valvular emergencies october 11, 2005 dr. kanagala
TRANSCRIPT
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Valvular EmergenciesValvular Emergencies
October 11, 2005
Dr. Kanagala
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IntroductionIntroduction
There may be abnormalities of cusps, chordae, or papillary muscles causing valvular dysfunction.
Significant valvular abnormality increases stroke rate 3.2 times and death rate 2.5 times
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Chronic Valve DiseaseChronic Valve Disease
There may be decades between onset of dysfunction and symptoms
Dilation or hypertrophy may preserve cardiac function
Account for around ninety percent of valvular disease
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Acute Valve DiseaseAcute Valve Disease
Acute valve disease can result in dramatic symptoms.
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Diagnosing a New MurmurDiagnosing a New Murmur
Consider murmur in context of patient’s medical condition
Patient may have normal cardiac anatomy, but murmurs can be associated with other disease states.
Examples include anemia, thyrotoxicosis, sepsis, fever, renal failure, and pregnancy
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Diagnosing a New MurmurDiagnosing a New Murmur
A diastolic murmur or new murmur warrants cardiology referral for evaluation/echo.
Urgency for accurate diagnosis and referral or admission depends on severity of symptoms not presence of murmur unless aortic stenosis and syncope is suspected. Patient may be at risk for recurrent cardiovascular event.
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Innocent or Physiologic Innocent or Physiologic MurmurMurmur
No abnormal symptoms or signsSoft, systolic ejection murmur begins after
S1 and ends before S2, and heart sounds are normal
Review of symptoms reveals no symptoms compatible with cardiovascular disease, and complete physical exam is normal.
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Mitral StenosisMitral Stenosis
Most common cause is rheumatic heart disease
Progressive stenosis may lead to pulmonary hypertension causing pulmonary and tricuspid incompetence
Most patients develop atrial fibrillation
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Clinical Features of Mitral Clinical Features of Mitral StenosisStenosis
Symptoms include: tachycardia, anemia, pregnancy, infection, emotional upset, A-fib, exertional dyspnea, paroxysmal nocturnal dyspnea, acute pulmonary edema, hemoptysis, orthopnea, PAC, systemic emboli and infarction, right sided heart failure
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Clinical Features continued…Clinical Features continued…
mid-diastolic rumbling murmur with crescendo toward S2
With onset of Afib the presystolic accentuation of the murmur disappears. S1 is loud and followed by a loud opening snap (high pitched, heard at apex)
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Clinical Features continued…Clinical Features continued…
Apical impulse is small and tappingSystolic blood pressure is normal or lowSigns of pulmonary hypertension include
thin body habitus, peripheral cyanosis, and cool extremities
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DiagnosisDiagnosis
ECG: notched or biphasic P waves and right axis deviation
Chest X-ray: straightening of left heart border, findings of pulmonary congestion like kerley B lines and increase in vascular markings
Confirmed with echocardiography (TEE)
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TreatmentTreatment
Diuretics for pulmonary congestion Afib treatment Anticoagulation if at risk for embolic events With severe mitral stenosis patients should be
warned to avoid strenuous physical activity If hemoptysis occurs due to mitral stenosis and
pulmonary hypertension, thoracic surgery may be warranted
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Mitral IncompetenceMitral Incompetence
Causes include MI, MVP syndrome, rheumatic heart disease, coronary artery disease, collagen vascular disease
Inferior MI due to right coronary occlusion is most common ischemic cause
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Acute Mitral Incompetence Acute Mitral Incompetence CausesCauses
MIMitral valve prolapse syndromeRheumatic heart diseaseCoronary artery diseaseCollagen vascular diseaseInferior MI due to right coronary occlusion
is the most common cause of ischemic mitral valve incompetence
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Acute Mitral IncompetenceAcute Mitral Incompetence
Presents with dyspnea, tachycardia, and pulmonary edema
S3 and S4 is usually heardAcutely, a harsh apical systolic murmur
starts with S1 and may end before S2Patients may deteriorate quickly due to
cardiogenic shock or cardiac arrest
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Acute Mitral IncompetenceAcute Mitral Incompetence
Intermittent mitral incompetence usually presents with acute episodes of respiratory distress due to pulmonary edema and can be asymptomatic in between attacks
Pronounced dyspnea may mask angina that accompanies the ischemia
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Chronic Mitral IncompetenceChronic Mitral Incompetence
