BOLDED STUFF IS TESTABLE
Vascular Valve Disease
Picture – valves with atria removed
Largest valve is the tricuspid valve –...
LEFT VENTRICULAR EJECTION FRACTION – Diagnostic of
Ventricular Efficiency  Normal Value is 55% anything less is impaired ...
When you have a heart valve that is compromised or stenosed  same amount of blood
needs to get though  velocity must inc...
Bicuspid Aortic Valve  After years covered with calcium deposits.
Degenerative Valves has problems with the cusps  degen...
In an older person – 70’s and 80’s – give a tissue valve  no blood thinners required as
long as they have a regular rhyth...
When mitral valve opens it makes a snapping noise and followed by a diastolic rumble.
After the second heart sound and a l...
Heart Failure
Fatigue
Weakness
Most common cause of microregurgitation
Mitral prolapse
Ischemic heart disease
Endocarditis
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Valvular Heart Disease notes.doc

  1. 1. BOLDED STUFF IS TESTABLE Vascular Valve Disease Picture – valves with atria removed Largest valve is the tricuspid valve – separates right ventricle and atria Next to largest valve is mitral valve (normal size is needed to determine if (4cmxcm) intervention is needed. All four valves are together in the Annulus Fibrosis AORTIC VALVE The coronary arteries come from the Sinus of valsalva  Aortic Valvue have three leaflets  form sinuses of valsalva  two coronary arteries Fine lines are commisures – smallest valve in the heart (3 cmxcm) PULMONIC VALVE In front of the aortic valve CARDIAC CYCLE: Left atrial pressure 5-10 mmHg Pressure wave forms from the Left Atrium via a catheter Sorry was doing camera work There is a time interval between closing of the aortic and opening of the mitral valve. Mitral valve is getting leaky  sounds are in systole Murumur due to a leaky mitral valve  will begin at the beginning of systole, will continue all the way until atrial pressure overtakes ventricular pressure Systolic mitral prolapse will begin before aortic stenosis begins. Left ventricle is beginning to contract, mitral is closed first heart sound. Throughout systole not murmur  as systole completes the aortic valve closes  blood rushes back toward ventricle but the aortic valve closes causing the second heart sound. Then the ventricle begins filling up with blood  usually doesn’t make sound due to the quietness. During systole we have a QRS, and P wave is diastole. LEFT VENTRICLE: Ejection Fraction = EDV – ESV/EDV Function of the ventricle determines the ability to provide contractility and eject the proper blood volume. How do we asses ventricular function? If we had abilities to asses ventricular volume – we would be able to detect ventricular abilities/function.
  2. 2. LEFT VENTRICULAR EJECTION FRACTION – Diagnostic of Ventricular Efficiency  Normal Value is 55% anything less is impaired left ventricular systolic function. How to determine Systolic Function of the Left Ventricle. Our range of hearing is in thousands (small thousands) – Millions of cycles per second that is ultrasound. ECHO CARDIOGRAM – Most valvuable and frequently used instrument in diagnosis of Coronary Heart Disease. So good, often it is the only test needed for a diagnosis. Sends out a sound wave – millions of cycles per second. Every 1/1000 of a second a sound wave is transmitted – 999/1000 it becomes a receiver. Bounces off the pericardium, pericardial fluid (30cc), epicardium, myocardium, endocardium, cavity fluid, bounces off the valves (movement, structure, clots in the heart, cancer, etc.). Doppler the red blood cells – ECHO shows us the heart in real time Two types of machines 1) transthoracic – TTE transthoracic through the skin and down into the body 2) transesophageal - for people who have big lungs COPD there is a transducer that can be swallowed a TEE transesophageal echo Almost like a CAT SCAN cross-section – TTE Uses a little paste to help the waves be transmitted – impinges on all structures – waves are reflected back. The first tissue layer seen is the Right Ventricle. If Right Atrium is very large, huge positive p wave deflection If Left Atrium is very large, huge negative p wave deflection Next structure is the Interventricular septum  it’s a portion of the left ventricle If the ultrasound shows that its still  usually ischemic If ventricular wall is thick, may be due to HTN etc. The newer chips will show a larger wave of window view – a pie shaped view showing live time movement of the heart. When looking at a stenotic valve  its not enough to see it thick and not move. How stenotic or leaky is that valve? The ECHO will give us an anatomical idea but you need to use the Doppler to get a functional idea of what is going on. DOPPLER – bounces off red blood cells Tells us the velocity of the blood by bouncing off the red cells in cm/sec
