This document discusses the case of a 75-year-old farmer who experienced a fainting spell while working and was found to have a heart murmur and signs of aortic stenosis upon examination. It provides details on the etiology, pathophysiology, natural history, and management guidelines for aortic stenosis. It also discusses guidelines for follow-up, recommendations for aortic valve replacement, and summaries key physical exam findings for aortic stenosis.
Valvular heart disease refers to abnormalities of the heart valves that result in obstruction of blood flow or backflow of blood. Echocardiography plays a key role in evaluating valve function and structure non-invasively. Common valvular abnormalities include aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. Treatment depends on severity and symptoms, ranging from medical management to surgical repair or replacement of the affected valve.
Valvular heart disease is caused by damage or defects to the heart's valves. The main types are stenosis, where the valve opening is narrowed, and regurgitation, where the valve leaks.
The most common causes are rheumatic fever, which can cause scarring of the valves, and aging/degeneration. Symptoms depend on the severity but can include shortness of breath, chest pain, and fatigue. Treatment options include medications to manage symptoms or surgery to repair or replace the damaged valve.
Valvular heart disease refers to disorders of the cardiac valves that cause stenosis or regurgitation. Common types include mitral stenosis and regurgitation, aortic stenosis and regurgitation. Anesthesia management focuses on maintaining normal heart rate and rhythm, preload, afterload, and contractility based on the specific valve affected to optimize cardiac output. Regional techniques like epidurals are generally preferred over general anesthesia when possible.
This document discusses different types of valvular heart disease. It begins by explaining that valvular heart disease is characterized by damage or defects to the heart's valves, which normally ensure proper blood flow. Stenotic valves become narrowed and prevent full opening, while incompetent valves do not close completely and allow blood to leak back. Over time, the heart compensates by enlarging and thickening, losing efficiency.
The document then examines specific valve diseases in more detail, outlining their causes, effects on heart function, symptoms, diagnostic tests, and treatment options. Diseases covered include mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid regurgitation
Valvular heart disease refers to disorders that affect one of the heart's valves, causing stenosis (narrowing) or regurgitation (leakage). The major types are aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, tricuspid stenosis, and tricuspid regurgitation. Symptoms depend on the specific valve affected and include shortness of breath, chest pain, fatigue, and heart failure. Diagnosis involves listening for murmurs, ECGs, echocardiograms, and cardiac catheterization. Treatment ranges from medication and lifestyle changes to surgery depending on severity, with valve replacement or repair being done for severe cases.
Valvular heart disease refers to abnormalities of the heart valves that result in obstruction of blood flow or backflow of blood. Echocardiography plays a key role in evaluating valve function and structure non-invasively. Common valvular abnormalities include aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. Treatment depends on severity and symptoms, ranging from medical management to surgical repair or replacement of the affected valve.
Valvular heart disease is caused by damage or defects to the heart's valves. The main types are stenosis, where the valve opening is narrowed, and regurgitation, where the valve leaks.
The most common causes are rheumatic fever, which can cause scarring of the valves, and aging/degeneration. Symptoms depend on the severity but can include shortness of breath, chest pain, and fatigue. Treatment options include medications to manage symptoms or surgery to repair or replace the damaged valve.
Valvular heart disease refers to disorders of the cardiac valves that cause stenosis or regurgitation. Common types include mitral stenosis and regurgitation, aortic stenosis and regurgitation. Anesthesia management focuses on maintaining normal heart rate and rhythm, preload, afterload, and contractility based on the specific valve affected to optimize cardiac output. Regional techniques like epidurals are generally preferred over general anesthesia when possible.
This document discusses different types of valvular heart disease. It begins by explaining that valvular heart disease is characterized by damage or defects to the heart's valves, which normally ensure proper blood flow. Stenotic valves become narrowed and prevent full opening, while incompetent valves do not close completely and allow blood to leak back. Over time, the heart compensates by enlarging and thickening, losing efficiency.
The document then examines specific valve diseases in more detail, outlining their causes, effects on heart function, symptoms, diagnostic tests, and treatment options. Diseases covered include mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid regurgitation
Valvular heart disease refers to disorders that affect one of the heart's valves, causing stenosis (narrowing) or regurgitation (leakage). The major types are aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, tricuspid stenosis, and tricuspid regurgitation. Symptoms depend on the specific valve affected and include shortness of breath, chest pain, fatigue, and heart failure. Diagnosis involves listening for murmurs, ECGs, echocardiograms, and cardiac catheterization. Treatment ranges from medication and lifestyle changes to surgery depending on severity, with valve replacement or repair being done for severe cases.
This document discusses various types of valvular heart disease including stenosis, regurgitation, and specific valve diseases like mitral stenosis. It covers the etiology, pathophysiology, clinical manifestations and diagnostic studies for each type. Treatment options discussed include medications, percutaneous balloon valvuloplasty, various surgical repair procedures like valvuloplasty, annuloplasty and chordoplasty, and valve replacements using mechanical or biologic prosthetic valves. Nursing management focuses on assessment, monitoring, education, and addressing diagnoses like activity intolerance and fluid overload.
This document contains 8 case studies presented by Dr. Md. Toufiqur Rahman regarding patients with symptoms of dyspnea and cardiac abnormalities. For each case, the document describes the patient's history, examination findings, and in some cases diagnostic test results. It also provides background information on mitral stenosis including causes, pathophysiology, clinical features, investigations, and stages of severity.
Valvular heart disease can cause mitral regurgitation and mitral stenosis. Rheumatic fever is a common cause of valvular heart disease and results in scarring of the heart valves over multiple attacks. Mitral stenosis causes the mitral valve to narrow over time, increasing the pressure in the lungs and right side of the heart. Mitral regurgitation occurs when the mitral valve does not close properly, allowing blood to flow back into the left atrium. Both conditions can cause shortness of breath and heart failure if left untreated. Echocardiography is the primary test used to diagnose valvular heart disease and determine severity.
The document discusses various heart valve conditions including mitral valve stenosis, mitral valve regurgitation, tricuspid stenosis, tricuspid regurgitation, aortic valve stenosis, aortic valve regurgitation, pulmonary valve stenosis, and pulmonary valve regurgitation. It defines each condition, discusses their causes, symptoms, diagnostic evaluations, and potential treatments which may include medications, balloon valvuloplasty procedures, or valve repair/replacement surgeries.
In heart valve disease, one or more of the valves in your heart doesn't work properly.
Your heart has four valves that keep blood flowing in the correct direction. In some cases, one or more of the valves don't open or close properly. This can cause the blood flow through your heart to your body to be disrupted.
Your heart valve disease treatment depends on the heart valve affected and the type and severity of the valve disease. Sometimes heart valve disease requires surgery to repair or replace the heart valve.Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (leaflets or cusps) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body.
Heart valve disease may be present at birth (congenital). It can also occur in adults due to many causes and conditions, such as infections and other heart conditions.
Heart valve problems may include:
Regurgitation. In this condition, the valve flaps don't close properly, causing blood to leak backward in your heart. This commonly occurs due to valve flaps bulging back, a condition called prolapse.
