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
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)
In front of the aortic valve
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.
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
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
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,
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
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
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
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
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.
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.
those less than 70 years old most frequent cause is bicuspid
Over 70 most frequent for stenosis of aortic valve is trileaflet degenerative aortic
Rigormortis – No ATP no ATP to allow those myosin heads from separating from the
Ventricle may not squeeze well resulting in low ejection fraction– systole
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
Heart Pain Angina
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
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.
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
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
Short of Breath
MURUMUR OF MITRAL STENOSIS
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
If you crack the leaflets – you cause a microregurgitation. Above 8 will need surgical
intervention. Too risky to crack the valve.
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
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.
Most common cause of microregurgitation
Ischemic heart disease