Valvular Emergencies October 11, 2005 Dr. Kanagala.

Valvular EmergenciesValvular Emergencies

October 11, 2005

Dr. Kanagala

IntroductionIntroduction

There may be abnormalities of cusps, chordae, or papillary muscles causing valvular dysfunction.

Significant valvular abnormality increases stroke rate 3.2 times and death rate 2.5 times

Chronic Valve DiseaseChronic Valve Disease

There may be decades between onset of dysfunction and symptoms

Dilation or hypertrophy may preserve cardiac function

Account for around ninety percent of valvular disease

Acute Valve DiseaseAcute Valve Disease

Acute valve disease can result in dramatic symptoms.

Diagnosing a New MurmurDiagnosing a New Murmur

Consider murmur in context of patient’s medical condition

Patient may have normal cardiac anatomy, but murmurs can be associated with other disease states.

Examples include anemia, thyrotoxicosis, sepsis, fever, renal failure, and pregnancy

Diagnosing a New MurmurDiagnosing a New Murmur

A diastolic murmur or new murmur warrants cardiology referral for evaluation/echo.

Urgency for accurate diagnosis and referral or admission depends on severity of symptoms not presence of murmur unless aortic stenosis and syncope is suspected. Patient may be at risk for recurrent cardiovascular event.

Innocent or Physiologic Innocent or Physiologic MurmurMurmur

No abnormal symptoms or signsSoft, systolic ejection murmur begins after

S1 and ends before S2, and heart sounds are normal

Review of symptoms reveals no symptoms compatible with cardiovascular disease, and complete physical exam is normal.

Mitral StenosisMitral Stenosis

Most common cause is rheumatic heart disease

Progressive stenosis may lead to pulmonary hypertension causing pulmonary and tricuspid incompetence

Most patients develop atrial fibrillation

Clinical Features of Mitral Clinical Features of Mitral StenosisStenosis

Symptoms include: tachycardia, anemia, pregnancy, infection, emotional upset, A-fib, exertional dyspnea, paroxysmal nocturnal dyspnea, acute pulmonary edema, hemoptysis, orthopnea, PAC, systemic emboli and infarction, right sided heart failure

Clinical Features continued…Clinical Features continued…

mid-diastolic rumbling murmur with crescendo toward S2

With onset of Afib the presystolic accentuation of the murmur disappears. S1 is loud and followed by a loud opening snap (high pitched, heard at apex)

Clinical Features continued…Clinical Features continued…

Apical impulse is small and tappingSystolic blood pressure is normal or lowSigns of pulmonary hypertension include

thin body habitus, peripheral cyanosis, and cool extremities

DiagnosisDiagnosis

ECG: notched or biphasic P waves and right axis deviation

Chest X-ray: straightening of left heart border, findings of pulmonary congestion like kerley B lines and increase in vascular markings

Confirmed with echocardiography (TEE)

TreatmentTreatment

Diuretics for pulmonary congestion Afib treatment Anticoagulation if at risk for embolic events With severe mitral stenosis patients should be

warned to avoid strenuous physical activity If hemoptysis occurs due to mitral stenosis and

pulmonary hypertension, thoracic surgery may be warranted

Mitral IncompetenceMitral Incompetence

Causes include MI, MVP syndrome, rheumatic heart disease, coronary artery disease, collagen vascular disease

Inferior MI due to right coronary occlusion is most common ischemic cause

Acute Mitral Incompetence Acute Mitral Incompetence CausesCauses

MIMitral valve prolapse syndromeRheumatic heart diseaseCoronary artery diseaseCollagen vascular diseaseInferior MI due to right coronary occlusion

is the most common cause of ischemic mitral valve incompetence

Acute Mitral IncompetenceAcute Mitral Incompetence

Presents with dyspnea, tachycardia, and pulmonary edema

S3 and S4 is usually heardAcutely, a harsh apical systolic murmur

starts with S1 and may end before S2Patients may deteriorate quickly due to

cardiogenic shock or cardiac arrest

Acute Mitral IncompetenceAcute Mitral Incompetence

Intermittent mitral incompetence usually presents with acute episodes of respiratory distress due to pulmonary edema and can be asymptomatic in between attacks

Pronounced dyspnea may mask angina that accompanies the ischemia

Chronic Mitral IncompetenceChronic Mitral Incompetence

Late systolic left parasternal liftHigh pitched holosystolic murmur starting

with S1 and may end before S2, heard best in fifth intercostal space, mid-left thorax, and radiates to the axilla

