an increased left atrial compliance.

A 45-year-old woman who recently immigrated to the United states is hospitalized with exertional dyspnea and fatigue. She has no significant past medical history and takes no medications. The patient's blood pressure is 110/80 mm Hg and heart rate is 90/min and regular. After cardiopulmonary examination, the physician suspects mitral stenosis. Which of the following is the most useful measure for assessing the degree of mitral stenosis? A) A2 to opening snap time interval B) Audible S3 C)Audible S3 D) Diastolic murmur intensity E) Presystolic accentuation of te murmur

A) A2 to opening snap time interval

In which of the following conditions does the afterload increase? A) Aortic Stenosis B) Left Bundle Branch Block C) Systemic Hypertension

A) Aortic Stenosis C) Systemic Hypertension

An 80-year-old man is brought to the emergency department on an 80-degree day 2 hours after a syncopal episode while playing golf. He plays golf twice weekly. An ECG obtained at his last examination 6 months ago showed occasional premature ventricular contractions (PVCs). On arrival, his temperature is 38°C (100.4°F), blood pressure is 150/90 mm Hg, pulse is 80/min and regular, and respirations are 22/min. Cardiac examination shows a grade 3/6, late-peaking systolic ejection murmur. No bruits are heard over the carotid arteries, but the upstrokes are delayed. Which of the following is the most likely cause of the syncope? A) Aortic stenosis B) Heat stroke C) Hypertensive cardiomyopathy D) Platelet emboli E) PVCs

A) Aortic stenosis Syncope + Systolic murmur + Delayed upstroke Heatstroke is defined as increase in body temperature or hyperthermia that exceeds 41°C or 104°F with lack of sweating associated with mental confusion.

A 58-year-old man comes to the physician because of extreme fatigue and malaise for 3 weeks. He has felt well except for a toothache 5 weeks ago treated with a root canal procedure. He has a history of a cardiac murmur first noted at the age of 19 years. His temperature is 37.8°C (100°F), pulse is 110/min, and blood pressure is 120/80 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a grade 2/6, systolic ejection murmur heard best at the right second intercostal space, an S4, and an ejection click. Laboratory studies show: Hemoglobin 9.3 g/dL Leukocyte count 10,000/mm3 Segmented neutrophils 90% Bands 10% Erythrocyte sedimentation rate 90 mm/h Urine blood positive Blood cultures are obtained. Which of the following is the most likely underlying cardiac abnormality? A) Calcification of a bicuspid aortic valve B) Calcified mitral annulus C) Myxomatous degeneration of the aortic valve D) Myxomatous degeneration of the mitral valve E) Myxomatous degeneration of the tricuspid valve F) Rheumatic disease of the mitral valve G) Rheumatic disease of the tricuspid valve

A) Calcification of a bicuspid aortic valve Systolic ejection murmur + 2nd RICS + S4 + ejection click + decreased hemoglobin (hemolytic anemia)

Which one of the following conditions is most associated with giant V waves in the JVP? A) Tricuspid regurgitation B) Ventricular tachycardia C) Tricuspid stenosis D) Pulmonary hypertension E) Complete heart block F) Constrictive pericarditis

A) Tricuspid regurgitation In case of severe TR, giant C-V waves or the Lancisi sign can be found on the jugular venous examination. With increasing tricuspid regurgitation, there is an increased backflow of blood to the right atrium during systole. In patients with severe tricuspid regurgitation, the V wave of tricuspid regurgitation merges with the C wave forming a single prominent C-V wave that is often mistaken for the large carotid-pulse wave of severe aortic regurgitation.

