Valvular emerginces

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Emergency Medicine, Heart Valve Emergency, Emergency Cardiology, by Rashid Abuelhassan

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Valvular emerginces

  1. 1. A 67-year-old man presents to the ED with sudden onset of chest pain and shortness of breath. He is 5 days status-post inferior wall myocardial infarction. On examination the patient has pulmonary edema and a loud holosystolic murmur heard best at the left lateral sternal border, with adiation to the base. What is the most appropriate initial management? 2
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  3. 3. Non of my business , what else? 4
  4. 4. • How Is it an Emergency ? • How to know ? • Rheumatic heart Disease & Infective indocarditis • Understand ECHO images 5
  5. 5. • ↑ stroke rate 3.2 times • ↑ death rate 2.5 times • Mitral prolapse is the most common. • 3% annnual mechanical valve complications • systemic embolization from a prosthetic valve is 1% /yr. 6
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  8. 8. • Innocent (e.g. anemia, thyrotoxicosis, sepsis, fever, renal failure, and pregnancy) • New = N T • Diastolic Murmur = !!?? • Chronic e.g. Mitral (RHD)  AF, P-HTN , RVF 9
  9. 9. • Stenosis < 2 cm2 (4-6cm2) • C/O  ↓ exercise, DOE, orthopnea, RVF Also hoarseness & dysphagia (Ortner’s Syndrome) • O/E  small impulse, low sBP, , thin body habitus, p. cyanosis, and cool extremities 10 loud S1 , opening snap in early diastole low-pitched rumbling diastolic apical murmur.
  10. 10. INVESTIGATIONS ECG , CXR, ECHO TREATMENT ■ atrial fibrillation. ■ Anticoagulate if systemic embolization ■ Prophylaxis for endocarditis. ■ Cautious diuretic use. ■ Percutaneous balloon/operative repair. ■ Valve replacement is a last resort. 11 severe mitral stenosis  avoid strenuous physical activity If hemoptysis occurs –> thoracic surgery may be warranted
  11. 11. Valvoplasty 12
  12. 12. COMPLICATIONS ■ Atrial fi brillation ■ pulmonary hemorrhage ■ Pulmonary HTN and Rt HF ■ Systemic emboli 13
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  14. 14. 15 Chronic Acute C/O -Often asymptomatic -Gradual dyspnea on exertion and fatigue -Palpitations (AF ) -Abrupt dyspnea, tachypnea, Cardiogenic shock, Chest pain -Symptoms of (endocarditis, MI, trauma ) O/E holosystolic, at the apex and radiating to the axilla midsystolic murmur radiates to the base not the axilla. + Pulmonary edema Patients may deteriorate quickly due to cardiogenic shock or cardiac arrest
  15. 15. 16 Chronic Acute ECG left atrial and ventricular hypertrophy. Atrial fibrillation and P mitrale - no atrial enlargment - no LVH o/e minimally enlarged left atrium, pulmonary edema, left ventricular enlargement Normal cardiac silhouette, pulmonary edema
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  17. 17. 18 Chronic Acute ■ Treat CHF & AF ■ Anticoagulate if systemic embolization ■ Endocarditis prophylaxis ■ Valve replacement ■ pulmonary edema ttt. ■ Nitroprusside for afterload reduction (increases forward output by increasing aortic flow and partially restoring mitral valve competence as left ventricular size diminishes) ■ Dobutamine if hypotensive. ■ Intra-aortic balloon pump as bridge to surgery. ■ Immediate valve replacement. ■ Treat the underlying disease process.
