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Cardiology Part 4 (Valves) (Valves (Aortic Stenosis (pathophysiology…

- - - - BE JOAN OF ARC
        Major criteria
        B-blood culture positive
        E- echo evidence of vegetation
        Minor criteria
        J- janeway lesion
        O- oslers node
        A- aneurysm(mycotic); abuse(idu)
        N- nephritis
        O- other predisposing heart condition
        F-fever
        A- arterial emboli
        R-roth's spot; rheumatoid factor
        C- culture positive not meeting major criteria
    - - with acute infective endocarditis presenting with valve stenosis or regurgitation resulting in heart failure; left-sided infective endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms; infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesion; and infective endocarditis with persistent bacteremia or fever lasting longer than 5 to 7 days after starting antibiotic therapy or large vegetations (> 10 mm)
  - - - Vanc + gent
    - - vanc + gent + rifampin (or vanc + gent + carbapenem)
      - defined as
        
        diagnosed more than 72 hours after hospital admission in patients with no evidence of infective endocarditis on admission, or occurring within 60 days of a hospital admission that was associated with a risk for bacteremia or infective endocarditis
    - - Consider vancomycin + gentamicin + rifampin
  - - - manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa, procedures involving incision or biopsy of the respiratory tract mucosa, such as bronchial biopsy, tonsillectomy, and adenoidectomy.
    - - Amoxicillin 2 grams, or ampicillin 2 grams
      - if allergic to penicillin
        
        clindamycin 600 mg
- - - - calcific degeneration, aka senile calcificiation, bicuspid, rheumatic after mitral leads to stenosis of the valve and afterload concentric hypertrophy leading to diastolic HF and then systolic heart failure. Increased LVEDP leads to pulmonary congestion
    - - angina, dyspnea, and syncope
    - - 0.1 cm2 annually, tend to have symptoms below 1.0 cm2
    - - exercise treadmill testing
        
        ST-segment changes on ECG, or have an abnormal blood pressure response (lack of increase in systolic blood pressure by at least 20 mm Hg above baseline
        
        valve replacement indicated for assymptomatic
        
        Aortic valve replacement is indicated for asymptomatic patients with severe aortic stenosis and LV systolic dysfunction (LV ejection fraction <50%) as well as for those patients with severe aortic stenosis who are undergoing coronary artery bypass grafting or surgery on the aorta or other heart valves.
    - - Aortic valve replacement, TAVR (if high risk defined as STS score of 8% or higher)
    - - mild systolic crescendo-decrescendo murmur in the RUSB with S4, and decreased A2, parvus et tardus, high carotid upstroke, radiating to the carotid
  - - - infective endocarditis or aortic dissection (typically in a setting of hypertension or Marfan syndrome). Chronic severe aortic regurgitation is most commonly associated with a dilated ascending aorta from hypertension or primary aortic disease, calcific aortic sclerosis, bicuspid aortic valve, or rheumatic disease
      - if acute
        
        rapid increase in LV end-diastolic pressure and compensatory increase in heart rate and contractility to maintain cardiac output. When this compensation becomes inadequate, pulmonary edema, myocardial ischemia (due to decreased diastolic perfusion), and cardiogenic shock ensue
      - if chronic
        
        chronic aortic regurgitation permits a compensatory increase in LV size with increased LV diastolic volume and LV hypertrophy (eccentric and concentric) due to increased volume and afterload
    - - indicated for symptomatic patients with chronic severe aortic regurgitation irrespective of left ventricular (LV) systolic function, asymptomatic patients with chronic severe aortic regurgitation and LV systolic dysfunction (LV ejection fraction ≤50%), and patients with chronic severe aortic regurgitation undergoing coronary artery bypass graft (CABG) or surgery on the aorta or other heart valves.
    - - older, asymptomatic patients with a bicuspid aortic valve and severe aortic valve stenosis or regurgitation require yearly echocardiography; those with mild stenosis or regurgitation should have echocardiography every 3 to 5 years.
      - what needs to follow up
        
        aortic aneurysm and dissection owing to aortic connective tissue abnormalities. For this reason, the ascending aortic diameter should be reassessed by echocardiography if the aortic root or ascending aorta dimension is greater than or equal to 4.0 cm, with annual evaluation at 4.5 cm
      - Loeys-Dietz Syndrome
        
        Loeys-Dietz syndrome (hypertelorism, split uvula or cleft palate, and aortic aneurysms)
      - treatment for the aortic root
        
        Surgery to repair the aortic root or replace the ascending aorta is indicated in patients with a bicuspid aortic valve when the aortic root diameter is greater than 5.5 cm. Surgery is reasonable if the diameter of the ascending aorta or aortic root is greater than 5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter is ≥0.5 cm per year). Ascending aorta replacement is reasonable in patients who are undergoing aortic valve surgery because of severe aortic stenosis or aortic regurgitation if the diameter of the ascending aorta is greater than 4.5 cm.
    - - diastolic decrescendo or the LLSB, increased pulse pressure, bounding pulses,
  - - - rheumatic carditis, parachute mitral valve, mitral annular calcification
    - - 1.5 cm2
    - - This increase in left atrial pressure causes left atrial enlargement, with development of atrial fibrillation and a significantly increased risk of left atrial/left atrial appendage thrombus, as well as exertional dyspnea and eventual pulmonary edema owing to increased pulmonary venous pressure.
    - - Symptoms (class I)
        Very severe mitral stenosis (MVA <1.0 cm2) and no symptoms if valve morphology favorable for balloon valvotomy (class IIa)
        Severe mitral stenosis at time of other cardiac surgery (class I)
    - - diastolic, low pitched decrescendo with Opening snap, Apex, in the lateral decubitus
      - severity
        
        Interval between S2 and opening snap is short in severe mitral stenosis
  - - - mitral valve prolapse, myxomatous degeneration (the abnormal accumulation of proteoglycans), collagen vascular disease, and infective endocarditis
    - - papillary muscle rupture following acute myocardial infarction, flail mitral valve (dissociation of the valve leaflet from the chordae), and infective endocarditis with leaflet perforation, rapid LDEDV and resultant pulmonary edema
      - treatment
        
        Nitrates and diuretics reduce filling pressures in patients with acute severe mitral regurgitation, and sodium nitroprusside and an intra-aortic balloon pump reduce afterload and regurgitant fraction.
    - - Symptoms (class I)
        LVEF 30%-60% (class I)
        LV end-systolic diameter ≥40 mm (class I)
        Moderate (class IIa) or severe (class I) mitral regurgitation at time of other cardiac surgery
        LVEF >60% and LV end-diastolic diameter <40 mm with high likelihood of surgical success (>95%) and low expected mortality (<1%) (class IIa)
        LVEF >60% and LV end-diastolic diameter <40 mm with progressive increase in LV size or decrease in LVEF on serial imaging studies (class IIa)
        Pulmonary hypertension (PA systolic pressure ≥50 mm Hg) (class IIa)
        New-onset atrial fibrillation (class IIa)