• 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-split S2.
Aortic Stenosis
  • Introduction
    • most often occurs in the elderly
    • mechanical wear and tear is the primary etiology resulting in dystrophic calcification   
    • can result from chronic rheumatic fever, though more often the mitral valve is damaged
    • pediatric patients usually have unicuspid or bicuspid defects
  • Symptoms/physical exam
    • asymptomatic until very advanced  
    • once symptomatic, patients progress rapidly (5 years)
      • angina with exercise due to ↓ coronary perfusion
      • syncope with exercise
      • concentric LV hypertrophy leading to CHF
    • chest auscultation reveals
      • parodoxically split S2 
        • aortic valve closes later than normal which results in a single sound during inhalation when P2 closes later and a split S2 during exhalation when P2 closes earlier
      • classic crescendo-decrescendo murmur
        • peaks in early systole
        • heard in the 2nd right intercostal space and radiates to the carotids
        • ↓ preload = ↓ murmur intensity (less blood passing through stenotic valve)
        • the later in systole the crescendo peaks → the more advanced the stenosis
    • other signs include
      • pulsus parvus et tardus
        • weak and late pulse due to the lost pressure traversing the stenotic valve
      • ejection velocity of blood is increased due to the same amount of blood needing to pass through a smaller valve area
        • speed is directly proportional to severity of valvular stenosis
Aortic Regurgitation
  • Introduction
    • may appear acutely or chronic
      • acute causes include trauma, aortic dissection, and infection
        • due to aortic root dilation
      • chronic cases include
        • birth defects
        • rheumatic fever
        • connective tissue disorders
        • longstanding essential hypertension
  • Symptoms/physical exam
    • patients may present with worsening symptoms including
      • dyspnea on exertion
      • orthostatic hypotension
    • chest auscultation reveals
      • blowing early diastolic murmur at LSB
        • due to blood rushing back into heart
      • Austin Flint murmur
        • retrograde blood from aortic valve during diastole hits the anterior leaflet of the mitral valve
    • other signs
      • head-bobbing with heart beats
        • due to wide pulse pressure
      • Corrigan's pulse: carotid pulse with rapid rise and fall 
      • water hammer pulse
      • femoral bruits on compression of femoral pulse 
Mitral Stenosis
  • Introduction
    • most common etiology continues to be chronic rheumatic fever
    • reduced blood flow through valve results in LA dilation
  • Symptoms/physical exam
    • presents with wide range of symptoms
      • dyspnea on exertion
      • arrhythmias
      • orthopnea
      • infective endocarditis
    • chest auscultation may reveal
      • opening snap
        • heard best at the apex
        • time between A2 and OS is inversely correlated with severity of MS  
      • followed by mid-diastolic rumble
        • due to turbulent blood passing with increased velocity through the stenotic valve
    • other signs include
      • crackles and rales indicative of pulmonary edema
        • due to congestion of blood behind the left heart
      • dilated atria may
        • alter conduction and result in atrial fibrillation
        • compress esophagus resulting in dysphagia for solids but not liquids
        • compress the left recurrent laryngeal nerve resulting in hoarsness
    • pressure is propagated proximally to the stenosis 
      • pulmonary capillary wedge pressure (PCWP) is elevated
      • Elevation in pressure is not seen past the stenosis
        • HOWEVER left ventricular end diastolic pressure is typically normal i.e., in mitral stenosis PCWP does NOT reflect LVEDP
        • The transmitral gradient is elevated 
Mitral Regurgitation
  • Introduction
    • major causes include
      • rheumatic fever
      • chordae tendonae rupture 
      • mitral valve prolapse
    • results in retrograde blood flow into left atria, leading to increased LV end-diastolic volume and increased left atrial volume
    • dilatation of the left atrium as well as dilation and hypertrophy of the left ventricle are late manifestations of chronic disease 
  • Symptoms/physical exam
    • presents with a range of symptoms including
      • dyspnea
      • orthopnea
      • fatigue
    • symptoms develop if regurgitation develops acutely or if the atria can no longer compensate in a chronic problem 
    • chest auscultation reveals
      • holosystolic murmur that radiates to the axilla  
Tricuspid regurgitation
  • Introduction
    • two major causes include
      • carcinoid heart disease
        • tumor of GI tract metastasizes to liver
          • note: must metastasize to liver because any hormones produced distal to the liver in the venous system would be metabolized by MAO in lungs
        • produces serotonin which fibroses the tricuspid and pulmonary valves
      • IV drug use
        • results in right heart endocarditis (S. aureus)
  • Symptoms/physical exam
    • pulsating liver
      • due to ↑ venous pressures behind the right heart
    • chest auscultation reveals
      • pansystolic murmur
        • ↑ intensity during inspiration due to ↑ venous return to right heart

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