Which of the following right heart catheterization findings would be consistent with papillary muscle rupture causing severe mitral valve regurgitation during an inferior myocardial infarction? A. Prominent V waves in the pulmonary artery capillary wedge pressure tracing B. Increased right heart pressures and decreased left heart pressures with inspiration C. Elevation and equalization of cardiac pressures D. An oxygen step-up from the right atrium to the pulmonary artery E. Prominent V waves in the right atrial pressure tracing F. Both B and C

A. Prominent V waves in the pulmonary artery capillary wedge pressure tracing Choice A describes the findings in acute mitral valve regurgitation which can occur as a complication of an inferior myocardial infarction from papillary muscle rupture. When a large pressure is forced into the left atrium during systole from the mitral regurgitant volume, a large pressure wave is created which is the V wave. Normal V waves are small, however it becomes quite large with severe mitral regurgitation. Likewise, choice E describes severe tricuspid regurgitation which has similar hemodynamics, only translated to the right heart.

Aortic Stenosis causes _________________ (concentric/eccentric) LV hypertrophy Mitral Regurgitation causes _________________ (concentric/eccentric) LV hypertrophy Aortic Regurgitation causes _________________ (concentric/eccentric) LV hypertrophy

AS: concentric hypertrophy MR: eccentric hypertrophy AR: eccentric hypertrophy

Acute vs Chronic Mitral Regurgitation

Acute: Acute mitral regurgitation presents with the rapid onset of severe congestive heart failure with a low cardiac output, and is commonly due to rupture of a recently infarcted papillary muscle (i.e. a patient who has suffered a myocardial infarction within the past couple of days). Chronic: Patients with chronic mitral regurgitation may be asymptomatic with normal exercise tolerance; however, they are often sensitive to shifts in volume status and may be at risk for development of acute volume overload (flash pulmonary edema) and right-sided heart failure. Acute mitral regurgitation presents with jugular venous distention and sudden onset of congestive heart failure, while chronic disease presents with an apical thrill without signs of congestive heart failure. In acute onset mitral regurgitation, the left atrium is unable to remodel rapidly enough to accommodate the increased volume. This leads to a rapid increase in left atrial filling pressure, resulting in increased pulmonary capillary pressure and pulmonary edema. **************88

A 60-year-old man comes to the physician for a routine health maintenance examination. A systolic murmur is heard, which is loudest at the point indicated by the X on the diagram shown. Which of the following cardiac abormalities is the most likely cause of the murmur in this patient? A) Aortic regurgitation B) Aortic stenosis C) Mitral stenosis D) Mitral regurgitation E) Pulmonic regurgitation F) Pulmonic stenosis G) Tricuspid regurgitation H) Tricupid stenosis

Aortic Area + Systolic murmur = AS (AR = diastolic)

A 50-year-old man presents complaining of chest pain that occurs at gradually diminishing levels of physical exertion, as well as two recent episodes of syncope while golfing. Cardiovascular examination reveals a blood pressure of 120/90 mm Hg, a loud crescendo decrescendo systolic murmur best appreciated at the upper right sternal border (with radiation to both carotid arteries), and a weak and delayed carotid upstroke. An ECG reveals left ventricular hypertrophy, and an echocardiogram reveals a bicuspid aortic valve with reduced valvular orifice (<1 cm^2). What is the diagnosis?

Aortic Stenosis

What are the top 3 cause of paradoxical splitting of the second heart sound?

Aortic Stenosis Left Bundle Branch Block Systemic Hypertension

A 45 year old woman presents to her dermatologist after she noticed soft tumors on her hands and elbows. She has no significant past medical history and takes no medications. She is sexually active, has multiple partners, and occasionally uses condoms. On physical examination, the dermatologist notices a high pitched blowing diastolic murmur. What is the most likely cause of the murmur? A) Aortic stenosis B) Aortic regurgitation C) Mitral valve prolapse D) Mitral regurgitation E) Mitral stenosis

B) Aortic regurgitation Soft, tumor-like growths are concerning for gummas, which manifest during the tertiary phase of syphilis. Within the context of a high-pitched, blowing diastolic murmur suggestive of aortic regurgitation, tertiary syphilis must be ruled out. Syphilis infects the aorta and causes dilation which compromises the elasticity of the aortic valve