Late systolic left parasternal liftHigh pitched holosystolic murmur starting
with S1 and may end before S2, heard best in fifth intercostal space, mid-left thorax, and radiates to the axilla
First heart sound is soft and often obscured by the murmur
S3 heard and followed by a diastolic rumble
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DiagnosisDiagnosis
ECG: acute inferior MI, left atrial enlargement, LVH, new onset pulmonary edema
CXR: minimally enlarged left atrium, pulmonary edema, left ventricular enlargement
Echocardiography is essential. TEE done once patient is stable
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Acute Mitral Incompetence Acute Mitral Incompetence TreatmentTreatment
Pulmonary edema: oxygen, diuretics, nitrates, intubation
Nitroprusside: increases forward output by increasing aortic flow and partially restoring mitral valve competence as left ventricular size diminishes
Dobutamine may be required for hypotensive patients
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Mitral Incompetence Mitral Incompetence TreatmentTreatment
Aortic balloon counter pulsationSurgery may be warranted if mitral valve
ruptureEvaluate for and treat endocarditisTreat atrial fibrillation with heparin, control
ventricular rate with beta blockers and calcium channel blockers
Keep INR 2-3
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Mitral Valve ProlapseMitral Valve Prolapse
Click murmur syndromeMay be congenitalMale, age above 45, and the presence of
regurgitation place patient at higher risk for complications
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Mitral Valve Prolapse Clinical Mitral Valve Prolapse Clinical FeaturesFeatures
Most are asymptomatic Atypical chest pain Palpitations Fatigue Dyspnea unrelated to exertion Midsystolic click Second heart sound may be diminshed by late
systolic murmur with crescendos into S2
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Mitral Valve Prolapse Mitral Valve Prolapse DiagnosisDiagnosis
ECG: usually normalChest X-ray: may be normal, or show
pectus excavatum, straight thoracic spine, or scoliosis
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Treatment of Mitral Valve Treatment of Mitral Valve ProlapseProlapse
Usually not needed in ED Beta blockers may be used for patients with
palpitations, chest pain, or anxiety Suggest avoidence of alcohol, tobacco, and
caffeine to relieve symptoms Patients with Afib/ risk for embolization: warfarin
with INR of 2-3 Patients with MVP and Afib without mitral
regurg., HTN, heart failure, and above 65 can be managed with aspirin 160mg qd.
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Aortic StenosisAortic Stenosis
Most common cause: degenerative heart disease/ calcific aortic stenosis
Most common cause in young adults: congenital heart disease
Third most common cause in US, but most common cause world wide: rheumatic heart disease
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Aortic Stenosis: Clinical Aortic Stenosis: Clinical FeaturesFeatures
Classic triad of dyspnea, chest pain, and syncope Exercise may induce symptoms Dyspnea is typically first symptom, followed by
PND, exertional syncope, and angina Atrial Fibrillation is less common than in mitral
disease but 10% of patients have it at time of surgery
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Clinical Features Continued…Clinical Features Continued…
A small amplitude pulse Slow rate of of increase of carotid pulse LVH Paradoxical splitting of S2 S3, S4 present Classic harsh systolic ejection murmur heard best
at second intercostal space radiating to right carotid artery
Sudden death
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Clinical Features Continued…Clinical Features Continued…
Brachioradial delayECG: LVH, in 10% of patients
LBBB/RBBBChestX-ray: starts out normal, but
eventually LVH and CHF
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Treatment of Aortic StenosisTreatment of Aortic Stenosis
Pulmonary Edema: oxygen and diureticsNew onset Afib: heparin and cardioversionLimit vigorous activityPatients with symptoms secondary to aortic
stenosis such as syncope should be admitted
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Aortic IncompetenceAortic Incompetence
Majority of acute cases due to infective endocarditis
Aortic dissection of the root is the second most common cause
May be due to trauma
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Causes:Causes:
Increased ventricular pressure: elevates pressure in left ventricle, pulmonary congestion results
Appetite suppressant drugs have been linked to aortic incompetence
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Causes:Causes:
Calcific degeneration, Ankylosing spondylitis Congenital disease, Ehlers-Danlos syndrome Systemic hypertension, Reiters Myxomatous proliferation Rheumatic heart disease Marfan syndrome Syphils
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Aortic incompetence Clinical Aortic incompetence Clinical Features…Features…
DyspneaAcute pulmonary edema with pink, frothy
sputumFever, chills: EndocarditisSystemic emboliSinus tachDissection of ascending aorta
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Clinical Features Continued…Clinical Features Continued…
