Emergency Medicine, Heart Valve Emergency, Emergency Cardiology, by Rashid Abuelhassan

2. A 67-year-old man presents to
the ED with sudden onset of
chest pain and shortness of
breath. He is 5 days status-post
inferior wall myocardial
infarction. On examination the
patient has pulmonary edema
and a loud holosystolic murmur
heard best at the left lateral
sternal border, with adiation to
the base.
What is the most appropriate
initial management?
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3. 3

4. Non of my business , what else? 4

5. • How Is it an Emergency ?
• How to know ?
• Rheumatic heart Disease
& Infective indocarditis
• Understand ECHO
images
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6. • ↑ stroke rate 3.2 times
• ↑ death rate 2.5 times
• Mitral prolapse is the most
common.
• 3% annnual mechanical valve
complications
• systemic embolization from a
prosthetic valve is 1% /yr.
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9. • Innocent (e.g. anemia, thyrotoxicosis,
sepsis, fever, renal failure, and pregnancy)
• New = N T
• Diastolic Murmur = !!??
• Chronic
e.g. Mitral (RHD)  AF, P-HTN , RVF
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10. • Stenosis < 2 cm2 (4-6cm2)
• C/O  ↓ exercise, DOE, orthopnea,
RVF Also hoarseness & dysphagia
(Ortner’s Syndrome)
• O/E  small impulse, low sBP, , thin
body habitus, p. cyanosis, and cool
extremities
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loud S1 , opening snap in early diastole low-pitched
rumbling diastolic apical murmur.

11. INVESTIGATIONS
ECG , CXR, ECHO
TREATMENT
■ atrial fibrillation.
■ Anticoagulate if systemic embolization
■ Prophylaxis for endocarditis.
■ Cautious diuretic use.
■ Percutaneous balloon/operative repair.
■ Valve replacement is a last resort.
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severe mitral stenosis  avoid strenuous physical activity
If hemoptysis occurs –> thoracic surgery may be warranted

12. Valvoplasty 12

13. COMPLICATIONS
■ Atrial fi brillation
■ pulmonary hemorrhage
■ Pulmonary HTN and Rt HF
■ Systemic emboli
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Chronic Acute
C/O
-Often asymptomatic
-Gradual dyspnea on
exertion and fatigue
-Palpitations (AF )
-Abrupt dyspnea, tachypnea,
Cardiogenic shock, Chest pain
-Symptoms of (endocarditis, MI,
trauma )
O/E holosystolic, at the apex
and radiating to the axilla
midsystolic murmur radiates to
the base not the axilla. +
Pulmonary edema
Patients may deteriorate quickly due to
cardiogenic shock or cardiac arrest

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Chronic Acute
ECG
left atrial and ventricular
hypertrophy.
Atrial fibrillation and P mitrale
- no atrial enlargment
- no LVH
o/e
minimally enlarged left atrium,
pulmonary edema, left ventricular
enlargement
Normal cardiac silhouette,
pulmonary edema

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Chronic Acute
■ Treat CHF & AF
■ Anticoagulate if
systemic embolization
■ Endocarditis
prophylaxis
■ Valve replacement
■ pulmonary edema ttt.
■ Nitroprusside for afterload reduction
(increases forward output by increasing
aortic flow and partially restoring mitral
valve competence as left ventricular size
diminishes)
■ Dobutamine if hypotensive.
■ Intra-aortic balloon pump as bridge to
surgery.
■ Immediate valve replacement.
■ Treat the underlying disease process.