Stenosis. In valve stenosis, the valve flaps become thick or stiff, and they may fuse together. This results in a narrowed valve opening and reduced blood flow through the valve.
Atresia. In this condition, the valve isn't formed, and a solid sheet of tissue blocks the blood flow between the heart chambers.Several factors can increase your risk of heart valve disease, including:
Older age
History of certain infections that can affect the heart
History of certain forms of heart disease or heart attack
High blood pressure, high cholesterol, diabetes and other heart disease risk factors
Heart conditions present at birth (congenital heart disease)Heart valve disease can cause many complications, including:
Heart failure
Stroke
Blood clots
Heart rhythm abnormalities
Death
1. Valvular heart disorders involve abnormalities of the valves that regulate blood flow through the heart. The main types are mitral valve prolapse, mitral stenosis, and mitral regurgitation.
2. Mitral valve prolapse involves a portion of the mitral valve bulging back into the left atrium. Mitral stenosis is a narrowing of the mitral valve that obstructs blood flow. Mitral regurgitation allows blood to flow back from the left ventricle to the left atrium.
3. Nursing management of valvular disorders focuses on patient education, medication administration, monitoring for symptoms, and supporting patients through valve repair or replacement procedures.
The document discusses various types of heart valve disorders including stenosis, regurgitation, and prolapse of the mitral, aortic, tricuspid, and pulmonary valves. It describes the causes, effects, symptoms, treatments including medications, valvuloplasty, and valve replacement surgery for each type of valve disorder. Nursing diagnoses and interventions are also provided focusing on monitoring cardiac function and output, managing fluid volume and electrolytes, conserving energy, and educating the patient.
Valvular heart disease, specifically mitral stenosis, places a hemodynamic burden on the heart over time. The disease results in a narrowed mitral valve opening that obstructs blood flow from the left atrium to the left ventricle. This obstruction can lead to elevated left atrial pressure and pulmonary hypertension. Symptoms include breathlessness and fatigue. Echocardiography is used to evaluate the severity based on mitral valve area and pressure gradients. Treatment involves managing symptoms medically or surgically replacing/repairing the valve. Anesthetic management focuses on maintaining preload, controlling heart rate, and avoiding pulmonary vasoconstriction.
A 52-year-old woman presents with gradually worsening shortness of breath over 2 years and now requires 2 pillows at night. On examination, she has an apical diastolic murmur. This suggests she has valvular heart disease, likely mitral stenosis given the murmur location and symptoms. Mitral stenosis narrows the opening between the left atrium and ventricle, causing shortness of breath and difficulty sleeping flat. Surgical options may include balloon valvuloplasty or valve replacement depending on severity.
This document provides an overview of congenital and acquired valvular heart diseases. It defines valvular heart disease and describes the four main types of valves in the heart. It then discusses several specific congenital valvular diseases that can occur, including pulmonary atresia, pulmonary stenosis, tricuspid atresia, and bicuspid aortic valve disease. Symptoms, causes, investigations, treatments and complications are outlined for each one. It also discusses acquired valvular diseases such as aortic stenosis and mitral regurgitation.
This document discusses different types of valvular heart disease including stenosis, regurgitation, and functional regurgitation. It provides details on specific valve diseases like mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation. For each condition, it outlines the causes, pathophysiology or effects, which depend on the degree and duration of the disease. Long term effects can include hypertrophy and failure of the left or right ventricle leading to pulmonary congestion, edema, and heart failure.
Anaesthetic management of a case of valvular heart disease... finalDr Ravi Shankar Sharma
Mrs. Savitha is a 42 year old female presenting with palpitations, breathlessness, and fatigue for evaluation prior to an ovarian cyst excision. Her history reveals rheumatic heart disease since age 12, a balloon mitral valvuloplasty 13 years ago, and no other significant medical history. On examination, she has an opening snap and mid-diastolic murmur at the apex. Echocardiogram shows mitral stenosis with a valve area of 2.0 cm2 and mild pulmonary hypertension. She is diagnosed with mild mitral stenosis of rheumatic origin. Anesthetic management aims to prevent decreases in cardiac output and avoid hypotension or precipitating congestive heart failure.
This document provides information on abnormal valve function, essential questions in evaluating patients for valvular intervention, and tricuspid valve disease. It discusses valve stenosis, regurgitation, combined lesions, and the causes of abnormal valve function. Physical exam findings, echocardiography, ECG, chest x-ray, and invasive evaluations are described for diagnosis. Pathophysiology and management considerations for tricuspid regurgitation and stenosis are also covered.
The document discusses various types of valvular heart disease including stenosis, regurgitation, mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonary stenosis and pulmonary regurgitation. For each condition, the causes, consequences, clinical presentation, investigations, and management are described. Common investigations like echocardiography and treatments like valve replacement surgery are also summarized.
This document discusses various valvular heart diseases including global burden, aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. Key points include: rheumatic heart disease is a leading cause in developing countries while age-related calcific disease is most common in developed nations; surgical options depend on severity and include valve repair/replacement; complications can include atrial fibrillation, pulmonary hypertension, and systemic embolism. Medical management focuses on symptom control through medications and lifestyle changes while surgery aims to correct valvular abnormalities.
1) Valvular heart disease is characterized by damage or defects to the heart's valves, with the two most common types being aortic stenosis and mitral regurgitation.
2) The document discusses the different types of valvular heart diseases including their etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. The types covered include mitral stenosis/regurgitation, aortic stenosis/regurgitation, tricuspid stenosis, and pulmonic stenosis.
3) Nursing management of valvular heart disease involves monitoring for symptoms, ensuring proper medical and surgical treatments are followed, and health education about valvular heart conditions.
ECG- Atrial Fibrillation, CXR-P/A view-Cardiomegaly,
Echocardiogram-severe mitral stenosis with severe MR with
moderate pulmonary hypertension. Patient underwent MVR and
she is doing well.
The document summarizes tobacco cessation legislation in India. It provides background on the history of tobacco use in India, current prevalence rates, and health impacts of tobacco. It then outlines key events in India's tobacco control efforts, including various acts passed between 1975-2003 to regulate tobacco advertising, sales, and use. The summary highlights challenges in implementing these laws and the need for continued education strategies to curb tobacco consumption.
The document discusses various types of heart valve disorders including stenosis, regurgitation, and prolapse. It describes the causes, effects, symptoms, and treatments for different valve conditions affecting the mitral, aortic, tricuspid, and pulmonary valves. Surgical interventions for valve disorders include valvuloplasty procedures to repair valves as well as valve replacement using mechanical or biological prosthetics.
Valvular heart disease can be caused by stenosis, which is a narrowing of the valve that prevents forward blood flow, or insufficiency/regurgitation, which is a failure of the valve to close completely allowing reverse blood flow. Common causes mentioned include rheumatic fever, which can cause thickening and fusion of valves, calcification due to aging, and myxomatous degeneration of the mitral valve. Infective endocarditis is an infection of the heart valves that can be acute and destructive or subacute with lower virulence, and is commonly caused by bacteria entering the bloodstream from procedures or infections elsewhere in the body.
