this lecture covered the various valvular disorders that can occur in the heart. in general, each of the four main valves can have two main dysfunctions; either blood flowing in the opposite direction when the valve should be closed (retrograde flow causing regurgitation) or blood flowing through in the right direction being blocked by a tight valve when it should be open. the mitral valve also has a third variation called mitral valve prolapse where the valve leaflets actually blow back into the left atrium when they should be closed.
aortic regurgitation is retrograde blood flow from the aorta to the left ventricle during diastole and has a number of etiologies: myxomatous degeneration (accumulation of glycosaminoglycans on the valve), rheumatic fever, endocarditis (and can also cause a predisposition to endocarditis), congenital bicuspid valve (two leaflets instead of three). it can lead to left ventricular dilation and hypertrophy, and the symptoms can include DOE, fatigue, syncope, chest pain, cardiogenic shock, frank CHF. it sounds like a high pitched blowing decrescendo diastolic murmur heard best in the 3rd/4th interspace with the patient leaning forward with held expiration.
aortic stenosis is the loudest of all the murmurs, a crescendo-decrescendo systolic murmur which is caused by aged valves, RF, or congenital bicuspid valve. it resembles and shares risk factors with atherosclerosis and might lead to left ventricular hypertrophy and eventually left heart failure. the hallmark symptoms are syncope, angina, DOE, arrhythmias. the murmur is so loud it radiates to the right clavicle and carotid and can be enhanced further if the patient does the valsalva maneuver.
mitral valve prolapse, as described above, occurs when the leaflets of the mitral valve are compromised by myxomatous degeneration (or simply weakened chordae tendonae or papillary muscles) and billow back into the left atrium during systole. people with marfan's, or severe dehydration are at higher risk for MVP, as are pregnant ladies. symptoms reflect inefficient pumping of blood to the body, and include orthostatic hypotension, fatigue, palpitations, arrhythmias, dyspnea. patients with MVP might have pectus excavatum (caved in chest) or decreased AP chestwall diameter, hypomastia, or a straight back.
the next mitral valve dysfunction is mitral regurgitation, retrograde flow from the left ventricle to the left atrium during systole. this is a relatively common murmur, seen especially in males, and is sometimes co-exists with other mitral valve dysfunction such as prolapse and stenosis. mitral regurgitation can be caused by a number of different sources such as infection (RF, endocarditis), muscle dysfunction (chordae tendonae or papillary muscles), or dilation of the annular muscle or left ventricle. eventually it will lead to left heart hypertrophy and LV failure. it sounds like a holosystolic blowing sound and is best heard at the apex in the left lateral decubitus position. in addition to screening with echo and ECG, CXR can be helpful for diagnosis to reveal pulmonary edema and hypertrophy.
mitral valve stenosis is the last dysfunction of the mitral valve and is obstructed blood flow from the left atrium to the left ventricle during diastole, most commonly caused by rheumatic fever. compared to the other mitral dysfunctions, there is an increased risk for developing atrial fibrillation, because the extra blood volume in the left atrium will lead to atrial dilation and hypertrophy, distorting the myocardium and increasing the potential for re-entry and disrupted conduction pathway. if atrial hypertrophy occurs, the ECG will detect this with notched or wide P waves. symptoms include exertional fatigue, dyspnea, tachycardia, fever (if infectious origin), arrhythmia, PND, p.edema. the murmur itself will sound like a diastolic murmur with an opening snap and may have a loud S1 as well. treatment is similar to that of mitral regurgitation or CAD.
pulmonary valve regurgitation is retrograde blood flow from the pulmonary artery to the right ventricle on diastole and generally occurs due to pulmonary artery dilation that results from pulmonary hypertension. it can be asymptomatic, or mimic RCHF symptoms. the murmur is a high pitched blowing diastolic murmur (recall that the analogous murmur on the left side, aortic regurgitation, has the same description) which is best heard on the left upper sternal border.
pulmonic stenosis occurs when blood flow from the left ventricle is blocked when passing through the pulmonic valve during systole, creating a widened S2 sound, crescendo-descresendo murmur, and possible early systolic click that is best heard in the 2nd left interspace during inspiration. it is generally due to a congenital defect and usually affects children. it might also remain undetected for years and then manifest as aortic stenosis symptoms (syncope, angina, dyspnea). other clinical features might include right ventricular hypertrophy, heaving/thrills, jugular waves. pulmonic stenosis is best diagnosed through echo and ECG, which might detect a RBBB (see the arrhythmia lecture notes) or hypertrophy. severe cases of pulmonic stenosis might require balloon valvuloplasty.
tricuspid regurgitation is retrograde flow from the RV to the RA during systole. it can be secondary to atrial fibrillation and RV dilation and is usually asymptomatic. eventually tricuspid regurgitation might lead to right heart enlargement and RCHF symptoms, as pulmonary regurgitation does. it is a blowing, pansystolic murmur, (similar to its analog on the left side, mitral regurgitation) that is heard best on the right/left lower sternal border during inspiration. the ECG might show RV overload signs or RA hypertrophy.
the last valvular dysfunction is tricuspid stenosis, blocked flow from the RA to the RV during diastole. like mitral stenosis, the main cause is RF, but may be congenital as well. symptoms are also similar to mitral stenosis and may also resemble RCHF. it can in fact be seen in combination with mitral stenosis and tricuspid regurgitation. the sound is a short scratchy diastolic murmur best heard on the R/L lower sternal border during inspiration. like tricuspid regurgitation, the ECG tricuspid stenosis might also show RA hypertrophy.
questions
aortic regurgitation...
