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Pulmonary Valve
The pulmonary valve sits between the right ventricle and the pulmonary artery.
Pulmonary Stenosis
- 80% of right ventricular outflow obstruction
Causes
- Congenital issue
- Thickened leaflets
- Tetralogy of Fallot
Clinical Presentation
- Most are asymptomatic
- Murmur
- The left sternal border in the intercostal spaces 2–4
- Crescendo-decrescendo ejection murmur without radiation
- Wide splitting of S2 (takes longer to empty RV)
- Heard best with patient leaning forward and Valsalva will enhance the murmur
- Cyanosis
- Dyspnea
- Dizziness
Labs & Studies
- Echocardiogram is diagnostic
Treatment
- Follow with Echocardiogram
- Valvotomy
- Valve repair
- Valve replacement
Pulmonary Regurgitation
Causes
- Congenital
- Pulmonary HTN
- Endocarditis
- Rheumatic heart disease
- Myocardial infarct
- Plaque
- Iatrogenic
Physical Exam Findings
- Routine medical exam
- – Mild cases are well tolerated and have few or no symptoms
- Severe cases may have right ventricular hypertrophy
- Severe cases may have right heart failure
- Murmur
- Early diastolic decrescendo murmur
- Heard best with patient sitting up and holding their breath at end expiration
- Left sternal border
- May radiate to the right sternal border
Labs & Studies
- ECG may show right ventricular hypertrophy
- Echocardiogram with doppler will show extent of regurgitation
- Cardiac cath may be used to gain more information
Treatment
- Pulmonary regurgitation is by itself is well tolerated and typically does not require treatment
- Valve may be replaced or repaired
- Underlying causes should be addressed, pulmonary regurgitation is a symptom of a bigger problem.
Mitral Valve (bicuspid)
- The mitral valve sits between the left atrium and the left ventricle.
- Memory trick – There is a an L in mitral and not in tricuspid, L for left.
- If the mitral valve does not open sufficiently you can visualize how the backup will go and eventually cause congestion in the lungs.
Mitral Valve Stenosis
Causes
- Rheumatic heart disease
Clinical Presentation
- Routine medical exam
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea secondary to pulmonary congestion
Physical Exam
- Murmur
- Opening snap following S2
- Heard best at the apex of the heart
- No radiation
- Decrescendo-Crescendo diastolic
- Listen at the end of expiration in the left lateral decubitus position.
- Valsava or exercise will exacerbate the murmur
- Tachycardia possible
- Rales secondary to pulmonary congestion
Labs & Studies
- ECG
- – Atrial Fibrillation
- Echocardiogram with Doppler – is diagnostic
- Cardiac cath is often used to assess the overall health of the heart in this situation
Treatment
- Atrial fibrillation
- – Cardioversion
- – Warfarin
- Pulmonary congestion
- – Diuretics
- – Vasodilators
- Surgery
- – Percutaneous balloon valvuloplasty
- – Valve replacement
Mitral Valve Regurgitation
- When the left ventricle contracts blood leaks back into the the left atrium.
- An increase in preload and an increase ejection fraction.
- Long term causes an enlarged left ventricle and a decreased ejection fraction.
- Eventually leads to pulmonary congestion.
Causes
- Congenital
- Degenerative mitral valve disease
- Mitral valve prolapse is the most common cause
- – Thin females are most common for mitral valve prolapse
- Rheumatic heart disease (obviously less often now)
- Trauma
- Myocardial infarction
- Ruptured chordae tendineae (caused by MI or endocarditis most likely)
- Endocarditis (regurge will also put a patient at increased risk of endocarditis)
- Cardiomyopathy
Clinical Presentation
- Routine medical exam both mitral prolapse and regurgitation may be asymptomatic for years.
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea secondary to pulmonary congestion
Physical Exam Findings
- Murmur
- Pansystolic blowing murmur at the apex and radiating to the axilla
- Left lateral decubitus
- Decrease with valsalva or standing
- Increase with hand grip or squatting
- S3 may be present indicating heart failure
- Mitral valve prolapse has a midsystolic click
- Brisk carotid upstroke
- Rales secondary to pulmonary congestion
Labs & Studies
- ECG
- – Atrial Fibrillation
- – Left ventricular hypertrophy
- Echocardiogram with Doppler will show flow of blood and assess severity of regurgitation
- Cardiac cath may be used for further assessment
Treatment
- Atrial fibrillation
- – Cardioversion
- – Warfarin
- Pulmonary congestion
- – Diuretics
- – Vasodilators
- Surgery
- – Valve repair
- – Valve replacement
Tricuspid Valve
The tricuspid valve sits between the right atrium and the right ventricle.
Tricuspid Regurgitation
Causes
- Right ventricular hypertrophy (tricuspid regurgitation also causes right ventricular hypertrophy)
- Pulmonary hypertension often caused by left-sided heart failure
- Ebstein’s anomaly – congenital heart defect with displaced tricuspid leaflets
- Tricuspid prolapse
- Endocarditis
Clinical Presentation
- Exertional dyspnea
- Chest pain
- Swelling of feet and ankles
- Neck pulsations due to increased jugular pressures
Physical Exam Findings
- Murmur
- Along the lower left sternal border.
- It is holosystolic blowing and radiates to the right sternum and xiphoid.
- Heard best with he patient sitting up
- Jugular venous distention
Labs & Studies
- ECG may show abnormal p wave due to enlarged right atrium
- Chest X-ray – enlarged right atrium
- Echocardiogram with Doppler can assess severity
- Cardiac cath can be used for more information
Treatment
- Diuretics to decrease fluid volume
- Salt restrictions to decrease fluid volume
- If pulmonary hypertension is a problem treat it with arterial vasodilators
- Surgical valve repair
- Valve replacement
Study Tip
A tale of two attitudes.