  3. 3. When you have a heart valve that is compromised or stenosed  same amount of blood needs to get though  velocity must increase causing a vibration of the valve  causing a murmur and a thrill. Echo will show us the velocity. MITRAL STENOSIS CAUSED BY Rhematic Heart Disease When blood vessel or valve gets thinner  the Doppler signal will become narrow and increase in amplitude. This is due to turbulance. Velocity on ventricular side and has to get though a narrow orafice so the velocity increases. If we know what the velocity on the right side of the valve we can estimate the degree of stenosis. Velocity across the valve (Pi-Po) pressure gradient. (Normal is 1 mmHg no significant gradient is normal). For absolute pressure you need to insert a tube into the heart. Velocity squared and multiplied by four. Add the new Pressure to his systolic pressure and that is the Ventricular Systolic Pressure. Red blood cells going away from the Doppler/Ultrasound transducer (its going away through the aorta). This produces a negative deflection. Detect the speed and square it and multiply by four. Away will be blue, towards will be yellow. Positive deflection after ventricular systole, is evident of aortic regurgitation. Aortic Stenosis with Aortic regurgitation. There should be no positive signal. The negative deflection should be about 1 m/sec. Question is going to be Equation for Pressure Gradient and a situation for test question? The Doppler signal doesn’t tell you the pressure in the aorta and the ventricle. It just tells you the pressure/velocity difference across the aortic valve. That pressure added to the systolic blood pressure = the ventricular systolic pressure. Doppler describes the pressure gradient. AORTIC VALVE DISEASE: Upside down Mercedes benz sign – two coronary cusps and one non-coronary cusp. When the aortic valve opens, valves spread apart  very thin. Very low blood supply. Usually doesn’t have a blood supply. You take a homograft (cadaver) and inplant it into another person and it survives. If it had vessels it wouldn’t survive. Bicuspid Semilunar Valve. When they are pushed around they become thicker, then they become ridgid and calcified  then symptoms arrive. Rhumatic Aortic Valve – Calcium deposition around the commisures. Caused by autoimmune reaction  myocarditis and pericarditis Once resolved it leaves the patient with thick valves.
  4. 4. Bicuspid Aortic Valve  After years covered with calcium deposits. Degenerative Valves has problems with the cusps  degenerative trileaflet valve is the most common cause of aortic stenosis in the old population Most common cause of aortic stenosis in young people is bicuspid aortic stenosis. The new theory – shown over and over again that the risk factors for atherosclerosis are much higher in those people who have trileaflet degenerative valve disease. Place them on Statins, eat well, folic acid, etc. Same risk factors. When valves become thicker, they don’t open or close very well  could be the one in the Doppler exaple. Aortic Stenosis  those less than 70 years old most frequent cause is bicuspid Over 70 most frequent for stenosis of aortic valve is trileaflet degenerative aortic valve. Rigormortis – No ATP  no ATP to allow those myosin heads from separating from the actin filaments. Ventricle may not squeeze well resulting in low ejection fraction– systole  Ventricular Failure Ventricle may not squeeze and may not relax as well  Blood backs up into the lungs  diastolic failure Both can happen from aortic stenosis. MAJOR Clinical SIGNS AND SYMPTOMS OF aortic stenosis Fainting Heart Pain Angina Heart Failure Dimond shaped murmur  palpable thrill aortic stenosis. Right after first heart sound and ends at the last heart sound. As soon as patient has clinical symptoms of aortic stenosis  death within a couple years The findings that give worst prognosis is that of heart failure. If you faint or have angina you will still be doing bad but not as bad as if you had heart failure. Tissue valves in younger people don’t last very long  calcified easier. The prosthetic valve lasts longer about 20 years – Have to be on blood thinners the rest of the lives.