A 62-year-old man dies suddenly while playing tennis. He had no known cardiac risk factors and had no history of coronary artery disease. At autopsy, examination shows a cardiac valve defect and concentric left ventricular hypertrophy. Which of the following valve abnormalities is most likely involved in his sudden death? A) Aortic insufficiency B) Aortic stenosis C) Mitral insufficiency D) Mitral stenosis E) Pulmonic insufficiency F) Pulmonic stenosis

B) Aortic stenosis

A 72-year-old man with long-standing dyspnea was seen in the clinic after experiencing an episode of syncope. Physical examination showed weak and slowly rising arterial pulses. Cardiac auscultation showed a harsh midsystolic murmu rbest heard at the second RICS with decreased intensity of the 2nd heart sound. Electrocardiogram and echocardiogram confirmed the diagnosis of severe aortic stenosis. Two months later, the patient comes to the emergency department with palpitations and increased shortness of breath. His blood pressure is 90/60 mm Hg and his heart rate is 130/min with an irregularly irregular rhythm. Electrocardiogram shows new onset atrial fibrillation without significant ST-segment or T-wave changes .Chest x-ray shows bilateral pulmonary edema. Which of the following hemodynamic changes is most likely associated with this patient's current presentation? A) Insidious right ventricular failure B) Sudden decrease in left ventricular prelad C) Sudden decrease in left ventricular systolic function D) Sudden increase in left ventricular afterload E) Sudden increase in left ventricular filling

B) Sudden decrease in left ventricular preload AF = loss of atrial kick loss of atrial kick = sudden decrease in left ventricular preload as atrial contraction contributes significantly to left ventricular filling in patients with AS

Which of the following is a functional cause of mitral regurgitation? A. Mitral valve endocarditis B. Dilated cardiomyopathy C. Mitral valve prolapse D. Rheumatic mitral valve disease

B. Dilated cardiomyopathy

Which of the following is most likely to cause acute severe mitral valve regurgitation from papillary muscle rupture? A. Anterior myocardial infarction B. Inferior myocardial infarction C. Lateral myocardial infarction

B. Inferior myocardial infarction There are two papillary muscles that comprise part of the complex anatomy of the mitral valve. The anterolateral papillary muscle receives dual blood supply from the left anterior descending coronary artery and the left circumflex coronary artery in most individuals while the posteromedial papillary muscle receives its sole blood supply from the right coronary artery. Complete infarction of the posteromedial papillary muscle can occur during an inferior MI (from thrombosis of the right coronary artery) while only partial or no damage will be done to the anterolateral papillary muscle during an anterior (left anterior descending) or lateral (circumflex) infarction since there is dual blood supply to this papillary muscle. Thus, the posteromedial papillary muscle is the most likely to rupture after an inferior myocardial infarction.

Which of the following is the cause of mitral regurgitation in the setting of hypertrophic obstructive cardiomyopathy? A. Myocardial disarray of the papillary muscles causing dysfunction B. Systolic anterior motion of the mitral valve leaflet into the left ventricular outflow tract C. Mitral annular dilation causing functional mitral regurgitation D. Mitral valve leaflet degeneration from the increased hemodynamic stress present in HOCM

B. Systolic anterior motion of the mitral valve leaflet into the left ventricular outflow tract The Venturi effect is described as a decrease in pressure when blood flows through a stenosis at a high velocity. This relates to the hemodynamics in hypertrophic obstructive cardiomyopathy (HOCM). In HOCM, the increased velocity in the left ventricular outflow tract decreases pressure in this region causing the anterior leaflet of the mitral valve to be pulled in that direction. This is called "systolic anterior motion" of the mitral valve or SAM. Mitral regurgitation can result and contribute to congestive heart failure symptoms in the setting of HOCM.

What is the prevalence of congenitally bicuspid aortic valve in the population?