19. • presents
– with acute episodes of respiratory distress
due to pulmonary edema and
asymptomatic in between attacks
– Pronounced dyspnea may mask angina
that accompanies the ischemia
• Treatment
– Aortic balloon counter pulsation
– Surgery may be warranted if mitral valve rupture
– Evaluate for endocarditis
– Treat atrial fibrillation with heparin, control ventricular
rate with beta blockers and calcium channel blockers
– Keep INR 2-3
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20. • Common, specially
young thin females.
• autosomal dominantmainly
• association with anxiety dis.
and ↓BMI.
PATHOPHYSIOLOGY
Myxomatous proliferation of
leaflet → abnormal stretching
of valve leaflets during systole
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21. SYMPTOMS
asymptomatic, Atypical chest pain,
Palpitations, Lightheadedness, Dyspnea.
EXAM
■ Early to midsystolic click with high-pitched
late systolic murmur best at left lateral
border
■ standing→ earlier and greater prolapse →
accentuates the click +moves it closer to S1
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TREATMENT
■ asymptomaticNo treatment.
■ Proph. endocarditis if regurgitation or
thickened valve leaflets.
■ β-Blockers may help with atypical
chest pain
DIAGNOSIS
■ ECG: Nonspecific c ST-T wave
changes, (PSVT)
■ CXR: NAD
■ Echo

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Complications
 Stroke
 Endocarditis
 Tachydysrhythmias (atrial and ventricular)
 PSVT (most common dysrhythmia)
 Increased incidence of WPW, PACs, PVCs
 Ventricular tachycardia (VT) possible
 Sudden death ( Risk factors include syncope/pre-
syncope, inferolateral ST-T changes and thickened or
redundant valve leaflet on TTE).

24. A 72-year-old woman is brought to the ED
following a syncopal event.
She reports orthopnea and vague,
intermittent chest pain, both present for the
past 6 months.
o/e : BP of 108/84, rales at both lung bases,
a prolonged apical impulse, and a loud
systolic murmur radiating into her neck.
What test will confirm the most likely
diagnosis?
What medication is important to avoid in
this patient?
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25. Angina + Syncope + Dyspnea(dCHF)
- >65 years, calcified valve degeneration.
- younger patients congenital bicuspid valve.
- Rheumatic heart disease (less common)
specially if mitral valve diseased.
Pathophysiology
■ LV outflow is obstructed → LVH, ↓ cardiac output,
and eventual dilated cardiomyopathy with
hypertrophy.
■ signs or symptoms if aortic outflow is ↓75% (to < 1
cm).
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26. EXAM
■ Narrowed pulse pressure
■ Heaving, prolonged apical impulse
■ Crescendo–decrescendo systolic to the neck
■ CHF symptoms
DIAGNOSIS
■ ECG: LVH with strain, left bundle branch block.
■ CXR: LVH, pulmonary congestion .
■ Echocardiography: Confirms & measures.
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Angina + Syncope + Dyspnea(dCHF)
Exercise stress testing may provoke dysrhythmias and
is contraindicated.

27. Aortic valve stenosis 27

28. Bicuspid aortic valve 28

29. TREATMENT
■ Treat CHF with gentle diuresis.
■ Rule out ACS in acute presentations.
■ Hydrate gently for hypotension.
Avoid:
■ Preload or afterload reducers (no nitroglycerin)
■ Negative inotropes.
■ Prophylaxis for endocarditis.
■ Definitive treatment is valve replacement.
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Complications
■ Sudden death from dysrhythmias or acute onset of failure may occur
■ Survival is 2–5 without replacement.

30. ETIOLOGIES
Acute aortic regurgitation
■ Infective endocarditis
■ Aortic dissection with proximal extension
■ Trauma
■ Prosthetic valve dysfunction
Chronic aortic regurgitation
■ Rheumatic heart disease
■ Bicuspid aortic valve
■ Dilation of the aortic root (Marfan, ankylosing
spondylitis, rheumatoid arthritis)
PATHOPHYSIOLOGY
Acute aortic valve failure → rapid rise in LV
diastolic pressure → acute pulmonary edema
and cardiogenic shock
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Acute Chronic
C/O
-Abrupt onset of dyspnea
-fever(endocarditis)
-Chest pain ( if aortic dissection)
Gradual onset of dyspnea on exertion,
orthopnea, nocturnal dyspnea
EXAM
- Tachycardia, tachypnea
- Pulmonary edema and
cardiovascular collapse
- High-pitched blowing diastolic
murmur heard best at left
sternal border
- Normal pulse pressure
■ Widened pulse pressure (opposite of AS)
■ same diastolic murmur.
■ Austin Flint murmur (mid-diastolic rumble)
■ “Water hammer” pulse
■ Quincke’s sign
■ Duroziez’s murmur
■ De Musset sign
■ Congestive heart failure