  5. 5. In an older person – 70’s and 80’s – give a tissue valve  no blood thinners required as long as they have a regular rhythm. AORTIC REGURGITATION Bacteria and fungus chew on them  perforations positive diastolic deflection Bicuspid, infective, Rheumatic Valves can all be regurgitive. Sometimes the fibrous ring will dilate not allowing the leaflets to touch. Marfan’s  weak connective tissue  aneurysms of aortas. Females die in Postpartum with marfan’s. MURMUR of AORTIC REGURGITATION Exists in Diastole Decrescendo after the second sound and ends at S1. The pulse pressure is Huge 140/35 – bounding pulse Perforation of valve  Endocarditis (higher in those that use IV drugs) Look for petichial hemorrhages, jaundice, weight loss, fever, etc. MITRAL STENOSIS – The Left Ventricle is typically okay Once you tweak a valve  not good Little abnormalities will become large KNOW THE JONES STUFF FROM GILBERT FOR RF Reoccurance is somewhat high once you have had RF. Left Ventricle and Left atrium  four pulmonary veins lead to Left Atrium. Pathway to the lungs is via the Right Atrium and Right Ventricle. Over time the Right atrial pressure increases. Right ventricle protects itself from pressure by thickening its wall. Pulmonary arteries become very thick due to increase in the pressure. Right Ventricular Hypertrophy. MITRAL STENOSIS Heart Failure Edema Systemic Emboli Short of Breath MURUMUR OF MITRAL STENOSIS
  6. 6. When mitral valve opens it makes a snapping noise and followed by a diastolic rumble. After the second heart sound and a little after until the mitral valve snaps open. Know the difference between this and sound of aortic regurgitation. If you allow the Diastole to be much longer you can minimize that pressure gradient. Give Beta Blockers to slow the heart down and lengthen the diastole. If not severe. If no operation – 7 years they are dead Treatment of Mitral Stenosis – valvuloplasty  like angioplasty. If the valve is ridgid 1 point If the vavle is really rigid 4 points Calcium really bad is 4 points Chordae tendinae 1- 4 Best case 4 points total Worst case 16 points total If you get an echo score of 8 points or less  balloon valvulo plasty. Same prognosis if the valve is opened or better than a replaced valve. Perforate the interatrial septum with a needle and put a tube into it and use this tube to put a balloon across the mitral valve… cracks the commisures. Mitral stenosis will be reduced. If you crack the leaflets – you cause a microregurgitation. Above 8 will need surgical intervention. Too risky to crack the valve. MICROREGURGITATION – Most common valve abnormality All over the place – almost everyone has a little leak here and there. Degree of leak is abnormal, not leaking. Papillary muscles bind to the ventricle. The leaflets are floppy or the chordae snap, leaflets tears loose, papillary muscles are infracted, dilatation of the ventricle and ring pull the leaflets apart. MITRAL VALVE REGURGITATION Left Ventricle  Left atrium the pressure goes really high. Left atrium dilates because of ventricular pressure. Pressure generated by the atrium is very small. Pressure goes way up during systole. High in the pulmonary veins and the pulmonary arteries  pulmonary edema. SYSTOLIC MITRAL REGURGITATION Begins when Left ventricle overtakes the Left atrium and continues though the second heart sound. No heart sounds… lost in the murmur.
  7. 7. Heart Failure Fatigue Weakness Most common cause of microregurgitation Mitral prolapse Ischemic heart disease Endocarditis

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