1. what is aortic regurgitation?
2. what is aortic regurgitation due to? √ √
3. aortic regurgitation can lead to...
4. what are the symptoms of aortic regurgitation? † † † √
5. aortic regurgitation predisposes patients to which condition?
6. what will aortic regurgitation sound like upon auscultation? † † √ †
7. where is the aortic regurgitation murmur loudest? how is it best heard? √ √
aortic stenosis...
8. what is aortic stenosis and what commonly causes it? † † X
9. what condition does aortic stenosis resemble and share risk factors with?
10. aortic stenosis might result in... † √ √
11. what are the hallmark symptoms of aortic stenosis? √ √
12. what does the aortic stenosis murmur sound like? √ √
13. where can you hear an aortic stenosis murmur? √ √
14. what can the patient do to increase the volume of the aortic stenosis murmur? X
15. when is surgery necessary for aortic stenosis?
mitral valve prolapse...
16. what is mitral valve prolapse?
17. mitral valve prolapse is usually due to... X X † √
18. mitral valve prolapse is sometimes seen with what conditions? √
19. what are the symptoms of mitral valve prolapse? √ † √
20. what are the usual sounds heard with mitral valve prolapse? √ √
21. what are some common PE findings of patients with mitral valve prolapse? √ √
22. how is the diagnosis of mitral valve prolapse made?
mitral valve regurgitation...
23. what is mitral valve regurgitation?
24. how common is this condition and which gender is it more common in? √
25. what are the common causes of mitral valve regurgitation? † √
26. mitral valve regurgitation may co-exist with what other conditions? √ √
27. what might the progression of mitral valve regurgitation lead to? X √ √
28. what does mitral valve regurgitation sound like? √ √ √
29. how is the mitral valve regurgitation murmur best heard? √ √
30. what are the tests used to diagnosis mitral valve regurgitation? √ √
31. what is the standard naturopathic treatment for mitral valve regurgitation?
mitral stenosis...
32. what is mitral stenosis?
33. what is the most common cause of mitral stenosis? √ √
34. how can mitral stenosis lead to atrial fibrillation? √
35. what are the symptoms of mitral stenosis? √ √ X
36. what does mitral stenosis sound like? √ X †
37. what does the ECG of mitral stenosis look like? √ √
38. what is the naturopathic approach to treatment of mitral stenosis?
pulmonic regurgitation...
39. what is pulmonic regurgitation?
40. what is pulmonic regurgitation usually caused by? √ √
41. pulmonic regurgitation is rarely seen as a primary disease except with what condition? √ √
42. what are the symptoms of pulmonic regurgitation? † † √ √
43. what does pulmonic regurgitation sound like? where is it best heard? √ † √
pulmonic stenosis...
44. what is pulmonic stenosis?
45. pulmonic stenosis is usually due to __ and affects mostly __.
46. what is the symptom picture for patients with pulmonic stenosis? X †
47. pulmonic stenosis might result in what clinical features? √ √
48. what does pulmonic stenosis sound like? X † † X
49. where is the pulmonic stenosis murmur best heard and when is it loudest? √
50. diagnosis of pulmonic stenosis is made through... X X √
51. what type of treatment might be needed with severe cases of pulmonic stenosis? √
tricuspid regurgitation...
52. what is tricuspid regurgitation?
53. tricuspid regurgitation can be secondary to which conditions? X † √
54. what are the symptoms of tricuspid regurgitation? X √ X
55. tricuspid regurgitation may lead to... √
56. what does tricuspid regurgitation sound like? √ √
57. where is the tricuspid regurgitation murmur best heard and when is it loudest? √
58. ECG of tricuspid regurgitation might show... √
tricuspid stenosis...
59. what is tricuspid stenosis?
60. what is the most common cause of tricuspid stenosis? √
61. what is the symptom picture of tricuspid stenosis? †
62. tricuspid stenosis can be seen with what other conditions? √
63. what does tricuspid stenosis sound like? √
64. where is the tricuspid stenosis murmur heard best and when is it loudest? √
65. an ECG of tricuspid stenosis might show...
answers
1. retrograde flow from the aorta to the left ventricle during diastole.
