Updated: 12/21/2019

Valvular Diseases

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Snapshot
  • A 57-year-old man presents to the emergency department complaining of severe chest pain and difficulty breathing. His  exam reveals a weak, delayed carotid upstroke and a parodoxically-spliting S2. His EKG is shown. 
Introduction
  • The leading cause of valvular heart disease in the United States is
    • mechanical degeneration
  • In the developing world
    • rheumatic fever is the most common etiology
  • Types
    • aortic stenosis
    • aortic regurgitation
    • mitral stenosis
    • mitral regurgitation
Aortic Stenosis
  • See topic
Aortic Regurgitation
  • May appear acutely or as a chronic condition
    • acute causes include trauma, aortic dissection, and infection
    • chronic cases include
      • birth defects 
      • rheumatic fever
      • connective tissue disorders
  • Symptoms/Physical exam
    • patients may present with worsening symptoms including
      • dyspnea on exertion
      • paroxysmal nocturnal dyspnea
      • lightheadedness on standing or changing positions too quickly
    • chest ausculation characterized by three distinct murmurs  
      • blowing diastolic murmur at LSB
      • midsystolic murmur at the apex
      • mid-diastolic rumble
    • other signs 
      • head-bobbing with heart beats
        • caused by caudal venous outflow obstruction
      • water hammer pulse
      • femoral bruits on compression of femoral pulse 
        • Duroziez sign
  • Evaluation
    • echocardiography is diagnostic
      • Doppler imaging shows back-flow across the aortic valve during diastole
    • EKG may show signs of dilated ventricles
  • Differential Diagnosis
    • other valvular disease, including aortic stenosis or mitral regurgitation, CHF
  • Treatment
    • Medical management until symptoms warrant intervention
      • Vasodilator therapy
        • CCBs and ACEIs
  • Prevention, Prognosis, and Complications
    • acute cases rapidly progress to pulmonary congestion, shock, and death if not treated 
Mitral Valve Stenosis
  • Most common etiology continues to be rheumatic fever
  • Symptoms/Physical exam
    • presents with wide range of symptoms
      • dyspnea on exertion
      • arrhythmias
      • orthopnea
      • infective endocarditis
      • paroxysmal nocturnal dyspnea
    • chest auscultation may reveal
      • opening snap
    • other signs include
      • crackles and rales indicative of pulmonary edema
  • Evaluation
    • Doppler echocardiography is diagnostic
    • CXR will likely demonstrate mild to severe pulmonary edema
  • Differential Diagnosis
    • other valvular disease, CHF
  • Treatment 
    • Antiarrhythmics for symptom relief
      • Beta blockers, digoxin
    • Severe cases require surgical intervention
      •  Repair by commissurotomy preferred over replacement 
      • Balloon valvotomy 
      • Valve replacement
  • Prevention, Prognosis, and Complications
    • If left untreated, can progress to severe CHF and ultimately death
Mitral Valve Regurgitation
  • Two major causes include
    • rheumatic fever
    • chordae tendonae rupture
  • Symptoms/Physical exam
    • presents with a range of symptoms including
      • dyspnea
      • orthopnea
      • fatigue
    • chest auscultation reveals
      • holosystolic murmur that radiates to the axillae
  • Evaluation
    • Doppler echocardiography is diagnostic
      • shows regurgitant flow
    • CXR may show enlarged left atrium
    • Angiography used to assess severity of disease
  • Differential Diagnosis
    • other valvular diseases, CHF
  • Treatment
    • Decrease afterload
      • ACE inhibitors and ARBs
    • Antiarrythmics may be necessary if AF or others develop
  • Prevention, Prognosis, and Complications
    • at increased risk of developing atrial fibrillation due to enlargement
Cardiac Auscultation in Valvular Disease
  • Aortic Stenosis
    • loud crescendo-decrescendo systolic ejection murmor in right 2nd intercostal space
  • Mitral Regurgitation
    • high pitched holosystolic loudest at apex radiating to axilla
  • Tricuspid Regurgitation
    • soft holosystolic at left sternal border
  • Mitral Prolapse
    • crisp midsystolic click and a delayed or late systolic regurgitation murmur.
  • Aortic Regurgitation
    • high pitched blowing early diastolic decrescendo murmor at left sternal border
  • Mitral Stenosis
    • rumbling mid-diastolic murmor with ccenuated S1. S2, best heard on expiration or when the patient is squating or excercising because venous return is increase

Treatment
  • Medical management as above
  • Surgical management
    • surgical repair
    • surgical replacement: mechanical valve or bioprosthetic valve
      • requires post-surgical anticoagulation
      • can cause hemolysis due to shearing force
        • schistocytes seen on peripheral smear 
        • elevated LDH, decreased haptoglobin, and mild hyperkalemia
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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