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C44 Cardiology and Cardiac Surgery S S ValvulSar Heart Disease Toronto Notes 2019 121
Table 16. Valvular Heart Disease (continued)
S1 S2 S1
Tricuspid Regurgitation (TR)
Etiology
RV dilatation, IE (particularly due to IV
drug use), rheumatic disease, congenital
(Ebstein anomaly), carcinoid
Pathophysiology S1 S2 S1 RV dilatation → TR further RV dilatation
Tricuspid Stenosis (TS)
Etiology
Rheumatic disease, congenital, carcinoid
syndrome, fibroelastosis; usually
accompanied by MS (in RHD)
Pathophysiology
Increased RA pressure → right heart
failure → decreased CO and fixed on exertion
Symptoms
Peripheral edema, fatigue, palpitations
Physical Exam
Prominent “a” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, diastolic rumble 4th left intercostal space
Investigations
ECG: RAE
CXR: dilatation of RA without pulmonary artery enlargement
Echo: diagnostic
Treatment
Preload reduction (diuretics), slow HR
Surgery if: only if other surgery required (e.g. mitral valve replacement)
Surgical Options
Valve Replacement:
– if severely diseased valve
– bioprosthesis preferred
S1
S2 OS
S1
S 1
S
2
os
S
S1
S1
S1
S1
S S S 121
1
→ right heart failure
Symptoms
Peripheral edema, fatigue, palpitations
Physical Exam
“cv” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, holosystolic murmur at LLSB accentuated by inspiration, left parasternal lift
Investigations
ECG: RAE, RVH, AFib
CXR: RAE, RV enlargement S1 S2 OS S1 Echo: diagnostic
Treatment click
Preload reduction (diuretics)
Surgery if: only if other surgery required (e.g. mitral valve replacement)
Surgical Options
Annuloplasty (i.e. repair, rarely replacement)
S1 S2os S1
Pulmonary Stenosis (PS) Etiology
Usually congenital, rheumatic disease (rare), carcinoid syndrome Pathophysiology
click
Pulmonary Regurgitation (PR) Etiology
Pulmonary HTN, IE, rheumatic disease, tetrology of Fallot (post-repair) Pathophysiology
Increased RV volume → increased wall S1 tension → RV hypertrophy →
right heart failure
Symptoms
Chest pain, syncope, fatigue, peripheral edema
Physical Exam
Increased RV pressure →
RV hypertrophy → right heart failure
Symptoms
Chest pain, syncope, fatigue, peripheral edema
Physical Exam
Systolic murmur at 2nd left intercostal space accentuated by inspiration, pulmonary ejection click, right-sided S4
Investigations
ECG: RVH S1
CXR: prominent pulmonary arteries enlarged RV
Echo: diagnostic
Treatment
Balloon valvuloplasty if severe symptoms
Surgical Options
Percutaneous or open balloon valvuloplasty
S1 click S2
S2
S2 S1
S1
S2
S2
Early diastolic murmur at LLSB, Graham Steell (diastolic) murmur 2nd and 3rd left intercostal space increasing with inspiration
Investigations S1 S2 S1 ECG: RVH
CXR: prominent pulmonary arteries if pulmonary HTN; enlarged RV Echo: diagnostic
Treatment
Rarely requires treatment; valve replacement (rarely done) Surgical Options
Pulmonary valve replacement
Mitral Valve Prolapse (MVP)
Etiology
Myxomatous degeneration of
chordae, thick, bulky leaflets that crowd orifice, associated with Marfan’s syndrome, pectus excavatum, straight back syndrome, S1 other MSK abnormalities; <3% of population Pathophysiology
S1 S2 OS S1
Mitral valve displaced into LA during systole; no causal mechanisms found for symptoms
Symptoms
S SOS S 121
Auscultation: mid-systolic click (due to billowing of mitral leaflet into LA; tensing of redundant valve tissue); mid to late systolic murmur at apex, accentuated by Valsalva or squat-to-stand maneuvers
Investigations
ECG: non-specific ST-T wave changes, paroxysmal SVT, ventricular ectopy Echo: systolic displacement of thickened mitral valve leaflets into LA Treatment
Asymptomatic: no treatment; reassurance
Symptomatic: β-blockers and avoidance of stimulants (caffeine) for significant palpitations, anticoagulation if AFib
Surgical Options
Mitral valve surgery (repair favoured over replacement) if symptomatic and significant MR
Prolonged, stabbing chest pain, dyspnea, anxiety/panic, palpitations, fatigue, presyncope
Physical Exam
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