  18. 18. • presents – with acute episodes of respiratory distress due to pulmonary edema and asymptomatic in between attacks – Pronounced dyspnea may mask angina that accompanies the ischemia • Treatment – Aortic balloon counter pulsation – Surgery may be warranted if mitral valve rupture – Evaluate for endocarditis – Treat atrial fibrillation with heparin, control ventricular rate with beta blockers and calcium channel blockers – Keep INR 2-3 19
  19. 19. • Common, specially young thin females. • autosomal dominantmainly • association with anxiety dis. and ↓BMI. PATHOPHYSIOLOGY Myxomatous proliferation of leaflet → abnormal stretching of valve leaflets during systole 20
  20. 20. SYMPTOMS asymptomatic, Atypical chest pain, Palpitations, Lightheadedness, Dyspnea. EXAM ■ Early to midsystolic click with high-pitched late systolic murmur best at left lateral border ■ standing→ earlier and greater prolapse → accentuates the click +moves it closer to S1 21
  21. 21. 22 TREATMENT ■ asymptomaticNo treatment. ■ Proph. endocarditis if regurgitation or thickened valve leaflets. ■ β-Blockers may help with atypical chest pain DIAGNOSIS ■ ECG: Nonspecific c ST-T wave changes, (PSVT) ■ CXR: NAD ■ Echo
  22. 22. 23 Complications  Stroke  Endocarditis  Tachydysrhythmias (atrial and ventricular)  PSVT (most common dysrhythmia)  Increased incidence of WPW, PACs, PVCs  Ventricular tachycardia (VT) possible  Sudden death ( Risk factors include syncope/pre- syncope, inferolateral ST-T changes and thickened or redundant valve leaflet on TTE).
  23. 23. A 72-year-old woman is brought to the ED following a syncopal event. She reports orthopnea and vague, intermittent chest pain, both present for the past 6 months. o/e : BP of 108/84, rales at both lung bases, a prolonged apical impulse, and a loud systolic murmur radiating into her neck. What test will confirm the most likely diagnosis? What medication is important to avoid in this patient? 24
  24. 24. Angina + Syncope + Dyspnea(dCHF) - >65 years, calcified valve degeneration. - younger patients congenital bicuspid valve. - Rheumatic heart disease (less common) specially if mitral valve diseased. Pathophysiology ■ LV outflow is obstructed → LVH, ↓ cardiac output, and eventual dilated cardiomyopathy with hypertrophy. ■ signs or symptoms if aortic outflow is ↓75% (to < 1 cm). 25
  25. 25. EXAM ■ Narrowed pulse pressure ■ Heaving, prolonged apical impulse ■ Crescendo–decrescendo systolic to the neck ■ CHF symptoms DIAGNOSIS ■ ECG: LVH with strain, left bundle branch block. ■ CXR: LVH, pulmonary congestion . ■ Echocardiography: Confirms & measures. 26 Angina + Syncope + Dyspnea(dCHF) Exercise stress testing may provoke dysrhythmias and is contraindicated.
  26. 26. Aortic valve stenosis 27
  27. 27. Bicuspid aortic valve 28
  28. 28. TREATMENT ■ Treat CHF with gentle diuresis. ■ Rule out ACS in acute presentations. ■ Hydrate gently for hypotension. Avoid: ■ Preload or afterload reducers (no nitroglycerin) ■ Negative inotropes. ■ Prophylaxis for endocarditis. ■ Definitive treatment is valve replacement. 29 Complications ■ Sudden death from dysrhythmias or acute onset of failure may occur ■ Survival is 2–5 without replacement.