First heart sound is soft and often obscured by the murmur

S3 heard and followed by a diastolic rumble

DiagnosisDiagnosis

ECG: acute inferior MI, left atrial enlargement, LVH, new onset pulmonary edema

CXR: minimally enlarged left atrium, pulmonary edema, left ventricular enlargement

Echocardiography is essential. TEE done once patient is stable

Acute Mitral Incompetence Acute Mitral Incompetence TreatmentTreatment

Pulmonary edema: oxygen, diuretics, nitrates, intubation

Nitroprusside: increases forward output by increasing aortic flow and partially restoring mitral valve competence as left ventricular size diminishes

Dobutamine may be required for hypotensive patients

Mitral Incompetence Mitral Incompetence TreatmentTreatment

Aortic balloon counter pulsationSurgery may be warranted if mitral valve

ruptureEvaluate for and treat endocarditisTreat atrial fibrillation with heparin, control

ventricular rate with beta blockers and calcium channel blockers

Keep INR 2-3

Mitral Valve ProlapseMitral Valve Prolapse

Click murmur syndromeMay be congenitalMale, age above 45, and the presence of

regurgitation place patient at higher risk for complications

Mitral Valve Prolapse Clinical Mitral Valve Prolapse Clinical FeaturesFeatures

Most are asymptomatic Atypical chest pain Palpitations Fatigue Dyspnea unrelated to exertion Midsystolic click Second heart sound may be diminshed by late

systolic murmur with crescendos into S2

Mitral Valve Prolapse Mitral Valve Prolapse DiagnosisDiagnosis

ECG: usually normalChest X-ray: may be normal, or show

pectus excavatum, straight thoracic spine, or scoliosis

Treatment of Mitral Valve Treatment of Mitral Valve ProlapseProlapse

Usually not needed in ED Beta blockers may be used for patients with

palpitations, chest pain, or anxiety Suggest avoidence of alcohol, tobacco, and

caffeine to relieve symptoms Patients with Afib/ risk for embolization: warfarin

with INR of 2-3 Patients with MVP and Afib without mitral

regurg., HTN, heart failure, and above 65 can be managed with aspirin 160mg qd.

Aortic StenosisAortic Stenosis

Most common cause: degenerative heart disease/ calcific aortic stenosis

Most common cause in young adults: congenital heart disease

Third most common cause in US, but most common cause world wide: rheumatic heart disease

Aortic Stenosis: Clinical Aortic Stenosis: Clinical FeaturesFeatures

Classic triad of dyspnea, chest pain, and syncope Exercise may induce symptoms Dyspnea is typically first symptom, followed by

PND, exertional syncope, and angina Atrial Fibrillation is less common than in mitral

disease but 10% of patients have it at time of surgery

Clinical Features Continued…Clinical Features Continued…

A small amplitude pulse Slow rate of of increase of carotid pulse LVH Paradoxical splitting of S2 S3, S4 present Classic harsh systolic ejection murmur heard best

at second intercostal space radiating to right carotid artery

Sudden death


Brachioradial delayECG: LVH, in 10% of patients

LBBB/RBBBChestX-ray: starts out normal, but

eventually LVH and CHF

Treatment of Aortic StenosisTreatment of Aortic Stenosis

Pulmonary Edema: oxygen and diureticsNew onset Afib: heparin and cardioversionLimit vigorous activityPatients with symptoms secondary to aortic

stenosis such as syncope should be admitted

Aortic IncompetenceAortic Incompetence

Majority of acute cases due to infective endocarditis

Aortic dissection of the root is the second most common cause

May be due to trauma

Causes:Causes:

Increased ventricular pressure: elevates pressure in left ventricle, pulmonary congestion results

Appetite suppressant drugs have been linked to aortic incompetence

Causes:Causes:

Calcific degeneration, Ankylosing spondylitis Congenital disease, Ehlers-Danlos syndrome Systemic hypertension, Reiters Myxomatous proliferation Rheumatic heart disease Marfan syndrome Syphils

Aortic incompetence Clinical Aortic incompetence Clinical Features…Features…

DyspneaAcute pulmonary edema with pink, frothy

sputumFever, chills: EndocarditisSystemic emboliSinus tachDissection of ascending aorta


