Valvular emerginces
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A 67-year-old man presents to the emergency department with sudden onset of chest pain and shortness of breath. On examination, he has signs of pulmonary edema and a loud heart murmur, and has a history of a recent heart attack. The most appropriate initial management is to provide standard treatment for pulmonary edema and consider the need for urgent valve replacement surgery given the acute presentation in the setting of known valvular heart disease.
Valvular emerginces
- 2. A 67-year-old man presents to the ED with sudden onset of chest pain and shortness of breath. He is 5 days status-post inferior wall myocardial infarction. On examination the patient has pulmonary edema and a loud holosystolic murmur heard best at the left lateral sternal border, with adiation to the base. What is the most appropriate initial management? 2
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- 4. Non of my business , what else? 4
- 5. • How Is it an Emergency ? • How to know ? • Rheumatic heart Disease & Infective indocarditis • Understand ECHO images 5
- 6. • ↑ stroke rate 3.2 times • ↑ death rate 2.5 times • Mitral prolapse is the most common. • 3% annnual mechanical valve complications • systemic embolization from a prosthetic valve is 1% /yr. 6
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- 9. • Innocent (e.g. anemia, thyrotoxicosis, sepsis, fever, renal failure, and pregnancy) • New = N T • Diastolic Murmur = !!?? • Chronic e.g. Mitral (RHD) AF, P-HTN , RVF 9
- 10. • Stenosis < 2 cm2 (4-6cm2) • C/O ↓ exercise, DOE, orthopnea, RVF Also hoarseness & dysphagia (Ortner’s Syndrome) • O/E small impulse, low sBP, , thin body habitus, p. cyanosis, and cool extremities 10 loud S1 , opening snap in early diastole low-pitched rumbling diastolic apical murmur.
- 11. INVESTIGATIONS ECG , CXR, ECHO TREATMENT ■ atrial fibrillation. ■ Anticoagulate if systemic embolization ■ Prophylaxis for endocarditis. ■ Cautious diuretic use. ■ Percutaneous balloon/operative repair. ■ Valve replacement is a last resort. 11 severe mitral stenosis avoid strenuous physical activity If hemoptysis occurs –> thoracic surgery may be warranted
- 12. Valvoplasty 12
- 13. COMPLICATIONS ■ Atrial fi brillation ■ pulmonary hemorrhage ■ Pulmonary HTN and Rt HF ■ Systemic emboli 13
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- 15. 15 Chronic Acute C/O -Often asymptomatic -Gradual dyspnea on exertion and fatigue -Palpitations (AF ) -Abrupt dyspnea, tachypnea, Cardiogenic shock, Chest pain -Symptoms of (endocarditis, MI, trauma ) O/E holosystolic, at the apex and radiating to the axilla midsystolic murmur radiates to the base not the axilla. + Pulmonary edema Patients may deteriorate quickly due to cardiogenic shock or cardiac arrest
- 16. 16 Chronic Acute ECG left atrial and ventricular hypertrophy. Atrial fibrillation and P mitrale - no atrial enlargment - no LVH o/e minimally enlarged left atrium, pulmonary edema, left ventricular enlargement Normal cardiac silhouette, pulmonary edema
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- 18. 18 Chronic Acute ■ Treat CHF & AF ■ Anticoagulate if systemic embolization ■ Endocarditis prophylaxis ■ Valve replacement ■ pulmonary edema ttt. ■ Nitroprusside for afterload reduction (increases forward output by increasing aortic flow and partially restoring mitral valve competence as left ventricular size diminishes) ■ Dobutamine if hypotensive. ■ Intra-aortic balloon pump as bridge to surgery. ■ Immediate valve replacement. ■ Treat the underlying disease process.