Bicuspid aortic valves are the most common cardiac valvular anomaly, occurring in 1-2% of the general population The abnormally shaped valve experiences increased hemodynamic stress which accelerates the normal aging process and causes premature atherosclerosis and calcification of the valve leading to aortic stenosis in > 50% of patients

A 68-year-old man comes to the physician because of a 10-month history of shortness of breath and swelling of his feet. He has a family history of cardiovascular disease. He has smoked 2 packs of cigarettes daily for 50 years. His pulse is 80/min, respirations are 24/min, and blood pressure is 150/80. Physical exam shows 3+pitting edema of the lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest. Cardiac examination shows a grade 2/6 pansystolic mumur heard best at the lower left sternal border, which increases on inspiration. The point of maximal impulse is palpated in the sub-xiphoid area. S1 and S2 sounds are distant. Abdominal examination shows a liver span of 14 cm. Which of the following is the most likely diagnosis? A) Aortic Stenosis B) Cardiac amyloidosis C) Cor pulmonale D) Coronary artery disease E) Primary pulmonary hypertension

C) Cor pulmonale Pansystolic murur + LLSB + increases with inspiration = TR The TR is most likely functional due to RHF

A 75-year-old patient has a chronic murmur which is characterized as a late-diastolic rumbling preceded by an opening snap. It is highly likely that he: A) Had a prior MI B) Has a congenital valve defect C) Had prior rheumatic fever as a child D) Has tertiary syphilis E) Has angina

C) Had prior rheumatic fever as a child This is the description of a mitral stenosis murmur. Mitral stenosis is almost always secondary due to rheumatic heart disease.

A 35 year old female with a history of anxiety and panic attacks presents for a routine physical examination. She intermittently experiences palpitations but in general feels well. Physical examination reveals a mid-systolic click at the cardiac apex which moves earlier in systole with standing from a squatting position. No murmur is present. Which of the following is the likely diagnosis? A) Mitral valve regurgitation B) Mitral valve stenosis C) Mitral valve prolapse D) Normal mitral valve

C) Mitral valve prolapse

A 78-year-old man with syncope feels heaviness in his chest with exertion and breathlessness when lying down. A crescendo/decrescendo systolic murmur is heard best at the second right intercostal space with radiation to the carotid arteries. Which of the following measurements of left ventricular and aortic pressure are most likely to be found on cardiac catheterization? Left Ventricular (mm Hg) Aortic (mm Hg) A) 100/10 150/90 B) 100/18 100/50 C) 150/10 150/80 D) 150/18 100/50 E) 150/18 150/80

D) 150/18 100/50 Normal LV pressure: 130/10 Normal Aortic pressure: 130/80 In aortic stenosis, LV pressure increases and Aortic pressure will be slightly decreased

A 77 year old woman is presented with syncope during her routine daily exercise. Her history is significant with several other episodes of syncope within the past 6 months. She has a systolic murmur that is best heard at the right upper sternal border. There is radiation of the murmur into the neck. Which of the following is the most probable diagnosis? A) Mitral Stenosis B) Mitral Regurgitation C) Tricuspid Regurgitation D) Aortic Stenosis E) Aortic Insufficiency

D) Aortic Stenosis

A 62-year-old man has had the gradual onset of fatigue and shortness of breath over the past 3 years. There is striking jugular venous distention with a large wave occurring with S2. The carotid upstroke is normal. Cardiac examination shows a lifting systolic motion of the sternum and no palpable point of maximal impulse. A grade 3/6, holosystolic, plateau-shaped murmur that is loudest on inspiration is heard at the lower left sternal border. The liver is enlarged and tender, and the abdomen is swollen with a fluid wave. There is marked ankle edema. Which of the following is the most likely cause of the murmur? A) Aortic stenosis B) Mitral regurgitation C) Mitral stenosis D) Tricuspid regurgitation E) Ventricular septal defect

D) Tricuspid regurgitation Holosystolic murmur + increase with inspiration + LLSB = TR

A 48-year-old man complaining of chest pain is brought to the emergency room. Physical examination followed by echocardiography demonstrates aortic stenosis. His coronary blood flow is increased. Which of the following is the most likely explanation for the increased coronary blood flow in this individual? A. Decreased left ventricular oxygen consumption. B. Decreased left ventricular pressure. C. Decreased left ventricular work. D. Increased cardiac tissue adenosine concentration. E. Increased cardiac tissue oxygen concentration.

