Valvular Emergencies

1
Valvular Emergencies

• October 11, 2005
• Dr. Kanagala

2
Introduction

• 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

3
Chronic 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

4
Acute Valve Disease

• Acute valve disease can result in dramatic
  symptoms.

5
Diagnosing a New Murmur

• Consider murmur in context of patients 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

6
Diagnosing 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.

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Innocent or Physiologic Murmur

• No abnormal symptoms or signs
• Soft, 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.

8
Mitral 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

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Clinical Features of Mitral Stenosis

• 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

10
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)

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Clinical Features continued

• Apical impulse is small and tapping
• Systolic blood pressure is normal or low
• Signs of pulmonary hypertension include thin body
  habitus, peripheral cyanosis, and cool extremities

12
Diagnosis

• 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)

13
Treatment

• 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

14
Mitral 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

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Acute Mitral Incompetence Causes

• MI
• Mitral valve prolapse syndrome
• Rheumatic heart disease
• Coronary artery disease
• Collagen vascular disease
• Inferior MI due to right coronary occlusion is
  the most common cause of ischemic mitral valve
  incompetence

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Acute Mitral Incompetence

• Presents with dyspnea, tachycardia, and pulmonary
  edema
• S3 and S4 is usually heard
• Acutely, a harsh apical systolic murmur starts
  with S1 and may end before S2
• Patients may deteriorate quickly due to
  cardiogenic shock or cardiac arrest

17
Acute 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

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Chronic Mitral Incompetence

• Late systolic left parasternal lift
• High 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

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Diagnosis

• 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

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Acute Mitral Incompetence Treatment

• 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

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Mitral Incompetence Treatment

• Aortic balloon counter pulsation
• Surgery may be warranted if mitral valve rupture
• Evaluate for and treat endocarditis
• Treat atrial fibrillation with heparin, control
  ventricular rate with beta blockers and calcium
  channel blockers
• Keep INR 2-3

22
Mitral Valve Prolapse

• Click murmur syndrome
• May be congenital
• Male, age above 45, and the presence of
  regurgitation place patient at higher risk for
  complications

23
Mitral Valve Prolapse Clinical Features

• 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

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Mitral Valve Prolapse Diagnosis

• ECG usually normal
• Chest X-ray may be normal, or show pectus
  excavatum, straight thoracic spine, or scoliosis

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Treatment of Mitral Valve Prolapse

• 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.

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Aortic 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

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Aortic Stenosis Clinical Features

• 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

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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

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Clinical Features Continued

• Brachioradial delay
• ECG LVH, in 10 of patients LBBB/RBBB
• ChestX-ray starts out normal, but eventually LVH
  and CHF

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Treatment of Aortic Stenosis

• Pulmonary Edema oxygen and diuretics
• New onset Afib heparin and cardioversion
• Limit vigorous activity
• Patients with symptoms secondary to aortic
  stenosis such as syncope should be admitted

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Aortic 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

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Causes

• Increased ventricular pressure elevates pressure
  in left ventricle, pulmonary congestion results
• Appetite suppressant drugs have been linked to
  aortic incompetence

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Causes

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

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Aortic incompetence Clinical Features

• Dyspnea
• Acute pulmonary edema with pink, frothy sputum
• Fever, chills Endocarditis
• Systemic emboli
• Sinus tach
• Dissection of ascending aorta

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Clinical Features Continued

• Sudden death
• Tachycardia, tachypnea and rales
• High pitched blowing diastolic murmur heard after
  S2
• Some may have palpitations
• May have stabbing chest pain, fatigue or dyspnea
• LV failure

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Clinical Features Continued

• 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

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Aortic Incompetence Diagnosis

• 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 crucial
• TEE if aortic dissection suspected

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Acute Aortic Incompetence Treatment

• 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

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Chronic Aortic IncompetenceTreatment

• Vasodilators like Ace inhibitors or Nifedipine

40
Right Sided Valvular Heart Disease 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

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Clinical Features

• Dyspnea, orthopnea most common
• JVD
• Peripheral edema
• Hepatomegaly
• Splenomegaly
• ascites

42
Clinical Features

• 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

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Diagnosis

• Must obtain Echocardiogram

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Treatment

• Address the underlying problem
• diuretics

45
Prosthetic 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

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Complications

• 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.

47
Complications

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

48
Clinical Features

• Dyspnea
• CHF
• Minor/major embolic events
• Neurologic symptoms thromboemboli due to valve
  thrombi or endocarditis
• Bleeding due to anticoagulation

49
Clinical Features

• Abnormal heart sounds
• Mechanical model systolic murmur
• Aortic Bioprosthesis short midsystolic murmur
• Mitral Bioprosthesis loud diastolic murmur

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Diagnosis

• Chest x-ray can help identify change in position
  relative to previous films
• CBC, RBC, PT/INR
• If you suspect valve dysfunction-echo
• May need cardiac cath

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Treatment

• 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

52
Treatment

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

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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

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Question 2

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

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Question 3

• Causes of Acute Mitral Incompetence include
• A) MI
• B) Mitral Valve Prolapse
• C) Rheumatic Heart Disease
• D) All of the above

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Answers

• 1)D
• 2)T
• 3)D