lecture 20 brickner
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| regurgitant valves cause ventricles to ____ as opposed to _____ in stenotic valves | be dysfunctional due to enlargement (inc preload) // hypertrophic changes (inc afterload)
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| general causes for aortic insufficiency | either leaflet problem OR aortic annulus abnormality (most common)
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| examples of leaflet problems that might cause aortic insufficiency | infective endocarditis, rheumatic heart dz (causes both stenosis and regurg), bicuspid valves, SLE, ankylosing spondylitis, myxomatous degeneration, trauma (leaflet avulsion after MVC)
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| examples of aortoannular problems that might cause aortic insufficiency | HTN, aortoannular ectasia, Marfan's syndrome, aortic dissections, OI, Takayasu's & giant cell arteritis, syphilis
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| hemodynamics of aortic insufficiency | acute: rapid volume overload leads to acute onset of SOB due to pulm vasc involvement // chronic: LV diastolic overload over time allows for enlargement and maintenance of near nl LV filling pressures
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| type of hypertrophy seen in LV of pt with aortic regurg | vol overload causes eccentric hypertrophy: increase in muscle mass and # of sarcomeres without making the ventricular walls thicker
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| connection of MI with AV regurg | chronic and severe AR will widen pulse pressures. diastolic pressure is low in aorta, which means coronary artery flow is low and can cause ischemia in the absence of CAD
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| clinical manifestations of acute, severe AV regurg | pts have tachycardia, pulm edema, hypotension, soft/absent S2 (pressure in LV never drops low enough to suck TV open)
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| clinical manifestations of chronic, severe AV regurg | wide pulse pressure, Corrigan's (waterhammer), Traube's (pistol shot femoral), deMusset's (head bobbing), Muller's (uvula pulses), Quincke's (capillary pulse in nails) & Duroziez's sign
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| PEx of pt with AV regurg | hyperdynamic and laterally displaced apical impulse, soft/absent S2, early decrescendo midsystolic murmur (the longer, the more severe), low-pitch diastolic rumble over apex from retrograde jet of blood on ant mitral leaflet (Austin-Flint murmur)
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| CXR and EKG for AV regurg | CXR: may show CM if chronic and severe, pulm congestion // EKG: LVH? may be non-specific
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| 2 indications for AV regurg surg | presentation of acute and symptomatic AV regurg OR progressive LV dilation in asymptomatic pts
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| 55 rule | surg should be performed for AV regurg before LVEF is < 55% or before LV end-systolic diameter increases to 5.5cm
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| 2 general causes for MV regurg | myocardial dz or abnormality of mitral leaflets
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| examples of leaflet problems that might cause mitral insufficiency | rheumatic heart dz, infiltrative disorders, myxomatous degeneration, endocarditis, trauma, congenital abnormalities
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| examples of myocardial problems that might cause mitral insufficiency | myocarditis, ischemia, infartcs, infiltrative disorders may interfere with papillary muscle function or chordae tendinae can be elongated, shortened or ruptured by endocarditis, trauma or rheumatic heart dz
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| causes of acute, severe MV regurgitation | papillary muscle rupture after AMI, flailing leaflet from chordal rupture or endocarditis
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| hemodynamic changes seen with acute MV regurg | inc preload due to regurgitant volume + forward stroke vol coming from lungs. dec afterload for the blood going back into compliant, low-pressure LA during systole. amt of blood entering aorta is much less. LA/pulm artery pressures rise
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| hemodynamic changes seen with chronic MV regurg | LV dilates gradually to accomodate regurg vol and maintaining near nl filling pressures (compensated phase); once LV is stretched and loose, afterload becomes too much and LV function falls (decompensated stage)
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| clinical manifestations of MV regurg | especially when chronic, sx may develop very slowly and not bother pt much; sx are due to low forward CO: fatigue, lightheadedness, weakness, pulm congestion causing SOB
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| PEx of pt with MV regurg | may be soft S1 with holosystolic "blowing" murmur, apical impulse may be hyperdynamic and laterally displaced if LV is dilated. murmur may be mid or late systolic and very faint especially if papillary rupture allows constant flow btwn LA and LV
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| indications for mitral valve repair if regurgitant abnormality present | want to do surg early if seeing a slight decline in LV function. 1) surg for chronic MR in pts with sx 2) surg for asymptomatic pts with severe MR and LVEF < 60% or end systolic diameter > 4.5 cm
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| EKG findings of pt with mitral regurg | may just show ischemia or infarction that caused acute MR, a-fib if the LA is stretched and pressures are inc
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| characteristic murmur of PV regurgitation | heard over L 3rd intecostal space along the sternal border, will be soft decrescendo murmur that will likely increase with respiration (Carvallo's sign)
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| characteristic murmur of TV regurg | holosystolic murmur heard at lower left sternal border, 5th intercostal space with marked inspiratory increase (Carvallo's sign)
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