D. Increased cardiac tissue adenosine concentration. Blood flow through the coronary circulation is regulated almost entirely by the metabolic requirements of the cardiac muscle. When the oxygen consumption of the heart increases, a larger than normal proportion of the adenosine triphosphate (ATP) in the heart muscle cells degrades to adenosine. The adenosine then dilates the coronary blood vessels, increasing oxygen delivery to an adequate level. In this way, the coronary blood flow increases in direct proportion to the oxygen consumption of the heart. In aortic stenosis, the left ventricular pressure (choice B) becomes excessively high because the resistance of the aortic valve orifice is higher than normal. This increase in left ventricular pressure increases the work load on the left ventricle (choice C) because the heart now pumps blood with an elevated left ventricular pressure. The increased work load on the heart requires a greater consumption of oxygen (choice A). Under these conditions of increased cardiac work and increased oxygen consumption, one expects the cardiac tissue oxygen concentration (choice E) to be lower than normal.

Which of the following is considered organic mitral regurgitation? A. Hypertrophic obstructive cardiomyopathy causing the Venturi effect B. Dilated cardiomyopathy C. Marked left atrial enlargement D. Papillary muscle dysfunction

D. Papillary muscle dysfunction

_______________(Increasing/Decreasing) preload causes the characteristic click of Mitral Valve Prolapse to occur earlier in systole

Decreasing Preload => Decreasing LVEDV => Click is earlier in systole (i.e. standing,valsalva)

A 54-year-old woman is admitted to the hospital with an acute myocardial infarction. At the time of admission, she has no physical signs of heart failure, an no heart murmur is detected. Two days later, she becomes acutely short of breath and diaphoretic. Her pulse is 100/min, respirations are 24/min, and blood pressure is 160/90 mm Hg. Crackles are heard bilaterally throughout both lung fields on auscultation of the chest, a murmur is heard on cardiac examination. Which of the following is the most likely murmur in this patient? A) Grade 2/6 diastolic decrescendo murmur heard best over the 2nd and 3rd LICS B) Grade 2/6 rumbling diastolic murmur heard best 2 cm left of the sternal border at the 4th LICS C) Grade 3/6 crescendo-decrescendo systolic murmur heard best at the second left intercostal space D) Grade 4/6 continuous systolic and diastolic murmur heard best along the LSB E) Grade 4/6 holosystolic mumur heard best over the LLSB and the cardiac apex

E) Grade 4/6 holosystolic mumur heard best over the LLSB and the cardiac apex A systolic murmur is sometimes heard for the first time after an episode of myocardial infarction This murmur may be due to the rupture of a papillary muscle, or the rupture of a the interventricular septum, both of which are acute complications of an MI that can cause MR or VSD respectively Both an MR and VSD are holosystolic murmurs MR best heard over the the cardiac apex VSD best heard over tricuspid area/LLSB

A 68 year old man is brought to the emergency department 1 hour after the onset of nausea, sweating, and substernal chest pain radiating to his left arm. An ECG shows ST-segment elevation in precordial leads V1 through V4. Twenty minutes after arrival, the patient suddenly develops shortness of breath and diaphoresis. His temp is 98.6, pulse is 80, respirations are 28, and BP is 110/70. Pulse oximetry on room air shows an oxygen saturation of 89%. Cardiac examination shows a regular rhythm. A grade 2/6 holosystolic murmur is heard best at the apex with the patient in the left lateral decubitus position. Which of the following is the most likely cause of this patient's shortness of breath? A) Aortic dissection B) Aortic stenosis C) Atrial fibrillation D) Cardiac tamponade E) Mitral regurgitation F) Pericarditis G) VSD

E) Mitral regurgitation A systolic murmur is sometimes heard for the first time after an episode of myocardial infarction This murmur may be due to the rupture of a papillary muscle, or the rupture of a the interventricular septum, both of which are acute complications of an MI that can cause MR or VSD respectively Both an MR and VSD are holosystolic murmurs MR best heard over the the cardiac apex VSD best heard over tricuspid area/LLSB

