PHYA 510: Valvular Disorders +
Endocarditis
What is the most common valvular abnormality?
aortic stenosis
What is the most common surgical valve lesion?
aortic stenosis
aortic stenosis MC in what population?
older population bc the stenosis is progressive
narrowing of the aortic valve
aortic stenosis
What happens during aortic stenosis? Why is it problematic?
Narrowing of aortic valve → backs up into LV → increased LV pressure → LVH
→ ventricle less compliant now (dilated) → increased EDP → increased
pulmonary circulation pressure (dyspnea)
basically cannot go into the aorta so backs up into the LV then backs way up into
pulmonary circulation
Why can aortic stenosis cause angina?
Narrowing of aortic valve → backs up into LV → increased LV pressure → LVH →
increased O2 demand --> ANGINA
Why can aortic stenosis cause SOB or dyspnea?
Narrowing of aortic valve → backs up into LV → increased LV pressure → LVH →
increased EDP → increased pulm circulation pressure (dyspnea)
your patient was born with congenital aortic stenosis, what does this mean?
2 leaflets not 3
your patient has valvular stenosis due to gradual calcium deposition, what is this?
Calcific stenosis
how can rheumatic heart disease cause valve stenosis?
RHD causes inflammation, autoimmunity attacking the leaflets --> valve damage
What are the MCC of AS in US?
Congenital abnormality - get a bicuspid leaflet not a tricuspid
what is the MCC of AS
RHD
what is the MC sx that pts have with AS?
ASYMPTOMATIC
What is the "classic" triad of ssx for aortic stenosis (when they do have sx)?
CLASSIC TRIAD = EXERTIONAL DYSPNEA + ANGINA + SYNCOPE
your patient has exertional dyspnea, angina and syncope. What valve disorder are
you thinking to look for?
aortic stenosis = narrowing of aortic valve
,looking for AS bc this is the MC valve disorder
your patient's aortic valve is <1cm^2 on echo. What is this?
SEVERE aortic stenosis
as AS progresses, it turns into ___. What sx might we see with this?
turns into heart failure as it progresses!
LHF: Orthopnea, PND, pulmonary edema
RHF: (results from severe pulmonary HTN) systemic venous HTN, hepatomegaly, a
fib, tricuspid regurgitation
your patient has exertional dyspnea, angina and syncope. What PE findings would
you find that would support a suspicion of AS?
Palpable thrill/shudder over carotids (L>R)
Crescendo-decrescendo mid-systolic (between S1 and S2) heart murmur heard
best at 2nd ICS (may radiate to carotids) = Low-pitched, rasping, rough
sounding
Splitting of S2 d/t aortic valve closing after the pulmonic valve (delay bc trying to
push through tiny opening)
May have palpable S4 at LLR (bc ventricle becomes no longer compliant)
your patient has exertional dyspnea, angina and syncope. PE reveals
Crescendo-decrescendo mid-systolic heart murmur heard best at right 2nd
ICS. It is low-pitched, rasping, and rough sounding.
What findings would you see on EKG that supports the most likely dx?
likely AS
Development of a strain pattern (ST depression and T-wave inversion) in I and
aVL (lateral leads)
your patient has exertional dyspnea, angina and syncope. PE reveals
Crescendo-decrescendo mid-systolic heart murmur heard best at 2nd ICS. It is
low-pitched, rasping, and rough sounding.
What is the most definitive way to diagnose the most likely dx? What findings would
you see?
likely AS
DO ECHO!! → Thickened, calcific aortic valve with decreased systolic opening
of valve (<2cm^2)
may also see LVH!
, What are the severities/ways to grade aortic stenosis
2 cm^2 = normal
1.5 - 2 cm^2 = mild
1-1.5 cm^2 = moderate
<1 cm^2 = severe
your patient has exertional dyspnea, angina and syncope. PE reveals
Crescendo-decrescendo mid-systolic heart murmur heard best at 2nd ICS. It is
low-pitched, rasping, and rough sounding.
ECHO (attached) shows Thickened, calcific aortic valve with decreased systolic
opening of valve (<2cm^2)
IF you did a CXR, what might you see?
Little to no cardiac enlargement (for long time)
Rounding of cardiac apex (d/t LVH)
+/- calcified aortic valve
+/- pulmonary congestion (depending if it progressed to HF)
for all the valvular disorders, what is catheterization used for?
usually just for surgical planning
your patient has exertional dyspnea, angina and syncope. PE reveals
Crescendo-decrescendo mid-systolic heart murmur heard best at 2nd ICS. It is
low-pitched, rasping, and rough sounding.
ECHO shows Thickened, calcific aortic valve with decreased systolic opening
of valve (<2cm^2)
What would be involved in their INITIAL treatment?
Avoid dehydration, hypovolemia
Treatment of HTN and CAD with beta blockers and ACE inhibitors
angina sx → Nitroglycerin
your patient with a history of endocarditis has exertional dyspnea, angina and
syncope. PE reveals Crescendo-decrescendo mid-systolic heart murmur heard
best at 2nd ICS. It is low-pitched, rasping, and rough sounding.
ECHO shows Thickened, calcific aortic valve with decreased systolic opening
of valve (<1cm^2)
What would be involved in their INITIAL treatment?
severe AS, <1cm^2 → No strenuous activity
Hx of endocarditis → Abx prophylaxis
Avoid dehydration, hypovolemia
Treatment of HTN and CAD with beta blockers and ACE inhibitors
angina sx → Nitroglycerin
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