This document discusses various types of valvular heart disease including stenosis, regurgitation, and specific valve diseases like mitral stenosis. It covers the etiology, pathophysiology, clinical manifestations and diagnostic studies for each type. Treatment options discussed include medications, percutaneous balloon valvuloplasty, various surgical repair procedures like valvuloplasty, annuloplasty and chordoplasty, and valve replacements using mechanical or biologic prosthetic valves. Nursing management focuses on assessment, monitoring, education, and addressing diagnoses like activity intolerance and fluid overload.
This document contains 8 case studies presented by Dr. Md. Toufiqur Rahman regarding patients with symptoms of dyspnea and cardiac abnormalities. For each case, the document describes the patient's history, examination findings, and in some cases diagnostic test results. It also provides background information on mitral stenosis including causes, pathophysiology, clinical features, investigations, and stages of severity.
Valvular heart disease can cause mitral regurgitation and mitral stenosis. Rheumatic fever is a common cause of valvular heart disease and results in scarring of the heart valves over multiple attacks. Mitral stenosis causes the mitral valve to narrow over time, increasing the pressure in the lungs and right side of the heart. Mitral regurgitation occurs when the mitral valve does not close properly, allowing blood to flow back into the left atrium. Both conditions can cause shortness of breath and heart failure if left untreated. Echocardiography is the primary test used to diagnose valvular heart disease and determine severity.
The document discusses various heart valve conditions including mitral valve stenosis, mitral valve regurgitation, tricuspid stenosis, tricuspid regurgitation, aortic valve stenosis, aortic valve regurgitation, pulmonary valve stenosis, and pulmonary valve regurgitation. It defines each condition, discusses their causes, symptoms, diagnostic evaluations, and potential treatments which may include medications, balloon valvuloplasty procedures, or valve repair/replacement surgeries.
In heart valve disease, one or more of the valves in your heart doesn't work properly.
Your heart has four valves that keep blood flowing in the correct direction. In some cases, one or more of the valves don't open or close properly. This can cause the blood flow through your heart to your body to be disrupted.
Your heart valve disease treatment depends on the heart valve affected and the type and severity of the valve disease. Sometimes heart valve disease requires surgery to repair or replace the heart valve.Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (leaflets or cusps) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body.
Heart valve disease may be present at birth (congenital). It can also occur in adults due to many causes and conditions, such as infections and other heart conditions.
Heart valve problems may include:
Regurgitation. In this condition, the valve flaps don't close properly, causing blood to leak backward in your heart. This commonly occurs due to valve flaps bulging back, a condition called prolapse.
Stenosis. In valve stenosis, the valve flaps become thick or stiff, and they may fuse together. This results in a narrowed valve opening and reduced blood flow through the valve.
Atresia. In this condition, the valve isn't formed, and a solid sheet of tissue blocks the blood flow between the heart chambers.Several factors can increase your risk of heart valve disease, including:
Older age
History of certain infections that can affect the heart
History of certain forms of heart disease or heart attack
High blood pressure, high cholesterol, diabetes and other heart disease risk factors
Heart conditions present at birth (congenital heart disease)Heart valve disease can cause many complications, including:
Heart failure
Stroke
Blood clots
Heart rhythm abnormalities
Death
1. Valvular heart disorders involve abnormalities of the valves that regulate blood flow through the heart. The main types are mitral valve prolapse, mitral stenosis, and mitral regurgitation.
2. Mitral valve prolapse involves a portion of the mitral valve bulging back into the left atrium. Mitral stenosis is a narrowing of the mitral valve that obstructs blood flow. Mitral regurgitation allows blood to flow back from the left ventricle to the left atrium.
3. Nursing management of valvular disorders focuses on patient education, medication administration, monitoring for symptoms, and supporting patients through valve repair or replacement procedures.
The document discusses various types of heart valve disorders including stenosis, regurgitation, and prolapse of the mitral, aortic, tricuspid, and pulmonary valves. It describes the causes, effects, symptoms, treatments including medications, valvuloplasty, and valve replacement surgery for each type of valve disorder. Nursing diagnoses and interventions are also provided focusing on monitoring cardiac function and output, managing fluid volume and electrolytes, conserving energy, and educating the patient.
Valvular heart disease, specifically mitral stenosis, places a hemodynamic burden on the heart over time. The disease results in a narrowed mitral valve opening that obstructs blood flow from the left atrium to the left ventricle. This obstruction can lead to elevated left atrial pressure and pulmonary hypertension. Symptoms include breathlessness and fatigue. Echocardiography is used to evaluate the severity based on mitral valve area and pressure gradients. Treatment involves managing symptoms medically or surgically replacing/repairing the valve. Anesthetic management focuses on maintaining preload, controlling heart rate, and avoiding pulmonary vasoconstriction.
A 52-year-old woman presents with gradually worsening shortness of breath over 2 years and now requires 2 pillows at night. On examination, she has an apical diastolic murmur. This suggests she has valvular heart disease, likely mitral stenosis given the murmur location and symptoms. Mitral stenosis narrows the opening between the left atrium and ventricle, causing shortness of breath and difficulty sleeping flat. Surgical options may include balloon valvuloplasty or valve replacement depending on severity.
This document provides an overview of congenital and acquired valvular heart diseases. It defines valvular heart disease and describes the four main types of valves in the heart. It then discusses several specific congenital valvular diseases that can occur, including pulmonary atresia, pulmonary stenosis, tricuspid atresia, and bicuspid aortic valve disease. Symptoms, causes, investigations, treatments and complications are outlined for each one. It also discusses acquired valvular diseases such as aortic stenosis and mitral regurgitation.
This document discusses different types of valvular heart disease including stenosis, regurgitation, and functional regurgitation. It provides details on specific valve diseases like mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation. For each condition, it outlines the causes, pathophysiology or effects, which depend on the degree and duration of the disease. Long term effects can include hypertrophy and failure of the left or right ventricle leading to pulmonary congestion, edema, and heart failure.
Anaesthetic management of a case of valvular heart disease... finalDr Ravi Shankar Sharma
Mrs. Savitha is a 42 year old female presenting with palpitations, breathlessness, and fatigue for evaluation prior to an ovarian cyst excision. Her history reveals rheumatic heart disease since age 12, a balloon mitral valvuloplasty 13 years ago, and no other significant medical history. On examination, she has an opening snap and mid-diastolic murmur at the apex. Echocardiogram shows mitral stenosis with a valve area of 2.0 cm2 and mild pulmonary hypertension. She is diagnosed with mild mitral stenosis of rheumatic origin. Anesthetic management aims to prevent decreases in cardiac output and avoid hypotension or precipitating congestive heart failure.
This document provides information on abnormal valve function, essential questions in evaluating patients for valvular intervention, and tricuspid valve disease. It discusses valve stenosis, regurgitation, combined lesions, and the causes of abnormal valve function. Physical exam findings, echocardiography, ECG, chest x-ray, and invasive evaluations are described for diagnosis. Pathophysiology and management considerations for tricuspid regurgitation and stenosis are also covered.