A 27-year-old man comes to the physician because of back pain and muscle fatigue in his left lower leg for 6 months. He has not seen a physician for 10 years. He is 198 cm (6 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 17 kg/m2. Cardiac examination shows a normal S1 and S2. A midystolic click is heard without murmur. Physical examination shows dental malocclusion, long fingers, joint hyper mobility, and muscle hypotonia. There is scoliosis of the thoracic spine on the right. Which of the following is the most likely cause of this patient's cardiac finding? A) Aortic insufficiency B) Aortic regurgitation C) Aortic stenosis D) Atrial septal defect E) Mitral valve prolapse F) Tricuspid regurgitation

E) Mitral valve prolapse

A 37-year-old woman comes to the physician because of progressive shortness of breath over the past 5 years; she now has fatigue and shortness of breath with mild exertion. She has a history of mitral stenosis secondary to rheumatic fever at the age of 15 years. She was asymptomatic until 5 years ago when she developed severe shortness of breath during pregnancy. She was treated with diuretics, low-sodium diet, and bed rest, and she was able to deliver the baby at term. Her only medication is hydrochlorothiazide. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 100/min and regular, and respirations are 26/min. Cardiac examination shows an obvious opening snap in S2. A grade 3/6, late diastolic murmur is heard at the apex. A right ventricular lift is palpated along the left sternal border. Which of the following is most likely increased in this patient? A) Blood flow to the lower lung fields B) Diastolic filling time C) Left-to-right shunt of blood D) Left ventricular end-diastolic pressure E) Pulmonary artery pressure

E) Pulmonary artery pressure

A 2-month-old boy is brought to the physician for a well-child examination. The mother has concerns about his growth or breast-feeding habits and says that he has begun to smile. He is at the 25th percentile for length and 30th percentile for weight. Cardiac examination shows a blowing holosystolic murmur best heard over the lower left sternal border. Which of the following is the most likely cause of the cardiac findings in this patient? A) Coarctation of the aorta B) Functional murmur C) Patent ductus arteriosus D) Patent foramen ovale E) Ventricular septal defect

E) Ventricular septal defect Holosystolic murmur + Best heard in Tricuspid area/LLSB = VSD

Describe the typical presentation of the murmur in Mitral Regurgitation

High-pitched holosystolic "blowing" murmur at the apex with radiation to the axilla. (Remember that mitral regurgitation often occurs in patients with mitral valve prolapse, so the murmur of mitral regurgitation may co-occur with a mid-systolic click)

An 18 month old boy is brought to the physician's office for a follow up cardiac examination. He has a palpable thrill and a harsh grade 4/6 holosystolic murmur that radiates over the precordium and is heard best over the lower left sternal border. Which of the following is the most likely diagnosis? A-Ostium primum defect B-Ostium secundum defect C-Patent ductus arteriosus D-Ventricular septal defect E-Sinus of valsalva fistula F-Mitral valve regurgitation

Holosystolic murmur + Best heard in Tricuspid area/LLSB = VSD

The murmur of Aortic Stenosis _____________ (increases/decreases) with increased preload The murmur of Aortic Stenosis _____________ (increases/decreases) with increased afterload

Increases with increased preload Decreases with increased afterload

_______________(Increasing/Decreasing) preload causes the characteristic click of Mitral Valve Prolapse to occur later in systole

Increasing Preload => Increasing LVEDV => Click is later in systole (i.e. squatting)

A 3-year-old girl is found to have a grade 4/6, loud, harsh, high-pitched holosystolic murmur that radiates over the precordium and a palpable thrill at the left sternal border. Which of the following defects is most likely in this patient? A) Aortic regurgitation B) Aortic stenosis C) Atrial septal defect D) Coarctation of aorta E) Mitral regurgitaion F) Mitral stenosis G) Patent ductus arteriosis H) Pulmonic stenosis I) Tricuspid regurgitation J) Ventricular Septal defect.