2. idiopathic valve degeneration, myxoma, rheumatic fever, endocarditis, congenital tricuspid valve. [arrrr- idiot! you mixed the kangaroo card with the genitals!!]
3. left ventricular hypertrophy and dilation.
4. asymptomatic for decades, then develop DOE, fatigue, syncope, chest pain, arrhythmias, frank CHF, cardiogenic shock. [ar. ARR. de fat sin is frankly, painful and shocking]
5. endocarditis.
6. high pitched, blowing, decrescendo diastolic murmur.
7. 3rd/4th left interspace; heard best with patient leaning forward with held expiration.
8. narrowing of the aortic valve during systole blocks outflow of blood. caused by congenital bicuspid valve, RF, or aging. [ASS:old roof bike]
9. atherosclerosis.
10. ventricular hypertrophy, diastolic/systolic dysfunction, then heart failure.
11. syncope, angina, DOE, arrhythmias. [ASS:SAAD]
12. the loudest murmur of all conditions, happens during systole in a crescendo-decrescendo shape.
13. pulmonic area, sound radiates to right clavicle and neck with thrills and bruits.
14. valsalva.
15. if the valve area is less than 1 cm2, or if patient is severely symptomatic.
16. billowing up of the mitral valve leaflets during systole.
17. myxomatous degeneration, or stretched papillary muscles / chordae tendonae.
18. marfan's, dehydration, pregnancy.
19. usually asymptomatic, but may see fatigue, orthostatic hypotension, chest pain, dyspnea, palpitations, arrhythmias. "anxiety occurs frequently with unclear causative relationship" [MVP of tiredness; lie down on a P.A.D.]
20. late systolic murmur and midsystolic click.
21. pectus excavatum, hypomastia, narrow AP chest diameter, straight back.
22. echocardiogram with holter monitor or 12 lead ECG to detect associated arrhythmias.
23. mitral valve dysfunction causing retrograde blood flow into left atrium from left ventricle during systole.
24. common, more common in males.
25. infectious endocarditis, RF, papillary muscle damage, ruptured chordae tendiae, LV dilation, annular dilation. [MoVe'ing infection refers the pope to rupture the deal with anne] [dilation dilation damage damage infection infection]
26. mitral stenosis or mitral valve prolapse.
27. LV and LA hypertrophy and the resulting fatigue, dyspnea and LV failure.
28. blowing holosystolic murmur.
29. at the apex when the patient is in left lateral decubitus position.
30. echo, ECG, CXR (for pulmonary edema and hypertrophy).
31. general treatments which strengthen connective tissue and improve valve function.
32. narrowed, calcified mitral valve which impedes blood flow from left atrium to left ventricle.
33. rheumatic fever.
34. because blocked blood flow from left atrium will lead to atrial dilation which will cause distortion in the myocardium, causing re-entry of the conduction pathway and might ultimately cause fibrillation.
35. when severe: exertional fatigue, dyspnea, tachycardia, fever and arrythmia, PND, pulmonary edema. [miss exercise dissed the take five rhythm; pound the pedal!] [tired tachy achy arry peey p.edey]
36. opening snap, diastolic murmur, loud S1.
37. notched or wide P waves due to atrial hypertrophy.
38. natural treatment similar to that of CAD and regurgitant valves.
39. incompetent pulmonic valve leading to retrograde blood flow from pulmonary artery into right ventricle during diastole.
40. pulmonary artery dilation from pulmonary hypertension.
41. ventricular septal defect.
42. usually asymptomatic or symptoms of RCHF.
43. high pitched diastolic murmur in the upper left sternal border.
44. obstructed blood flow from right ventricle through pulmonic valve during systole.
45. congential, and affects mostly children.
46. usually asymptomatic, then may present with aortic stenosis symptoms. (angina, syncope, dyspnea)
47. RV hypertrophy, prominent jugular pulse wave, RV heave/thrill. [psst- hyper heaving jugs to the right]
48. widened S2 splitting, maybe early systolic click. harsh crescendo-decrescendo murmur.
49. left 2nd IS, louder on inspiration.
50. echo, ECG- may show RV hypertrophy or RBBB.
51. balloon valvuloplasty.
52. retrograde blood flow from the right atrium to the right ventricle during systole.
53. a fib or RV dilation.
54. usually asymptomatic.
55. RV / RA enlargement and RCHF symptoms due to systemic venous congestion.
56. pansystolic blowing murmur.
57. right/left lower sternal border, loudest on inspiration.
58. RV overload signs, tall peaked P waves from RA hypertrophy.
59. obstructed blood flow from right atrium to right ventricle during diastole which leads to RA hypertrophy.
60. RF, may be congenital.
61. similar to mitral stenosis. also see RCHF symptoms.
62. mitral stenosis, tricuspid regurgitation.
63. short, scratchy diastolic murmur.
64. lower right/left parasternal borders, increases in inspiration.
65. a heightened P wave.
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