  29. 29. ETIOLOGIES Acute aortic regurgitation ■ Infective endocarditis ■ Aortic dissection with proximal extension ■ Trauma ■ Prosthetic valve dysfunction Chronic aortic regurgitation ■ Rheumatic heart disease ■ Bicuspid aortic valve ■ Dilation of the aortic root (Marfan, ankylosing spondylitis, rheumatoid arthritis) PATHOPHYSIOLOGY Acute aortic valve failure → rapid rise in LV diastolic pressure → acute pulmonary edema and cardiogenic shock 30
  30. 30. 31 Acute Chronic C/O -Abrupt onset of dyspnea -fever(endocarditis) -Chest pain ( if aortic dissection) Gradual onset of dyspnea on exertion, orthopnea, nocturnal dyspnea EXAM - Tachycardia, tachypnea - Pulmonary edema and cardiovascular collapse - High-pitched blowing diastolic murmur heard best at left sternal border - Normal pulse pressure ■ Widened pulse pressure (opposite of AS) ■ same diastolic murmur. ■ Austin Flint murmur (mid-diastolic rumble) ■ “Water hammer” pulse ■ Quincke’s sign ■ Duroziez’s murmur ■ De Musset sign ■ Congestive heart failure
  31. 31. 32 Acute Chronic work - ECG : normal - CXR: Pulmonary edema. -ECG: LVH, left atrial enlargement. - CXR: Congestive heart failure. TREATMENT -Standard for pulmonary edema - Nitroprusside for afterload reduction - Dobutamine (in addition to nitroprusside) if hypotensive - Immediate valve replacement - Antibiotics: If endocarditis suspected - Avoid: Intra-aortic balloon pump ■ Nifedipine for asymptomatic AR ■ Afterload reducers, digoxin, hydralazine, and surgical referral for elective valve replacement for symptomatic AR ■ Prophylaxis for endocarditis
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  33. 33. CAUSES: right ventricular dilation (pulmonary HTN), endocarditis, and rheumatic heart disease. SYMPTOMS Fatigue, Dyspnea, Lower extremity swelling EXAM: Holosystolic murmur at left lower sternal border 34
  34. 34. 35 DIAGNOSIS ■ ECG: Right atrial and ventricular enlargement, atrial fi brillation (in the majority of cases). ■ Echo is confirmatory. TREATMENT ■ Treat atrial fibrillation. ■ Endocarditis prophylaxis
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  37. 37. 38 Complications ●Systemic embolization ●Bleeding ●Valve obstruction due to thrombosis or pannus. ●Endocarditis ●Structural deterioration, particularly with bioprosthetic valves ●Paravalvular regurgitation ( leak ) ●Hemolytic anemia ●Patient-prosthesis mismatch ● abrupt mechanical valve failure
  38. 38. 39 SYMPTOMS/EXAM ■ Vary with location and rapidity of valve failure ■ Findings of severe anemia (due to hemolysis) ■ Findings consistent with aortic/mitral regurgitation (acute or chronic) ■ Muted mechanical valve sounds, if mechanical valve failure
  39. 39. Percutaneous Aortic “Valve in Valve” Implantation for Severe Aortic Regurgitation in a Degenerated Bioprosthesis 40
  40. 40. Targeted INR is - 3.0 - 3.5  mitral valve. - 2.5 - 3.0  aortic valve. sudden  acute onset of hypotension, CHF  Muted mechanical valve sounds  gradual course discovered on ECHO TREATMENT ■ Anticoagulation ■ Valve replacement 41
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  42. 42. 43 ETIOLOGIES MURMUR PHYSICAL FINDINGS AS Calcific valve Bicuspid valve Cresc–dec systolic Radiating → neck Paradoxically split S2 Narrowed pulse pressure Diminished and slow-rising carotid pulse AR Endocarditis Aortic dissection Blowing diastolic Heard best at left sternal border Acute > Pulmonary edema and CV collapse Chronic > “Water hammer” pulse , Quincke’s sign, Duroziez’s murmur, De Musset sign MS Rheumatic heart Diastolic Heard best at apex Loud S1 MR Endocarditis, ACS Loud holosystolic Heard best at apex Radiating → base Acute : Pulmonary edema and CV collapse Chronic: LV heave MP Unknown, likely congenital Late systolic heard best at left lateral heart border Early to mid systolic click
  43. 43. ■ In a patient with severe mitral stenosis, hypovolemia and tachycardia are poorly tolerated. “Slow and full” are appropriate goals. ■ In patients with critical aortic stenosis, excessive preload reduction with vasodilators and diuretics is to be avoided. ■ In patients with acute aortic insufficiency, classic physical findings may be absent. Medical stabilization entails the cautious use of vasodilators and diuretics. Intra-aortic balloon counter pulsation is contraindicated. ■ Complications of prosthetic heart valves range from structural failure and thrombosis to systemic embolization, hemolysis, and endocarditis. ■ admission depends on severity of symptoms not presence of murmur unless aortic stenosis and syncope is suspected. ■ Valvular heart Disease pt. at risk for recurrent cardiovascular event. 4444
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