The document discusses various types of valvular heart disease including stenosis, regurgitation, mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonary stenosis and pulmonary regurgitation. For each condition, the causes, consequences, clinical presentation, investigations, and management are described. Common investigations like echocardiography and treatments like valve replacement surgery are also summarized.
This document discusses various valvular heart diseases including global burden, aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. Key points include: rheumatic heart disease is a leading cause in developing countries while age-related calcific disease is most common in developed nations; surgical options depend on severity and include valve repair/replacement; complications can include atrial fibrillation, pulmonary hypertension, and systemic embolism. Medical management focuses on symptom control through medications and lifestyle changes while surgery aims to correct valvular abnormalities.
1) Valvular heart disease is characterized by damage or defects to the heart's valves, with the two most common types being aortic stenosis and mitral regurgitation.
2) The document discusses the different types of valvular heart diseases including their etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. The types covered include mitral stenosis/regurgitation, aortic stenosis/regurgitation, tricuspid stenosis, and pulmonic stenosis.
3) Nursing management of valvular heart disease involves monitoring for symptoms, ensuring proper medical and surgical treatments are followed, and health education about valvular heart conditions.
ECG- Atrial Fibrillation, CXR-P/A view-Cardiomegaly,
Echocardiogram-severe mitral stenosis with severe MR with
moderate pulmonary hypertension. Patient underwent MVR and
she is doing well.
The document summarizes tobacco cessation legislation in India. It provides background on the history of tobacco use in India, current prevalence rates, and health impacts of tobacco. It then outlines key events in India's tobacco control efforts, including various acts passed between 1975-2003 to regulate tobacco advertising, sales, and use. The summary highlights challenges in implementing these laws and the need for continued education strategies to curb tobacco consumption.
The document discusses various types of heart valve disorders including stenosis, regurgitation, and prolapse. It describes the causes, effects, symptoms, and treatments for different valve conditions affecting the mitral, aortic, tricuspid, and pulmonary valves. Surgical interventions for valve disorders include valvuloplasty procedures to repair valves as well as valve replacement using mechanical or biological prosthetics.
Valvular heart disease can be caused by stenosis, which is a narrowing of the valve that prevents forward blood flow, or insufficiency/regurgitation, which is a failure of the valve to close completely allowing reverse blood flow. Common causes mentioned include rheumatic fever, which can cause thickening and fusion of valves, calcification due to aging, and myxomatous degeneration of the mitral valve. Infective endocarditis is an infection of the heart valves that can be acute and destructive or subacute with lower virulence, and is commonly caused by bacteria entering the bloodstream from procedures or infections elsewhere in the body.
Tobacco use is the leading cause of preventable death and disease in the United States, responsible for nearly 20% of annual deaths. In response, the Centers for Disease Control and Prevention (CDC) established programs to promote tobacco prevention and control. While smoking rates have declined by around 50% since the 1960s, further reductions are still needed to meet public health targets. Legislative actions, taxation, and prevention programs have improved health outcomes but disparities remain for some groups. Continued evaluation is crucial to refine interventions and sustain progress on this important public health issue.
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Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Rheumatic fever is the most common cause of valvular heart disease, often resulting in mitral stenosis. Mitral stenosis causes elevated left atrial pressure, pulmonary hypertension, and right heart failure if severe. It is diagnosed based on symptoms, murmurs, echocardiogram findings and history of rheumatic fever. Treatment involves medications, balloon valvuloplasty, or valve replacement depending on severity.
This patient presented with progressive chest pain on exertion and shortness of breath. A physical exam revealed a systolic murmur and echocardiogram showed aortic stenosis with a mean gradient of 32mm Hg and valve area of 0.88cm^2. A cardiac catheterization showed severe aortic stenosis with a peak gradient of 68mm Hg and valve area of 0.83cm^2. Given her symptoms and severity of stenosis, surgical aortic valve replacement is recommended. Coronary angiography will also be performed to assess for need for concomitant CABG prior to surgery.
This document discusses surgical options for treating heart failure. It begins by providing background on heart failure, including definitions, incidence rates, mortality rates, clinical types, and causes. It then discusses various surgical interventions for acute and chronic heart failure, such as CABG, valve surgery, ventricular reconstruction procedures like the Dor procedure, restraint devices like the Acorn and Myosplint, ventricular assist devices, total artificial hearts, and heart transplantation. The risks, benefits, indications, and outcomes of these different surgical treatments are summarized.
The document provides information on electrocardiogram (ECG) findings and their significance in patients presenting with syncope. It discusses diagnostic criteria and risk stratification tools for evaluating causes of syncope, including the CHESS criteria and San Francisco Syncope Rule. Important ECG findings that warrant further investigation or indicate an underlying cardiac condition are highlighted, such as arrhythmias, conduction abnormalities, signs of ischemia, and structural heart disease. Specific arrhythmias and cardiac conditions like long QT syndrome and Brugada syndrome are also reviewed in the context of evaluating syncope.
This document discusses aortic stenosis, including its causes, symptoms, diagnostic studies, prognosis, and treatment options. It begins with an overview and definitions, then describes the main types and risk factors for aortic stenosis. Diagnostic tests like echocardiography are outlined for evaluating the severity of stenosis. The prognosis without treatment is explained. Treatment involves initially managing symptoms, with surgical aortic valve replacement as the definitive treatment for severe symptomatic stenosis. A case study is presented of an elderly woman found to have incidental moderate aortic stenosis while being evaluated for anemia.
This document provides an overview of shock, including its definition, types, physiology, and management. It discusses the key features and immediate treatment of hemorrhagic, neurogenic, septic, anaphylactic, cardiogenic, and obstructive shock through case examples. The main points are that shock results from inadequate tissue perfusion, early recognition and aggressive fluid/vasopressor resuscitation are critical to improving outcomes across different shock types.
Data is based on ESC & ACC guidelines 2017
Assessment of aortic stenosis severity
Step by step management algorithm
Management in special populations
Case-based questions
MCQs
This document provides an overview of cardiac emergencies for nurses. It begins with definitions of medical and cardiovascular emergencies. It then covers assessment of the cardiovascular system, ECG interpretation, common rhythm disturbances like tachycardias and bradycardias, and treatment protocols for cardiac arrest, chest pain, acute coronary syndrome, and other conditions. Nursing interventions are described for monitoring, medication administration, and supporting patients experiencing cardiovascular emergencies.
This document provides an overview of electrocardiogram (ECG or EKG) basics including:
- The 12 leads of a standard ECG and what each views of the heart
- Components of the ECG tracing including the P, Q, R, S, and T waves
- Methods for calculating heart rate from the ECG
- Identification and classification of common cardiac rhythms, arrhythmias, conduction abnormalities, chamber enlargements, and other ECG findings
- Interpretation of ECG findings in the context of underlying cardiac conditions, structures, or pathologies
A 22-year-old male presented with complaints of easy fatigability, abdominal discomfort, leg swelling, and shortness of breath with exertion over the past 6-8 months. Examination found edema, elevated jugular venous pressure, hepatomegaly, and cachexia. Testing showed elevated liver enzymes and BNP. Echocardiogram demonstrated thickened pericardium with ventricular interdependence and equal diastolic pressures, consistent with constrictive pericarditis. The patient was diagnosed with constrictive pericarditis likely due to a prior unknown infection or inflammatory process causing thickening and scarring of the pericardium.
