A 67-year-old man presents to the emergency department with sudden onset of chest pain and shortness of breath. On examination, he has signs of pulmonary edema and a loud heart murmur, and has a history of a recent heart attack. The most appropriate initial management is to provide standard treatment for pulmonary edema and consider the need for urgent valve replacement surgery given the acute presentation in the setting of known valvular heart disease.

2. 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

3. 3

4. Non of my business , what else? 4

5. • How Is it an Emergency ?
• How to know ?
• Rheumatic heart Disease
& Infective indocarditis
• Understand ECHO
images
5

6. • ↑ 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

7. 7

8. 8

9. • 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

10. • 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.

11. 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

12. Valvoplasty 12

13. COMPLICATIONS
■ Atrial fi brillation
■ pulmonary hemorrhage
■ Pulmonary HTN and Rt HF
■ Systemic emboli
13

14. 14

15. 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

16. 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

17. 17

18. 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.

19. • 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

20. • 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

21. 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

22. 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

23. 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).

24. 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

25. 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

26. 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.

27. Aortic valve stenosis 27

28. Bicuspid aortic valve 28

29. 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.

30. 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

31. 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

32. 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

33. 33

34. 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

35. 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

36. 36

37. 37

38. 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

39. 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

40. Percutaneous Aortic “Valve in Valve”
Implantation for Severe Aortic Regurgitation in
a Degenerated Bioprosthesis
40

41. 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

42. 42

43. 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

44. ■ 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

45. 45

46. 46