Sudden deathTachycardia, tachypnea and ralesHigh pitched blowing diastolic murmur
heard after S2Some may have palpitationsMay have stabbing chest pain, fatigue or
dyspneaLV failure
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Clinical Features Continued…Clinical Features Continued…
2/3 have no symptoms for up to 20 years despite a significant lesion
Wide pulse pressure with prominent ventricular impulse
Water hammer pulse Accentuated precordial apical thrust Pulsus biferens Duroziez sign Quincke pulse
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Aortic Incompetence: Aortic Incompetence: DiagnosisDiagnosis
Acute: The chest x-ray shows acute pulmonary edema
Chronic: The ECG shows LVH and chest x-ray shows cardiomegally, aortic dilation, and possibly CHF
ECHO is crucialTEE if aortic dissection suspected
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Acute Aortic Incompetence: Acute Aortic Incompetence: TreatmentTreatment
Pulmonary Edema: oxygen, intubation Diuretics and nitrites can be used, but may not be
effective Nitroprusside plus ionotropic agents can be used
to augment forward flow and reduce LVEDP to prepare for surgery
Caution when using beta blockers-risk of blocking compensatory tachycardia
Emergency surgery
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Chronic Aortic IncompetenceChronic Aortic IncompetenceTreatment:Treatment:
Vasodilators like Ace inhibitors or Nifedipine
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Right Sided Valvular Heart Right Sided Valvular Heart Disease CausesDisease Causes
Endocarditis in drug users due to organisms such as S.Aureus-isolated symptomatic tricuspid pathology
COPD/pulmonary HTN RV failure with dilation Rheumatic heart disease Blunt trauma Congenital: tetrology of Fallot Pulmonary valve incompetence
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Clinical FeaturesClinical Features
Dyspnea, orthopnea: most commonJVDPeripheral edemaHepatomegalySplenomegalyascites
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Clinical FeaturesClinical Features
Tricuspid Valve Incompetence: soft blowing holosystolic murmur heard along left lower sternal border
Tricuspid Valve Stenosis: rumbling crescendo decrescendo diastolic murmur that occurs just before S1. It is heard at lower left sternal border
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DiagnosisDiagnosis
Must obtain Echocardiogram
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TreatmentTreatment
Address the underlying problemdiuretics
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Prosthetic Valve DiseaseProsthetic Valve Disease
Two groups exist: mechanical non-tissue vs. bioprostheses using porcine, bovine or human valves
Survival is better with mechanical, and bleeding more common in bioprosthetic valves
Valves may become stenotic and small amounts of regurgitations common due to incomplete closure
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ComplicationsComplications
Thrombi on valve Degeneration of valve Sutures around valve disrupted Valve failure Bleeding/embolism Endocarditis/ ring abscess May have increased susceptibility to
hemodynamic compromise from new onset A fib.
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ComplicationsComplications
Lifelong anticoagulation is needed to decrease risk of thromboembloism and valve thrombosis
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Clinical FeaturesClinical Features
DyspneaCHFMinor/major embolic eventsNeurologic symptoms: thromboemboli due
to valve thrombi or endocarditisBleeding due to anticoagulation
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Clinical FeaturesClinical Features
Abnormal heart soundsMechanical model: systolic murmurAortic Bioprosthesis: short midsystolic
murmurMitral Bioprosthesis: loud diastolic murmur
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DiagnosisDiagnosis
Chest x-ray: can help identify change in position relative to previous films
CBC, RBC, PT/INRIf you suspect valve dysfunction-echoMay need cardiac cath
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TreatmentTreatment
May need cardiac surgery referral if there is acute dysfunction
Treatment of prosthetic acute valvular dysfuntion due to thrombotic obstruction is thrombolytic therapy
Lesser degrees of mechanical valve obstruction: anticoagulate to INR of 2-3.5
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TreatmentTreatment
Disposition can be difficult decision if patient has worsening symptoms- consult cardiology
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Question 1:Question 1:
Which of the following are clinical features of Aortic Incompetence?
A) Water Hammer Pulse
B) Pulsus Biferens
C) Duroziez Sign
D) All of the Above
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Question 2:Question 2:
T/F The most common cause of Aortic Stenosis in young adults is congenital heart disease.
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Question 3:Question 3:
Causes of Acute Mitral Incompetence include:
A) MI
B) Mitral Valve Prolapse
C) Rheumatic Heart Disease
D) All of the above
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AnswersAnswers
1)D2)T3)D