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Acute Chronic
work
- ECG : normal
- CXR: Pulmonary edema.
-ECG: LVH, left atrial enlargement.
- CXR: Congestive heart failure.
TREATMENT
-Standard for pulmonary edema
- Nitroprusside for afterload reduction
- Dobutamine (in addition to
nitroprusside) if hypotensive
- Immediate valve replacement
- Antibiotics: If endocarditis suspected
- Avoid: Intra-aortic balloon pump
■ Nifedipine for asymptomatic AR
■ Afterload reducers, digoxin,
hydralazine, and surgical referral for
elective valve replacement for
symptomatic AR
■ Prophylaxis for endocarditis

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34. CAUSES: right ventricular
dilation (pulmonary HTN),
endocarditis, and rheumatic
heart disease.
SYMPTOMS Fatigue,
Dyspnea, Lower extremity
swelling
EXAM: Holosystolic murmur
at left lower sternal border
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DIAGNOSIS
■ ECG: Right atrial and ventricular
enlargement, atrial fi brillation (in the majority
of cases).
■ Echo is confirmatory.
TREATMENT
■ Treat atrial fibrillation.
■ Endocarditis prophylaxis

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Complications
●Systemic embolization
●Bleeding
●Valve obstruction due to thrombosis or
pannus.
●Endocarditis
●Structural deterioration, particularly with
bioprosthetic valves
●Paravalvular regurgitation ( leak )
●Hemolytic anemia
●Patient-prosthesis mismatch
● abrupt mechanical valve failure

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SYMPTOMS/EXAM
■ Vary with location and rapidity of valve
failure
■ Findings of severe anemia (due to hemolysis)
■ Findings consistent with aortic/mitral
regurgitation (acute or chronic)
■ Muted mechanical valve sounds, if
mechanical valve failure

40. Percutaneous Aortic “Valve in Valve”
Implantation for Severe Aortic Regurgitation in
a Degenerated Bioprosthesis
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41. Targeted INR is
- 3.0 - 3.5  mitral valve.
- 2.5 - 3.0  aortic valve.
sudden  acute onset of hypotension, CHF
 Muted mechanical valve sounds
 gradual course discovered on ECHO
TREATMENT
■ Anticoagulation ■ Valve replacement
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ETIOLOGIES MURMUR PHYSICAL FINDINGS
AS
Calcific valve
Bicuspid valve
Cresc–dec systolic
Radiating → neck
Paradoxically split S2
Narrowed pulse pressure
Diminished and slow-rising carotid pulse
AR
Endocarditis
Aortic dissection
Blowing diastolic Heard best at
left sternal border
Acute > Pulmonary edema and CV collapse
Chronic > “Water hammer” pulse ,
Quincke’s sign, Duroziez’s murmur, De
Musset sign
MS Rheumatic heart Diastolic Heard best at apex Loud S1
MR
Endocarditis,
ACS
Loud holosystolic Heard best at
apex Radiating → base
Acute : Pulmonary edema and CV collapse
Chronic: LV heave
MP
Unknown, likely
congenital
Late systolic heard best at left
lateral heart border
Early to mid systolic click

44. ■ In a patient with severe mitral stenosis, hypovolemia and tachycardia
are poorly tolerated. “Slow and full” are appropriate goals.
■ In patients with critical aortic stenosis, excessive preload reduction
with vasodilators and diuretics is to be avoided.
■ In patients with acute aortic insufficiency, classic physical findings
may be absent. Medical stabilization entails the cautious use of
vasodilators and diuretics. Intra-aortic balloon counter pulsation is
contraindicated.
■ Complications of prosthetic heart valves range from structural failure
and thrombosis to systemic embolization, hemolysis, and
endocarditis.
■ admission depends on severity of symptoms not presence of
murmur unless aortic stenosis and syncope is suspected.
■ Valvular heart Disease pt. at risk for recurrent cardiovascular event.
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