Valvular emergencies

Mitral Stenosis

• Most common cause is rheumatic heart dz

Diagnosis

• Mid-diastolic murmur
• Symptoms
  • Exertional dyspnea
  • PND
  • Acute pulmonary edema
  • R-sided HF symptoms
  • Hemoptysis (pulm htn > ruptured bronchial vein)
  • Precipitants:
    • Anemia
    • Pregnancy
    • Infection
    • A-fib
• ECG
  • RAD
  • Biphasic P waves
• CXR
  • Straightening of right heart border

Treatment

• Diuretics
  • Alleviates pulmonary congestion
• A-fib treatment
• Hemoptysis
  • Consider transfusion / surgery consult

Mitral Regurgitation

• Chronic
  • Most common cause is ischemia/infarction
• Acute
  • Most common cause is papillary / chordae rupture

Diagnosis

• Acute MR
  • Suspect if new-onset pulm edema + normal heart size
  • Severe dyspnea, tachycardia, pulmonary edema
  • Cardiogenic shock may develop
  • S4, apical systolic murmur

Treatment

• Decrease pulmonary edema
  • O2, nitrates, diuretics
• Increase forward flow
  • Decrease afterload
  • Consider nitroprusside in normotensive pts

Aortic Stenosis

Diagnosis

• Dyspnea, CP, syncope
  • Once symptoms present mean surival is 2-3yr
• Late systolic murmur radiating to carotids
• Pulsus parvus et tardus
• Narrowed pulse pressure

Treatment

• Admission
• Avoid BBs, CCBs
• Avoid afterload reduction
  • SV is fixed so could lead to profound hypotension
• AS + A-fib = emergency
  • Consider emergent cardioversion
• Pulm edema
  • Diuretics, intubation if necessary
  • Caution with use of nitrates/vasodilators

Aortic Regurgitation

• Causes
  • Endocarditis
  • Aortic dissection
  • Blunt chest trauma

Diagnosis

• Pulmonary edema
• Wide pulse pressure
• Dyspnea
• Hypotension (may progress to cardiogenic shock)
• Diastolic murmur heard immediately after S2
• CXR
  • Pulmonary edema w/o cardiac enlargement

Treatment

• Immediate surgical intervention
• Reduce afterload
  • Nitroprusside
• Diuretics and nitrates don't work
• Don't use beta blockers (block compensatory tachycardia)

See Also

Heart Murmurs

Source

Tintinalli