This document discusses drug therapy for heart failure. It begins by defining heart failure and describing the stages and phenotypes. The main causes of heart failure are then outlined, including ischemic heart disease, hypertension, cardiomyopathy, infections, toxins, and valvular disease. The document discusses the pathophysiology of heart failure in terms of ventricular dysfunction, compensatory mechanisms like the Frank-Starling mechanism and neurohormonal activation, and the determinants of ventricular function. General treatment measures and pharmacological management are described for different stages of heart failure.
The document discusses the diagnosis and management of various cardiac arrhythmias, outlining the assessment of patients' histories, ECG findings, and treatment options including medications, referral indications, and procedures. Case studies are provided examining scenarios involving bradycardias, conduction abnormalities, tachycardias, and their management in both stable and unstable patients.
Congestive Cardiac Failure presentation and diagnosisShah Abbas
This document provides an overview of congestive heart failure (CHF), including its definition, causes, pathophysiology, clinical manifestations, diagnostic evaluation, and management. CHF is defined as a clinical syndrome where the heart cannot pump enough blood to meet the body's needs. It is most commonly caused by conditions that overload or damage the heart such as hypertension, heart attacks, and cardiomyopathy. Clinically, it presents with symptoms of fluid backup like dyspnea, edema, and fatigue. Diagnostic tests include chest x-rays, EKGs, blood tests like BNP, and echocardiography. Treatment focuses on managing symptoms, addressing the underlying cause, and preventing complications through medications, lifestyle changes, and potentially devices
This document discusses the approach to patients with congenital cyanotic heart disease. It begins with a case example of a newborn found to have transposition of the great arteries. It then covers the prevalence, causes, presentations, investigations and management of cyanotic heart defects. One of the key cyanotic defects discussed in detail is tetralogy of Fallot, including its pathophysiology, clinical features, investigations and treatment, including surgical repair.
The Advanced Cardiovascular Life Support (ACLS) algorithm is a systematic, evidence-based approach designed to guide healthcare providers in the urgent treatment of: Cardiac arrest. Arrhythmias. Stroke. Other life-threatening cardiovascular emergencies.
The document discusses various types of arrhythmias including bradycardia, tachycardia, atrial fibrillation, ventricular fibrillation, and heart block. It provides two case studies, one involving a patient presenting with sudden onset shortness of breath and palpitations, and another involving an incidental finding of an irregular heartbeat. It also includes a quiz with rhythm strips and questions about treatment.
This document provides an overview of arrhythmias including atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular tachycardia, and ventricular fibrillation. It discusses the epidemiology, pathophysiology, diagnosis, and treatment options for these conditions. Treatment focuses on rate control, restoring sinus rhythm, and preventing thromboembolism depending on the specific arrhythmia. Diagnosis involves EKG, echocardiogram, blood tests, and other cardiac imaging tools. Management may include medications, cardioversion, ablation procedures, or implantable defibrillators.
approach to congenital cyanotic heart diseasesRyanKhan40
A document discusses the approach to patients with congenital cyanotic heart disease. Common cyanotic lesions include tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia. Physical exam should assess for cyanosis, murmurs, organomegaly and signs of congestive heart failure. Initial tests include chest x-ray, ECG, echocardiogram and arterial blood gas. Treatment may involve surgical repair, palliative surgeries like shunts, or managing cyanotic spells. Case examples provided diagnoses for specific patients as tetralogy of Fallot, transposition of the great arteries with ventricular septal defect, and tricuspid atresia.
1. The document discusses the approach to diagnosing and managing patients with congenital cyanotic heart disease. Common cyanotic lesions include tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia.
2. Physical examination focuses on signs of cyanosis, murmurs, organomegaly or congestive heart failure. Investigations include chest X-ray, ECG, echocardiogram and arterial blood gas. Management involves ruling out other causes, providing supplemental oxygen, addressing congestive heart failure, and definitive surgical repair if possible.
3. Case scenarios discuss specific patients with features of tetralogy of Fallot, transposition of the great arteries with ventricular sept
Paediatric Cardiology for General Paediatrics.pptSalam467227
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Diabetes during pregnancy can take three forms: gestational diabetes, pre-existing type 1 or 2 diabetes. All three increase risks like large baby size and c-section. High blood glucose in the womb can also cause problems for the baby after birth. Screening guidelines recommend testing women at high risk and sometimes all pregnant women. Treatment focuses on tight blood glucose control through diet, exercise and insulin if needed to improve outcomes for both mother and baby.
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LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
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help of Advanced technologies like Remote Sensing and Geographic Information Systems is
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9
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Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
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Leveraging Generative AI to Drive Nonprofit Innovation
Valvular Heart Disease
1. Valvular Heart Disease:
An Update in Management
Speaker: Prof.Malik Tariq Mahmood
Case:
An active 75 yo farmer comes to your office after experiencing a fainting
spell while baling hay. The episode occurred without warning and he had no
symptoms following the episode. However, on close questioning he admits to some
breathlessness and vague chest heaviness with his usual heavy exertion over the past
few months and a very unwelcome tendency to want to slow down which he
reluctantly attributed to his age. He has been healthy all his life, doesn’t smoke and
has not seen a doctor in 30 years. He served in the army in 1942; no abnormalities
were reported during his induction physical
Physical Exam:
Robust looking older man with a laceration on his forehead from falling on the
handle of his pitchfork.
BP 135/90 P 68 bpm, regular RR-12 T-98.6° F
JVP 6 cm with normal “a” and “v” waves
Carotids: Difficult to palpate, delayed upstroke
Lungs: Clear
Heart: Palpation:
Palpable “thrill” over the mid LSB. PMI 5 ICS, 2 cm lateral to the MCL.
Palpable presystolic impulse followed by a sustained ventricular lift.
Auscultation:
Loud S4. S1 is normal. A single S2 (P2) is heard at the upper left sternal border
but no S2 is heard at the lower left sternal border. There is a 4/6 systolic ejection
murmur (crescendo-decrescendo) heard best at the R 2nd interspace but radiating
widely to the LSB, and to the neck. No diastolic murmurs.
Abdomen and extremities are unremarkable.