- 19. • presents – with acute episodes of respiratory distress due to pulmonary edema and asymptomatic in between attacks – Pronounced dyspnea may mask angina that accompanies the ischemia • Treatment – Aortic balloon counter pulsation – Surgery may be warranted if mitral valve rupture – Evaluate for endocarditis – Treat atrial fibrillation with heparin, control ventricular rate with beta blockers and calcium channel blockers – Keep INR 2-3 19
- 20. • Common, specially young thin females. • autosomal dominantmainly • association with anxiety dis. and ↓BMI. PATHOPHYSIOLOGY Myxomatous proliferation of leaflet → abnormal stretching of valve leaflets during systole 20
- 21. SYMPTOMS asymptomatic, Atypical chest pain, Palpitations, Lightheadedness, Dyspnea. EXAM ■ Early to midsystolic click with high-pitched late systolic murmur best at left lateral border ■ standing→ earlier and greater prolapse → accentuates the click +moves it closer to S1 21
- 22. 22 TREATMENT ■ asymptomaticNo treatment. ■ Proph. endocarditis if regurgitation or thickened valve leaflets. ■ β-Blockers may help with atypical chest pain DIAGNOSIS ■ ECG: Nonspecific c ST-T wave changes, (PSVT) ■ CXR: NAD ■ Echo
- 23. 23 Complications Stroke Endocarditis Tachydysrhythmias (atrial and ventricular) PSVT (most common dysrhythmia) Increased incidence of WPW, PACs, PVCs Ventricular tachycardia (VT) possible Sudden death ( Risk factors include syncope/pre- syncope, inferolateral ST-T changes and thickened or redundant valve leaflet on TTE).
- 24. A 72-year-old woman is brought to the ED following a syncopal event. She reports orthopnea and vague, intermittent chest pain, both present for the past 6 months. o/e : BP of 108/84, rales at both lung bases, a prolonged apical impulse, and a loud systolic murmur radiating into her neck. What test will confirm the most likely diagnosis? What medication is important to avoid in this patient? 24
- 25. Angina + Syncope + Dyspnea(dCHF) - >65 years, calcified valve degeneration. - younger patients congenital bicuspid valve. - Rheumatic heart disease (less common) specially if mitral valve diseased. Pathophysiology ■ LV outflow is obstructed → LVH, ↓ cardiac output, and eventual dilated cardiomyopathy with hypertrophy. ■ signs or symptoms if aortic outflow is ↓75% (to < 1 cm). 25
- 26. EXAM ■ Narrowed pulse pressure ■ Heaving, prolonged apical impulse ■ Crescendo–decrescendo systolic to the neck ■ CHF symptoms DIAGNOSIS ■ ECG: LVH with strain, left bundle branch block. ■ CXR: LVH, pulmonary congestion . ■ Echocardiography: Confirms & measures. 26 Angina + Syncope + Dyspnea(dCHF) Exercise stress testing may provoke dysrhythmias and is contraindicated.
- 27. Aortic valve stenosis 27
- 28. Bicuspid aortic valve 28
- 29. TREATMENT ■ Treat CHF with gentle diuresis. ■ Rule out ACS in acute presentations. ■ Hydrate gently for hypotension. Avoid: ■ Preload or afterload reducers (no nitroglycerin) ■ Negative inotropes. ■ Prophylaxis for endocarditis. ■ Definitive treatment is valve replacement. 29 Complications ■ Sudden death from dysrhythmias or acute onset of failure may occur ■ Survival is 2–5 without replacement.
