PANCE - Valvular Disease

Here are key facts for PANCE from the Valvular Disease tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Definitions: Stenosis* = narrowed valve orifice impeding forward flow. Regurgitation/Insufficiency* = valve fails to close → backward flow. 2. Most Common Valvular Disease:

• Aortic stenosis from degeneration and calcification with age; due to hydroxyapatite deposition.

3. Bicuspid Aortic Valve (BAV):

• Present in \~1% of the population; accelerates calcification and stenosis.
• May be congenital or result from rheumatic heart disease.

4. Marfan Syndrome and Aortic Regurgitation:

• Connective tissue disorder associated with aortic root dilation, which can lead to aortic insufficiency.

5. Mitral Stenosis and Rheumatic Heart Disease:

• Post-rheumatic fever complication with characteristic “fish mouth”/buttonhole deformity.
• Fusion of leaflets and chordae tendineae.

6. Mitral Valve Prolapse (MVP):

• Leaflet ballooning during systole → regurgitation.
• Associated with myxomatous degeneration, calcification, and risk of stroke.

7. Mechanical vs. Bioprosthetic Valves: Mechanical*: Durable, high thrombosis risk → requires anticoagulation (e.g., warfarin). Bioprosthetic*: Less durable, lower thrombosis risk, less likely to need anticoagulation. 8. Risk of Infective Endocarditis:

• Increased in patients with prosthetic valves or valvular calcification.
• Antibiotic prophylaxis recommended for dental procedures that breach the gingiva.

9. Semilunar Valve Structure:

• Aortic valve: right, left, and posterior (non-coronary) cusps.
• Pulmonary valve: anterior, right, and left cusps.
• Prevent backflow into ventricles during diastole.

10. AV Valve Anatomy and Support:

• Mitral valve: anterior and posterior cusps, subdivided into A1–3 and P1–3.
• Chordae tendineae connect cusps to papillary muscles; disruption leads to functional regurgitation.

11. Annular Ring and Commissures: Annulus*: fibrous ring anchoring valve leaflets. Commissures*: points of leaflet attachment to the heart wall. 12. Myxomatous Valve Changes:

• Spongiosa layer deposits cause rubbery, thickened leaflets in prolapsed/calcified mitral valves.

13. Thrombus Formation in Valve Disease:

• Seen in mitral valve calcification, raises stroke risk.

14. Chronic Valvular Injury:

• Repetitive deformation (\~30 million contractions/year) causes structural damage and dysfunction.

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15. Nodule of Arantius:

• Central thickening on free edge of semilunar valve leaflet.

16. Lunule:

• The margin (free edge) of a semilunar leaflet.

17. Coronary Artery Origins:

• Arise from right and left aortic sinuses just above the aortic valve.

18. Sinotubular Junction:

• Marks the transition between sinuses of Valsalva and the aorta/pulmonary trunk.

19. Papillary Muscle Role:

• Anchors AV valve leaflets; dysfunction leads to functional regurgitation (especially post-MI).

20. Valve Leaflet Naming:

• Aortic cusps named for their proximity to coronary ostia (right coronary, left coronary).

21. Functional Regurgitation:

• Caused by structural dysfunction (e.g., rupture of papillary muscle), not primary valve defect.

22. Mitral Valve Subdivision:

• A1–A3 and P1–P3 segments allow for precise surgical repair planning.

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23. Classic Murmur Findings: Aortic stenosis*: systolic crescendo-decrescendo murmur, radiates to carotids. Aortic regurgitation*: early diastolic decrescendo murmur, wide pulse pressure. Mitral stenosis*: opening snap + diastolic rumble, best heard at apex in left lateral decubitus. Mitral regurgitation*: holosystolic murmur, radiates to axilla. 24. PANCE Diagnostic Modalities:

• First-line: transthoracic echocardiogram (TTE).
• TEE if poor windows or prosthetic valve/endocarditis suspected.
• CXR may show LA or LV enlargement.

25. Indications for Surgery:

• Symptomatic severe stenosis or regurgitation.
• Asymptomatic severe disease with LV dysfunction (EF <60%), LV dilation, or pulmonary hypertension.

26. Endocarditis Prophylaxis Guidelines (AHA/ACC):

• Needed in high-risk patients for dental, respiratory, or infected tissue procedures.

Amoxicillin* commonly used (unless allergic). 27. Pregnancy Considerations:

• Mitral stenosis worsens in pregnancy due to increased preload.
• Prefer bioprosthetic valves in women of childbearing age to avoid warfarin.

28. Post-Valve Replacement Management:

• Lifelong anticoagulation for mechanical valves (goal INR 2.5–3.5).
• Routine surveillance echocardiograms to monitor prosthetic function.

29. Complications of Valvular Disease:

• Heart failure, atrial fibrillation, stroke, thromboembolism, infective endocarditis.

30. Balloon Valvuloplasty:

• Treatment for mitral stenosis in select non-calcified cases (especially in young patients).