Aortic Stenosis:
Aortic Stenosis: Etiology:
♥ Congenital bicuspid aortic valve
♥ Rheumatic aortic valve disease
♥ Calcific (senile) aortic stenosis
Aortic Stenosis
Physiologic Principles-Natural History
2. • Normal aortic valve area is 3.0 - 4.0 cm2
• Circulation affected when valve area is reduced by ~ 75% (i.e. 0.75 - 1.0 cm2)
valve area (cm sq) mean gradient (mm Hg)*
Mild > 1.5 < 25
Moderate 1.0 - 1.5 25 - 50
Severe < 0.75 > 50
Aortic Stenosis
Physiologic Principles-Natural History:
• Primary adaptation is concentric hypertrophy
• Latent phase usually lasts decades
• Risk of sudden death is very low during this phase
• Rate of progression ranges from 0-0.3 cm2/yr. (average rate is 0.12 cm2/yr)
• 50% of patients with severe AS do not progress
• Cannot predict who will
Key Physical Findings in Severe
Aortic Stenosis:
♥ Carotid impulse: “parvus et tardus”
♥ JVP: Prominent “a” wave
♥ Heart: Systolic thrill
Palpable presystolic impulse (S4)
Sustained apical systolic impulse S4
Coarse late peaking systolic ejection murmur
(may radiate to neck and/or LSB)
Attenuated/absent aortic component of S2
Natural History of Aortic Stenosis:
♥ Long asymptomatic “latent” period
♥ “Cardinal” symptoms of severe aortic stenosis
Dyspnea
Angina
Syncope
♥ Sudden death
♥ Left ventricular dilatation and contractile failure
♥ Endocarditis
♥ Arrhythmias
Ventricular tachycardia
Conduction system disease
Atrial fibrillation
Natural History of AS:
3. Aortic Stenosis
Physiologic Principles-Natural History:
• Once symptoms develop, average survival is 2-3 yrs
• With LV systolic dysfunction, there may be increased risk of sudden death and
permanent LV dysfunction
Ross J Jr, Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61, 1968
Aortic Stenosis
Management Guidelines:
Initial Diagnostic Testing:
Lipids, renal fxn, Ca, P---all patients
CXR, ECG, Echocardiography---all patients
Cardiac catheterization with angiography
If clinical and echo data are discordant
To assess coronary circulation prior to surgery
Aortic Stenosis
Management Guidelines:
Initial Diagnostic Testing (cont.)
Treadmill stress testing
Dangerous in symptomatic pts
Not useful for dx of CAD
May be used to assess functional significance of severe AS in pts who deny
symptoms (e.g. bp response)
Aortic Stenosis
Management Guidelines:
Scheduled Follow-up:
4. office intervalecho interval
Mild AS 12 mos 5 yrs
Moderate AS 6 mos 2 yrs
Severe AS 6 mos 1 yr
Aortic Stenosis
Management Guidelines:
Low Gradient AS
• Special case
• Minimal valve mobility and low cardiac output
• Calculated valve area is small but pressure gradient is also small
• Functional vs. fixed AS?
• Consider dobutamine stress test (DSE) to clarify
ACC Classification of Recommendations:
Class I:
Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is useful and effective.
Class II:
Conditions for which there is conflicting evidence and/or a divergence of
opinionabout the usefulness/efficacy of a procedure or treatment.
IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb.
Usefulness/efficacy is less well established by evidence/opinion.
Class III:
Conditions for which there is evidence and/or general agreement that the
procedure/treatment is not useful/effective, and in some cases may be harmful.
Aortic Stenosis
Management Guidelines:
Recommendations for AVR
Class I
Severe AS and symptoms
Severe AS (with or without sxs) and need for CABG, other valve replacement
or aortic surgery
Class IIa
Moderate AS and need for other cardiac surgery
Asymptomatic severe AS and diminished LVEF or hypotensive response to
exercise
Aortic Stenosis
Management Guidelines:
Recommendations for AVR (cont.)
Class IIb
Asymptomatic AS and VT, severe LVH (>15mm)
or valve area <0.6 cm2
Class III
Asymptomatic AS with none of the above
CASE:A 52 yo salesman is referred to you for evaluation of a heart murmur. He
had applied for a pilot’s license and was denied because of the murmur. He is
5. asymptomatic and physically active. He denies chest pain, dyspnea or dizzy
spells and gives no history of a murmur being mentioned during his last physical
exam five years ago. He has no family history of heart disease. He has never had
high blood pressure or diabetes, doesn’t smoke, and takes no medications. A
lipid profile done five years ago was reported to be “OK”.
Physical Exam:
BP - 145/45 P - 78 reg RR - 12 Temp:98.6F
Carotids: Very brisk with sharp collapse
JVP: 5 with normal ‘a’ and ‘v’ waves
Lungs: Clear
Heart: Palpation: PMI is enlarged (4fb), in the anterior
axillary line
Auscultation:
S1 normal, S2 soft. A 2/6 early peaking systolic ejection murmur at
the upper RSB and a 3/6 holodiastolic blowing murmur, heard best
at the lower LSB when you ask the patient to hold his breath in
expiration and lean forward. There is a different 2/6 low-pitched
diastolic murmur at the apex.
Pulses are all very prominent and brisk; audible pulse over
the femoral arteries
Major Causes of Aortic Regurgitation:
Leaflet Dysfunction Aortic Root Dilation
Rheumatic fever Systemic hypertension
Endocarditis Dissecting aneurysm
Trauma Aortitis (syphilis)
Bicuspid aortic valve Reiter’s syndrome
Rheumatoid arthritis Ankylosing spondylitis
Myxomatous degeneration Ehlers-Danlos
Ankylosing spondylitis Osteogenesis imperfecta
Marfan’s syndrome Pseudoxanthoma elasticum
Fenfluramine-phentermine Marfan’s syndrome
Annulo-aortic ectasia
Physical Findings in Aortic Regurgitation:
Wide pulse pressure:
Bounding pulses
Soft aortic second sound (A2)
Early diastolic murmur (blowing) immediately after A2
Upper RSB with root dilation
Mid to lower LSB with leaflet dysfunction
Systolic murmur at base (similar to aortic stenosis)
Austin Flint murmur: mid to late diastolic “rumble” at apex
Some Really Neat Physical Findings in Severe Chronic Aortic Regurgitation:
♥ deMusset’s sign: Head bob with each systolic pulsation
♥ Corrigans’s pulses: “Pistol shot” pulses over femoral artery
♥ Mueller’s sign: Pulsation of the uvula
♥ Duroziez’s sign: Systolic/diastolic bruit over femoral arterY
6. ♥ Quincke’s pulses: Capillary pulsations seen in the nailbeds
♥ Becker’s sign: Pulsation of retinal arteries and pupils
♥ Hill’s sign: Popliteal BP exceeds brachial BP by > 60 mmHg
Pathophysiology of Chronic
Aortic Regurgitation:
♥ Slowly progressive diastolic volume overload
♥ Augmented stroke volume with rapid runoff
Increased systolic pressure with low
diastolic pressure: wide pulse pressure
♥ Progressive left ventricular dilation, some hypertrophy
♥ Increased diastolic compliance with maintenance of normal diastolic
pressures initially
♥ Late systolic failure with reduced ejection fraction and CHF
7. Additional Testing:
ECG: LVH with massive voltage in the lateral precordial leads (V4-V6)
Chest X-Ray: Large heart, predominant left ventricular enlargement. No
congestive heart failure.
Echo: Marked left ventricular dilation, estimated EF 65%. The end diastolic
dimension is 65 mm and the end diastolic dimension is 55 mm. Aortic valve:
bicuspid and thickened.
Doppler: Severe aortic regurgitation. The aorta is slightly enlarged (4.2 mm).