J) Ventricular Septal defect. Holosystolic = TR, MR, VSD MR = Apex + blowing and high pitched TR = LSB + Increases with inspiration VSD = LSB + Harsh

Mitral Stenosis is characterized by an increase in LVEDP T/F?

LVEDP is always normal or decreased in MS

How does the timing of the peak of the systolic murmur seen in Aortic Stenosis change depending on disease severity?

Mild AS: murmur peaks in early systole Severe AS: murmur peaks in late systole (Intensity of the murmur does not correlate with severity of stenosis)

What is myxomatous degeneration?

Myxomatous degeneration is an *increase in spongiosa (composed of dermatan sulfate)* and a *decrease in fibrosa* (which has more tensile strength) which results in redundant valvular tissue.

The normal aortic valve orifice is ________ cm^2 Symptoms and signs of aortic stenosis appear when the orifice is ________ cm^2 Severe aortic stenosis is present when the orifice is ________ cm^2

Normal: 3 Symptoms: <1 Severe: <0.5

The normal mitral valve is (Thin and firm/Thick and spongy) A prolapsed mitral valve is (Thin and firm/Thick and spongy)

Normal: Thin and Firm Prolapsed: Thick and Spongy

Organic vs Functional Mitral Regurgitation

Organic mitral regurgitation results from actual disease of the mitral valve apparatus. The mitral valve leaflets, annulus, papillary muscles and chordae tendinae must interact properly for the mitral valve to function properly. Thus, disruption of any of these structures can result in organic mitral regurgitation. Functional mitral regurgitation occurs when the left atrium or left ventricle dilates causing the mitral valve annulus to also dilate thus preventing the mitral valve leaflets from properly coapting. There are many causes of left atrium or left ventricular dilation and the treatment of this type of mitral regurgitation is directed at the primary cause. For example, if a patient develops systolic heart failure with a dilated left ventricle resulting in mitral regurgitation, treatment would be directed at reversal of the heart failure. *Summary* Organic = actual disease of mitral valve apparatus (leaflets, annulus, papillary muscles, chordae tendinae) Functional = dilation of the mitral valve annulus due to dilation of LA/LV

Are the values of PCWP and LVEDP in a patient with Mitral Stenosis increased, normal, or decreased?

PCWP: Increased LVEDP: Normal or decreased PCWP closely reflects LA. MS leads to an increase in LA pressure that is reflected as elevated PCWP Left ventricular filling and resultant LVEDP may be normal or decreased depending on the severity of the stenosis

What does pulsus parvus et tardus, a finding seen on physical exam in patients with Aortic Stenosis signify?

Pulsus parvus = weak pulse Pulsus tardus = delayed peak/max intensity relative to heart beat

What is the effect of squatting on the characteristic auscultatory finding of mitral valve prolapse?

Squatting increases preload, augmenting the LVEDV and placing greater tension on the chordae tendineae. This makes the click occur later in systole and decreases the length of the murmur

What causes the mid systolic click in Mitral Valve Prolapse

The click results from sudden tensing of the chordae tendinae as they are pulled taut by the ballooning valve leaflets The murmur is due to blood leaking back into the left atrium during

What is the key histological finding in Mitral Valve Prolapse

The key histologic change in the tissue is marked thickening of the spongiosa layer with deposition of mucoid (myxomatous) material, called myxomatous degeneration

What is the most common clinical presentation of patients with Mitral Valve Prolapse

The majority of patients are asymptomatic, some may complain of palpitations and chest pain.

What causes the Opening Snap in Mitral Stenosis?

The opening snap occurs due to abrupt tensing/halting of the valve leaflets (due to fusion of leaflet tips) as the mitral valve reaches its maximum diameter during forceful opening

Describe the typical presentation of the murmur in Aortic Stenosis

The typical murmur of AS is a high-pitched, "diamond shaped" crescendo-decrescendo, midsystolic ejection murmur heard best at the right upper sternal border radiating to the neck and carotid arteries

When does AR present in LSB, when in RSB?

mentioned in uworld that in developed countries, AR Is most commonly due to aortic root dilation and is RSB,