Sudden deathTachycardia, tachypnea and ralesHigh pitched blowing diastolic murmur

heard after S2Some may have palpitationsMay have stabbing chest pain, fatigue or

dyspneaLV failure


2/3 have no symptoms for up to 20 years despite a significant lesion

Wide pulse pressure with prominent ventricular impulse

Water hammer pulse Accentuated precordial apical thrust Pulsus biferens Duroziez sign Quincke pulse

Aortic Incompetence: Aortic Incompetence: DiagnosisDiagnosis

Acute: The chest x-ray shows acute pulmonary edema

Chronic: The ECG shows LVH and chest x-ray shows cardiomegally, aortic dilation, and possibly CHF

ECHO is crucialTEE if aortic dissection suspected

Acute Aortic Incompetence: Acute Aortic Incompetence: TreatmentTreatment

Pulmonary Edema: oxygen, intubation Diuretics and nitrites can be used, but may not be

effective Nitroprusside plus ionotropic agents can be used

to augment forward flow and reduce LVEDP to prepare for surgery

Caution when using beta blockers-risk of blocking compensatory tachycardia

Emergency surgery

Chronic Aortic IncompetenceChronic Aortic IncompetenceTreatment:Treatment:

Vasodilators like Ace inhibitors or Nifedipine

Right Sided Valvular Heart Right Sided Valvular Heart Disease CausesDisease Causes

Endocarditis in drug users due to organisms such as S.Aureus-isolated symptomatic tricuspid pathology

COPD/pulmonary HTN RV failure with dilation Rheumatic heart disease Blunt trauma Congenital: tetrology of Fallot Pulmonary valve incompetence

Clinical FeaturesClinical Features

Dyspnea, orthopnea: most commonJVDPeripheral edemaHepatomegalySplenomegalyascites


Tricuspid Valve Incompetence: soft blowing holosystolic murmur heard along left lower sternal border

Tricuspid Valve Stenosis: rumbling crescendo decrescendo diastolic murmur that occurs just before S1. It is heard at lower left sternal border

DiagnosisDiagnosis

Must obtain Echocardiogram

TreatmentTreatment

Address the underlying problemdiuretics

Prosthetic Valve DiseaseProsthetic Valve Disease

Two groups exist: mechanical non-tissue vs. bioprostheses using porcine, bovine or human valves

Survival is better with mechanical, and bleeding more common in bioprosthetic valves

Valves may become stenotic and small amounts of regurgitations common due to incomplete closure

ComplicationsComplications

Thrombi on valve Degeneration of valve Sutures around valve disrupted Valve failure Bleeding/embolism Endocarditis/ ring abscess May have increased susceptibility to

hemodynamic compromise from new onset A fib.

ComplicationsComplications

Lifelong anticoagulation is needed to decrease risk of thromboembloism and valve thrombosis


DyspneaCHFMinor/major embolic eventsNeurologic symptoms: thromboemboli due

to valve thrombi or endocarditisBleeding due to anticoagulation


Abnormal heart soundsMechanical model: systolic murmurAortic Bioprosthesis: short midsystolic

murmurMitral Bioprosthesis: loud diastolic murmur

DiagnosisDiagnosis

Chest x-ray: can help identify change in position relative to previous films

CBC, RBC, PT/INRIf you suspect valve dysfunction-echoMay need cardiac cath

TreatmentTreatment

May need cardiac surgery referral if there is acute dysfunction

Treatment of prosthetic acute valvular dysfuntion due to thrombotic obstruction is thrombolytic therapy

Lesser degrees of mechanical valve obstruction: anticoagulate to INR of 2-3.5

TreatmentTreatment

Disposition can be difficult decision if patient has worsening symptoms- consult cardiology

Question 1:Question 1:

Which of the following are clinical features of Aortic Incompetence?

A) Water Hammer Pulse

B) Pulsus Biferens

C) Duroziez Sign

D) All of the Above


T/F The most common cause of Aortic Stenosis in young adults is congenital heart disease.


Causes of Acute Mitral Incompetence include:

A) MI

B) Mitral Valve Prolapse

C) Rheumatic Heart Disease

D) All of the above

AnswersAnswers

1)D2)T3)D

Valvular Emergencies October 11, 2005 Dr. Kanagala.

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Transcript of Valvular Emergencies October 11, 2005 Dr. Kanagala.