- 30. ETIOLOGIES Acute aortic regurgitation ■ Infective endocarditis ■ Aortic dissection with proximal extension ■ Trauma ■ Prosthetic valve dysfunction Chronic aortic regurgitation ■ Rheumatic heart disease ■ Bicuspid aortic valve ■ Dilation of the aortic root (Marfan, ankylosing spondylitis, rheumatoid arthritis) PATHOPHYSIOLOGY Acute aortic valve failure → rapid rise in LV diastolic pressure → acute pulmonary edema and cardiogenic shock 30
- 31. 31 Acute Chronic C/O -Abrupt onset of dyspnea -fever(endocarditis) -Chest pain ( if aortic dissection) Gradual onset of dyspnea on exertion, orthopnea, nocturnal dyspnea EXAM - Tachycardia, tachypnea - Pulmonary edema and cardiovascular collapse - High-pitched blowing diastolic murmur heard best at left sternal border - Normal pulse pressure ■ Widened pulse pressure (opposite of AS) ■ same diastolic murmur. ■ Austin Flint murmur (mid-diastolic rumble) ■ “Water hammer” pulse ■ Quincke’s sign ■ Duroziez’s murmur ■ De Musset sign ■ Congestive heart failure
- 32. 32 Acute Chronic work - ECG : normal - CXR: Pulmonary edema. -ECG: LVH, left atrial enlargement. - CXR: Congestive heart failure. TREATMENT -Standard for pulmonary edema - Nitroprusside for afterload reduction - Dobutamine (in addition to nitroprusside) if hypotensive - Immediate valve replacement - Antibiotics: If endocarditis suspected - Avoid: Intra-aortic balloon pump ■ Nifedipine for asymptomatic AR ■ Afterload reducers, digoxin, hydralazine, and surgical referral for elective valve replacement for symptomatic AR ■ Prophylaxis for endocarditis
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- 34. CAUSES: right ventricular dilation (pulmonary HTN), endocarditis, and rheumatic heart disease. SYMPTOMS Fatigue, Dyspnea, Lower extremity swelling EXAM: Holosystolic murmur at left lower sternal border 34
- 35. 35 DIAGNOSIS ■ ECG: Right atrial and ventricular enlargement, atrial fi brillation (in the majority of cases). ■ Echo is confirmatory. TREATMENT ■ Treat atrial fibrillation. ■ Endocarditis prophylaxis
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- 38. 38 Complications ●Systemic embolization ●Bleeding ●Valve obstruction due to thrombosis or pannus. ●Endocarditis ●Structural deterioration, particularly with bioprosthetic valves ●Paravalvular regurgitation ( leak ) ●Hemolytic anemia ●Patient-prosthesis mismatch ● abrupt mechanical valve failure
- 39. 39 SYMPTOMS/EXAM ■ Vary with location and rapidity of valve failure ■ Findings of severe anemia (due to hemolysis) ■ Findings consistent with aortic/mitral regurgitation (acute or chronic) ■ Muted mechanical valve sounds, if mechanical valve failure
- 40. Percutaneous Aortic “Valve in Valve” Implantation for Severe Aortic Regurgitation in a Degenerated Bioprosthesis 40
- 41. Targeted INR is - 3.0 - 3.5 mitral valve. - 2.5 - 3.0 aortic valve. sudden acute onset of hypotension, CHF Muted mechanical valve sounds gradual course discovered on ECHO TREATMENT ■ Anticoagulation ■ Valve replacement 41
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- 43. 43 ETIOLOGIES MURMUR PHYSICAL FINDINGS AS Calcific valve Bicuspid valve Cresc–dec systolic Radiating → neck Paradoxically split S2 Narrowed pulse pressure Diminished and slow-rising carotid pulse AR Endocarditis Aortic dissection Blowing diastolic Heard best at left sternal border Acute > Pulmonary edema and CV collapse Chronic > “Water hammer” pulse , Quincke’s sign, Duroziez’s murmur, De Musset sign MS Rheumatic heart Diastolic Heard best at apex Loud S1 MR Endocarditis, ACS Loud holosystolic Heard best at apex Radiating → base Acute : Pulmonary edema and CV collapse Chronic: LV heave MP Unknown, likely congenital Late systolic heard best at left lateral heart border Early to mid systolic click
- 44. ■ In a patient with severe mitral stenosis, hypovolemia and tachycardia are poorly tolerated. “Slow and full” are appropriate goals. ■ In patients with critical aortic stenosis, excessive preload reduction with vasodilators and diuretics is to be avoided. ■ In patients with acute aortic insufficiency, classic physical findings may be absent. Medical stabilization entails the cautious use of vasodilators and diuretics. Intra-aortic balloon counter pulsation is contraindicated. ■ Complications of prosthetic heart valves range from structural failure and thrombosis to systemic embolization, hemolysis, and endocarditis. ■ admission depends on severity of symptoms not presence of murmur unless aortic stenosis and syncope is suspected. ■ Valvular heart Disease pt. at risk for recurrent cardiovascular event. 4444
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