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5. c) Pure i) stenosis or regurgitation d) mixed i) stenosis and regurgitation coexist in same valve - usually 1 defect predominates e) isolated i) 1 valve f) combined i) more than 1 valve dysfunctional www.freelivedoctor.com

6. g) flow anomalies through valves produce turbulent flow patterns i) murmurs h) acquired valvular heart disease **ii) students should be able to match various heart valve diseases with both the specific valve involved and whether the disease is a stenosis, regurgitation or both www.freelivedoctor.com

7. iii) most frequent causes: - AS  calcification of congenitally deformed valve - AI  dilation of ascending aorta (e.g., hypertension and aging) - MS  RHD - MI  mitral valve prolapse (myxomatous degeneration) www.freelivedoctor.com

9. b) deformations during each beat c) pressures on valves in closed phase i) 120 mmHg  mitral valve ii) 80 mmHg  aortic valve d) the factors listed above (a,b,c) contribute to valvular damage seen by calcium deposits (Calcium Phosphate) i) 1 0 dystrophic calcification (different from atherosclerosis) - calcific AS - mitral annular calcification www.freelivedoctor.com

11. f) Clinical: i) LV outflow obstruction - LV compensates by  LVP to ~ 200 Hg  develops - LV concentric hypertrophy (pressure overload !!): CHF - ischemic myocardium  - angina may appear - systolic and diastolic impairment (e.g., syncope) ii) the S & S above indicate decompensation (poor progno.) www.freelivedoctor.com

13. i) larger leaflet increases calcification ii) once stenosis occurs, progression is similar to normal aortic valve d) bicuspid aortic valves may be acquired (RHD)  fused leaflets e) other causes of bicuspid aortic valve incompetence i) aortic dilation ii) cusp prolapse iii) infective endocarditis www.freelivedoctor.com

14. A . Acquired bicuspid aortic valve with secondary calcification. At the center of the conjoined cusp (lower center) are elements of two preexisting cusps, now fused. B. Congenital bicuspid valve. The characteristic raphe of the congenital bicuspid aortic valve appears at the lower portion of the figure. C. Senile type. None of the commissures is fused, but there is a major intrinsic calcification of the three cusps. D. Unicuspid, unicommissural congenital aortic stenosis with secondary calcification. A B C D www.freelivedoctor.com

15. Calcific aortic stenosis occurring on a congenitally bicuspid valve. One cusp has a partial fusion at its center, called a raphe (arrow). www.freelivedoctor.com

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19. c) affected leaflets are thickened i) due to mucoid deposits (“ Myxomatous ”) ii) cords are usually elongated thinned and often ruptured iii) annular dilation characteristic - leaflets balloon - rare in other mitral insufficiencies iv) thrombi formation - behind ballooned cusps (on leaflets) www.freelivedoctor.com

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22. d) clinical: i) most asymptomatic - midsystolic “click” ii) ~3 % develop complications: - infective endocarditis - mitral insufficiency (requiring surgery) - stroke - arrhythmias (atria & ventricular - - “sudden death”) iii) if complications  surgery www.freelivedoctor.com

24. c) consequence of RF is chronic valvular deformities (fibrosis) i) mitral and aortic - mainly mitral stenosis - permanent www.freelivedoctor.com

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27. b) RHD – chronic i) organized acute inflammation - fibrosis  ii) leaflet thickening iii) commissure fusion (stenosis) - “buttonhole” or “fishmouth” stenoses iv) cord fusion / thickening v) Aschoff bodies replaced with fibrous scar www.freelivedoctor.com

28. Stenotic mitral Valve seen from left atrium. Both commissures are fused; the cusps Are severely thickened.The left atrium is huge. The valve is both incompetent and stenotic www.freelivedoctor.com

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30. Opened stenotic mitral valve showing thickening distorted cusps, adherent commissures with calcification and thrombus deposition, and thickening, fusion and shortening of chordae tendinae www.freelivedoctor.com

31. vi) major cause of mitral stenosis - ~ 99% - mitral valve alone ~ 70% - mitral / aortic valve ~ 25% c) etiology unknown i) believed to result from connective tissue defects -  in Marfan Syndrome www.freelivedoctor.com

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37. iii) other factors - calcific stenosis - prosthetic valves - bicuspid aortic valve - immunodeficiency - neutropenia - diabetes - alcohol c) causative organisms i) Strep viridans (50-60%) - previously damaged native valve www.freelivedoctor.com

38. ii) Staph aureus (10-20%) - found on skin -  virulence - attack normal or damaged valves - i.v. drug users !! iii) HACEK group - H aemophilus - A ctinobacillus - C ardiobacterium - E ikenella - K ingella www.freelivedoctor.com

40. i) chills ii) weakness iv) immune mediated GN v) murmurs (~90%) - left side lesions b) subacute (mild or absent T o ) - fatigue - flu-like symptoms - weight loss www.freelivedoctor.com

41. www.freelivedoctor.com Common Manifestations of Infective Endocarditis . Splinter hemorrhages (Panel A) are normally seen under the fingernails. Panel B shows conjunctival petechiae. Osler's nodes (Panel C) are tender, subcutaneous nodules, often in the pulp of the digits or the thenar eminence. Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles.

43. e) frequently occur with DVT and PE i) common origin with hypercoagulable states - may be related to some underlying disease, such as pancreatic cancer, leukemia, burns and sepsis, DIC - indwelling catheters (SG) induce right valve lesions www.freelivedoctor.com

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