Symptoms of pulmonary congestion (dyspnoea, cough, and occasionally haemoptysis)
Signs of pulmonary venous congestion
HS: loud S1, early opening diastolic snap, rumbling (mid-)diastolic murmur, presystolic accentuation of the diastolic murmur (if in sinus rhythm).
Enlarged left ventricle
Well-preserved carotid pulsation
HS: Apical pansystoilc murmur, S3 (often present)
HS in MR due to prolapse: systolic click (usually mid-systolic) usually followed by a murmur extending till the end of systole.
Triad: Angina, Syncope (exertional), Dyspnoea
Symptoms of heart failure
Sustained slowly rising cartoid pulse
HS: Mid- to late-peaking systolic murmur radiating to the neck (murmur may be soft in severe AS).
HS: In congenital aortic valve deformity, ejection click may be heard, which is then followed by the murmur.
HS: In severe AS, S4 and paradoxical splitting of S2 (P2 then A2)
A collapsing (water-hammer) pulse with wide pulse pressure
Other signs indicating severe disease:
HS: Aortic early diastolic murmur
HS: (sometimes) mid-systolic murmur due to increased flow
HS: (sometimes) an apical mid-diastolic murmur (Austin-Flint murmur) due to aortic backflow closing the mitral valve
Two dimensional and doppler echocardiography (for all patients)
Transoesophageal echocardiography (TEE) (for mitral lesions)
Preoperative coronary angiography to determine the extent of coronary artery disease in patients considered for surgical treatment of the valves.
Treat heart failure if present.
Anticoagulant therapy recommended except in mild MS.
Beta-blockers or calcium channel blockers to slow heart rate.
Treatment of atrial fibrillation.
Consider diuretics for treatment of pulmonary congestion and oedema.
Percutaneous ballon mitral valvuloplasty
Valve replacement
Open valvotomy and valvuloplasty
Consider anticoagulation therapy (atrial fibrillation occurs in late stages of MR)
Consider diuretics for treatment of pulmonary congestion and oedema
Nitrate, digoxin, vasodilators may improve systolic function
Mitral valve repair or replacement
75% of patients with symptoms will die within 3 years unless valve is replaced.
Digoxin
Avoid: diruretics, nitrate.
Aortic valve replacement. (Also consider PTCA or CABG at the time of AVR, if there is coexisting coronary disease)
Intra-aortic ballon counterpulsation
Percutaneous ballon aortic valvuloplasty (use only if poor surgical candidate for AVR)
Fluid and salt restriction, diuretics, digoxin, and vasodilators.
Aortic valve replacement
(most common causes underlined)
Abnormal leaftlets
Abnormal tensor apparatus
Abnormal ventricle
Intrinsic valvular disease
Aortic disease
Prophylaxis against endocarditis should be considered with patients (with acquired valvular heart disease) undergoes certain procedures:
Use:
Amoxycillin 2g (or ampicillin if IM/IV) as a single dose.
If PO, use 1hr before. If IM, 30min before. If IV, just before procedure.
For penicillin allergies, use instead:
PO:
Clindamycin 600mg,
OR
Cephalexin 2g
IV:
Clindamycin 600mg,
OR
Lincomycin 600mg,
OR
Vancomycin 1g,
OR
Teicoplanin 400mg.
Use:
Gentamicin 2mg/kg IV/IM
PLUS
Amoxycillin or Ampicillin 2g IV/IM
FOLLOWED BY
Amoxycillin or Ampicillin 1g IV/IM/PO 6 hours later
For penicillin allergies, substitute for amoxycillin or ampicillin:
Vancomycin 1g IV,
OR
Teicoplanin 400mg IV
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Created | 20031030 |
Updated | 20031102 |