Acute Aortic Regurgitation:
♥ Sudden diastolic volume overload without LV dilation:
- Acute elevation in left ventricular diastolic pressure◊ pulmonary
edema
- Acute LV systolic failure ◊ hypotension
♥ Provide inotropic support, vasodilator therapy if tolerated, urgent valve
replacement
Natural History of Chronic
Aortic Regurgitation:
♥ Long asymptomatic phase; may be decades long.
♥ Left ventricular systolic dysfunction ( decline in EF)
NOTE!! LV dysfunction may occur in the absence of symptoms
♥ Symptoms associated with LV dysfunction:
- Exercise intolerance
- Dyspnea on exertion
♥ Angina (rare)
♥ Sudden death (rare)
Natural history of aortic regurgitation:
8. Aortic Regurgitation
Physiologic Principles-Natural History:
• LV faces combined pressure and volume load
• Primary adaptation is dilatation (eccentric hypertrophy)
• Since this adaptation takes time, AR classified as acute or chronic
• Acute AR results in sudden increase in LVEDP >>> pulmonary edema and
cardiogenic shock
Aortic Regurgitation
Physiologic Principles-Natural History:
• Latent phase of AR, like AS, may last decades
• Decompensation when
• LV systolic function begins to fail
• Progressive LV dilatation occurs
• Spherical geometry develops
• Initially this is reversible
• LV systolic function and ESD are the most important predictors of postop
survival and LV function
Aortic Regurgitation
Physiologic Principles-Natural History
• In asymptomatic pts with severe AS and nl LV systolic function, progression
is slow
• 4.3%/yr develop symptoms of LV systolic dysfunction
• 1.3%/yr progress to LV dysfunction without symptoms†
pooled data from 7 series. 490 pts with mean follow-up of 6.4 yrs
Aortic Regurgitation
Management Guidelines:
Scheduled Follow-up (office and echo)
Severe AR without symptoms
• q 4-12 month depending on pace of change and current LV ESD/EDD
Moderate AR without symptoms
• 1st follow-up in 2-3 months to establish pace, then ~ q 12 months
9. Aortic Regurgitation
Management Guidelines:
Vasodilator Therapy
• Expected to ι afterload, η stroke volume and
ι regurgitant volume
• Hemodynamic benefit shown with hydralazine and nifedipine, less consistent
results with ACEi
• Improvement in clinical outcomes in trial of LA nifedipine vs. digoxin (need
for AVR in 143 pts followed for 6 yrs--- 15% vs 34%)
• Dose titrated to achieve ι in SBP, not normalization
Aortic Regurgitation
Management Guidelines:
Vasodilator Therapy Indications
Class I
• Severe AR with symptoms or severe LV dilatation but contraindications to
surgery
• Severe AR without symptoms but LV dilatation and elevated SBP
• Any degree of AR with hypertension
• Persistent LV systolic dysfunction s/p AVR (ACEi)
• Short term therapy prior to AVR
Aortic Regurgitation
Management Guidelines:
Vasodilator Therapy Indications
Class III
• Mild to mod AR without sxs and nl LV function
• In lieu of AVR in pts without contraindications
Aortic Regurgitation
Management Guidelines:
Recommendations for AVR (chronic severe AR)
Class I
• NYHA functional class III or IV sxs
• NYHA functional class II sxs and progressive LV dilatation or declining
LVEF on serial studies
• CCS class II angina
• Mild or moderate reduction in EF (25-50%)
• Need for CABG or surgery on other valves
Aortic Regurgitation
Management Guidelines:
Class IIa
• NYHA class II sxs with nl LVEF (>50%) with stable EF, LV size and exercise
tolerance
• Asymptomatic pts with nl LVEF but severe LV dilatation (ESD > 55 mm or
EDD > 75 mm)
Class IIb
• LVEF < 25%
10. • Asymptomatic pts with nl LVEF and progressive LV dilatation with ESD 50-
55
Valvular Heart Disease
Mitral Stenosis
A 75 year old woman with loud first heart sound and mid-diastolic murmur:
• Chronic dyspnea Class 2/4
• Fatigue
• Recent orthopnea/pnd
• Nocturnal palpitation
• Pedal edema
Mitral Stenosis:
• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery
Mitral Stenosis: Etiology:
• Primarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic damage )
• Scarring & fusion of valve apparatus
• Rarely congenital
• Pure or predominant MS occurs in approximately 40% of all patients with
rheumatic heart disease
• Two-thirds of all patients with MS are female.
Mitral Stenosis:
Pathophysiology
• Normal valve area: 4-6 cm2
• Mild mitral stenosis:
• MVA 1.5-2.5 cm2
• Minimal symptoms
• Mod mitral stenosis
• MVA 1.0-1.5 cm2 usually does not produce symptoms at rest
• Severe mitral stenosis
• MVA < 1.0 cm2
Mitral Stenosis: Symptoms:
• Fatigue
• Palpitations
• Cough
• SOB
• Left sided failure
• Orthopnea
• PND
11. • Palpitation
• Afib
• Systemic embolism
• Pulmonary infection
• Hemoptysis
• Right sided failure
• Hepatic Congestion
• Edema
• Worsened by conditions that cardiac output.
• Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy,
thyrotoxicosis
Recognizing Mitral
Stenosis
Palpation:
• Small volume pulse
• Tapping apex-palpable S1
• +/- palpable opening snap (OS)
• RV lift
• Palpable S2
ECG:
• LAE, AFIB, RVH, RAD
Auscultation:
• Loud S1- as loud as S2 in aortic area
• A2 to OS interval inversely proportional to severity
• Diastolic rumble: length proportional to severity
• In severe MS with low flow- S1, OS & rumble may be inaudible
Mitral Stenosis: Physical Exam
• First heart sound (S1) is accentuated and snapping
• Opening snap (OS) after aortic valve closure
• Low pitch diastolic rumble at the apex
• Pre-systolic accentuation (esp. if in sinus rhythm)
Common Murmurs and
Timing (click on murmur to play)
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
Auscultation-
Timing of A2 to OS Interval:
• Width of A2-OS inversely correlates with severity
12. • The more severe the MS the higher the LAP the earlirthe LV pressure falls
below LAP and the MV opens
Mitral Stenosis: Natural History:
• Progressive, lifelong disease,
• Usually slow & stable in the early years.
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to symptom onset.
• Additional 10 years before disabling symptoms
Mitral Stenosis: Complications:
• Atrial dysrrhythmias
• Systemic embolization (10-25%)
• Risk of embolization is related to, age, presence of atrial fibrillation, previous
embolic events
• Congestive heart failure
• Pulmonary infarcts (result of severe CHF)
• Hemoptysis
• Massive: 20 to ruptured bronchial veins (pulm HTN)
• Streaking/pink froth: pulmonary edema, or infection
• Endocarditis
• Pulmonary infections
Mitral Stenosis: EKG:
• LAE
• RVH
• Premature contractions
• Atrial flutter and/or fibrillation
• freq. in pts with mod-severe MS for several years
• A fib develops in ≈ 30% to 40% of pts w/symptoms
A 75 year old woman with loud first heart sound and mid-diastolic murmer:
13. Mitral Stenosis: Role of Echocardiography:
• Diagnosis of Mitral Stenosis
• Assessment of hemodynamic severity
• mean gradient, mitral valve area, pulmonary artery pressure
• Assessment of right ventricular size and function.
• Assessment of valve morphology to determine
suitability for percutaneous mitral balloon valvuloplasty
• Diagnosis and assessment of concomitant valvular lesions
• Reevaluation of patients with known MS with changing symptoms or signs.
• F/U of asymptomatic patients with mod-severe MS
Mitral Stenosis:Therapy:
14. • Medical
• Diuretics for LHF/RHF
• Digitalis/Beta blockers/CCB: Rate control in A Fib
• Anticoagulation: In A Fib
• Endocarditis prophylaxis
• Balloon valvuloplasty
• Effective long term improvement
Recommendations for Mitral Valve Repair for Mitral Stenosis:
• ACC/AHA Class I
• Patients with NYHA functional Class III-IV symptoms, moderate or severe
MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for
repair if percutaneous mitral balloon valvotomy is not available
• Patients with NYHA functional Class III-IV symptoms, moderate or severe
MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for
repair if a left atrial thrombus is present despite anticoagulation
• Patients with NYHA functional Class III-IV symptoms, moderate or severe
MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with
the decision to proceed with either repair or replacement made at the time of
the operation.
Recommendations for Mitral Valve Repair for Mitral Stenosis:
• ACC/AHA Class IIB
• Patients in NYHA functional Class I, moderate or severe MS (mitral valve
area <1.5 cm 2 ),* and valve morphology favorable for repair who have had
recurrent episodes of embolic events on adequate anticoagulation.
ACC/AHA Class III
Patients with NYHA functional Class I-IV symptoms and mild MS.
*The committee recognizes that there may be a variability in the measurement
of mitral valve area and that the mean trans-mitral gradient, pulmonary artery
wedge pressure, and pulmonary artery pressure at rest or during exercise should
also be considered.
Mitral Stenosis
Physiology/Natural History:
• Normal MVA 4 -5 cm2
• Symptoms not apparent until area < 2.5 cm2
• valve area (cm sq) mean gradient (mmHg)* Mild > 1.5
< 5
Moderate 1.0 - 1.5 5 -10
Severe < 1.0 > 10
Mitral Stenosis
Physiology/Natural History:
• Akin to severe diastolic dysfunction
• V = IR (electrical)
• P = QR (hydraulic)
• Q = P/Rvalve
15. Mitral Stenosis
Physiology/Natural History:
• LA pressure → PV pressure → interstitial edema → ± alveolar flooding
• Adaptations:
-pulmonary vascular constriction, intimal hyperplasia, medial hypertrophy
→ reversible pulmonary hypertension → ± fixed pulm htn
-downregulation of neuroreceptors, lymphatic drainage
Mitral Stenosis
Physiology/Natural History:
• Latent (subclinical) phase in RHD 20-40 yrs
• 10 yrs of symptoms before disabling
• With physically limiting symptoms
• 10 yr survival 0-15%
• 10-20% systemic embolism
• 30-40% develop AF
• With onset of severe pulm hypertension
• Mean survival < 3 yrs
Mitral Stenosis
Management Guidelines:
Initial Evaluation
• History
• Physical
• ECG
• CXR
• Echocardiogram
• ± Exercise echocardiogram
Mitral Stenosis
Management Guidelines:
Medical Therapy
• Rheumatic fever prophylaxis
• Infective endocarditis prophylaxis
• Limitation of strenuous physical activities
• Control of HR (negative chronotropes)
• Na restriction, intermittent diuretic use
• Prompt management of AF
Mitral Stenosis
Management Guidelines:
Interventional and Surgical Options
• Percutaneous mitral balloon valvotomy (PMBV)
• Closed commissurotomy (obselete)
• Open commissurotomy
• Mitral valve replacement
Mitral Stenosis
Management Guidelines:
16. Indications for PMBV (class I and IIa)
• Suitable anatomy, no LA clot, ≤ mild MR
• Symptomatic pts (NYHA class II-IV) with MVA <1.5 cm2
• Asymptomatic pts with MVA <1.5 cm2 and PASP 50 mmHg at rest, 60 with
exercise
Mitral Stenosis
Management Guidelines:
Indications for MVR (class I and IIa)
• Symptomatic pts (NYHA class III and IV) with MVA < 1.5 cm2 unsuitable
for PMBV
• NYHA class I and II pts with MVA < 1.0 cm2 and PASP >60 at rest
unsuitable for PMBV
Acute Mitral Regurgitation
Management Guidelines:
Medical Stabilization (while gathering OR team)
• If normotensive: nitroprusside
• If hypotensive: nitroprusside + dobutamine or
intra-aortic balloon pump (IABP)
Case 4
• On exam:
• obese, loquacious man with petite wife
• HR 86. BP 170/94. BMI 45.
• JVP 12 cm H2O. Nl carotid upstrokes
• diminished bs, no crackles
• apical impulse not palpable
• Neither S1 or S2 are well heard, obscured by a holosystolic blowing murmur
at apex and left parasternal border
Case 4:
• ECG:
• SR, RAD, LA abn, R>S in V1, NSSTT abn
• CXR:
• LA and LV enlargement
• Echo:
• severe LA enlargement, mild LV dilatation (ESD 45mm), nl LVEF (60%),
pulmonary hypertensio (est PASP 55 mmHg)
Chronic Mitral Regurgitation
Physiology and Natural History:
• Gradual development allows adaptation
• LA dilatation and increase in compliance
• LV dilatation and EF (via preload and ↓ afterload) → maintenance of
forward SV
• Compensation often adequate for vigorous exercise
• May last many years
17. Chronic Mitral Regurgitation
Physiology and Natural History:
• Eventually, volume overload → LV decompensation
• Preop LVEF (>60%) and LVESD (<45 mm) are primary predictors of
postop survival
Acute Mitral Regurgitation
Physiology and Natural History:
• Abrupt volume load---no time for adaptation
• Sudden ↓ in forward stroke volume
• Sudden in LA volume/pressure → PV pressure
• Rapidly fatal
Chronic Mitral Regurgitation
Management Guidelines:
Initial evaluation
• History
• Physical Exam
• ECG
• CXR
• Echo
• ± Exercise echo
Chronic Mitral Regurgitation
Management Guidelines
Scheduled Follow-up*
Instruct all pts to report any cv symptoms
office intervalecho interval
Mild MR 12 mos if sxs
Moderate MR 12 mos 1-2 yrs
Severe MR 6-12 mos 6-12 mos**
Chronic Mitral Regurgitation
Management Guidelines:
Medical Therapy
• No generally accepted rx in asymptomatic pts
• No long term studies suggesting benefit of afterload reduction in absence of
hypertension
• ACEi if hypertensive
• AF requires rate control, anticoagulation and 1 attempt at restoration of SR
Chronic Mitral Regurgitation
Management Guidelines:
Surgical Options
• Mitral valve repair
• Mitral valve replacement with preservation of subvalvular apparatus
• Mitral valve replacement with excision of subvalvular apparatus
• MVR with CABG (in ischemic MR)