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Current time:0:00Total duration:9:46

Valvular heart disease diagnosis and treatment

Video transcript

so the last topic that we should talk about is the diagnosis and treatment of valvular heart disease any good diagnostician will tell you that the majority of the diagnosis is made are based on a good HMP or history and physical now these valvular conditions are all very different there are multiple valves and there are multiple things that can go wrong with them but in general you should be able to elicit certain things from a history and physical exam that will point you in the direction of the heart and you move forward with different diagnostic tests to then confirm your diagnosis so let's start with history on history you want to know if the patients had any chest pain any shortness of breath any trouble with exercise or exercise intolerance any swelling and maybe in their extremities and maybe a chronic cough and again none of these are really specific for valvular heart disease but they could all point you in the direction of something going wrong with the heart and maybe some history of syncopal episodes or fainting or any palpitations on physical exam you want to look for any jugular venous distention or jvd assign that blood is kind of backing up in the right heart or any extra heart sounds like an s3 or an s4 changes in blood pressure or wide pulse pressure or different blood pressures in the arms can all lead you to think that maybe there's something wrong with the heart a change in pulse so maybe the pulse is not regular and there could be an arrhythmia that's associated with a primary valvular heart condition you can feel for the PMI or the point of maximal impulse and see if it's where it normally should be you can look for any edema usually in the extremities and in the gravity dependent portions of the body so usually the feet and ankles and finally one that is somewhat specific to valvular heart disease is listen for a murmur and so a murmur is just turbulent blood flow through a valve so how do we listen for a murmur well we use our stethoscope and we listen here in the right upper sternal border and then the left upper sternal border and then the left lower sternal border left mid to lower and then in the fifth intercostal space in the midclavicular line and this is also called the apical area and the right upper sternal border is usually indicative of aortic pathology the left upper sternal border is usually indicative pulmonic pathology the mid to lower left sternal border is usually tricuspid but can be aortic and the apex or mitral area is usually indicative of mitral valve pathology so now once you've elicited a good history from someone and you've done a thorough physical exam now maybe it's time to move on to some of your diagnostic tests so what are our options so with this history and physical some people may jump to an EKG or an electrocardiogram which measures the electrical impulses in the heart or a chest x-ray which will abbreviate cxr and so the EKG kind of looks like this and I'm sure you've all seen drawings of that and from this you can tell if someone has an arrhythmia and you can also tell if maybe some of the chambers of the heart are bigger or more muscular and you can also diagnose things like a heart attack and with the chest x-ray you can tell us the heart is dilated or larger and so if the heart silhouette that I've outlined here is actually larger than 50% of the thoracic cavity that I'm showing now and that's actually considered cardiomegaly meaning the heart is big and that could be a indication that there's something wrong with the valves but it's not necessarily specific now when we talk about the gold standard for diagnosing valvular heart disease we talk about echocardiography or simply known as echo and this is the use of sound waves to actually image the heart in real-time and so you'll see an example here and this is a specific view called the for chamber view and that's because there's one two three and four chambers that you can see and there are many other views that are used and those views can see the other valves that aren't shown in this one like the aortic and the pulmonic and they show them in real time and there are also certain modes of echo that can show you the actual flow of blood and if it's traveling in the right direction or the wrong direction and you can get a lot of good measurements from this that can really give you a firm diagnosis of valvular heart disease and quantify how bad the valvular heart disease whether it's mild regurgitation or stenosis to severe regurgitation or stenosis and so again this test is diagnostic for valvular heart disease and it is also the gold standard so what happens if for some reason the echo is inconclusive meaning you can't really tell from it if someone's got valvular heart disease well now you can go to a little bit more invasive of a test called a cardiac catheterization or just a cardiac cath and so what they'll do here is we'll take a catheter or a wire and stick it in one of the major arteries so here something like the femoral artery that I'm circling on this and I'm not sure if you'll be able to read that but that says femoral artery and so they stick this catheter in your femoral artery and they move it all the way up into the aorta and into the left side of the heart and in here that little catheter has a pressure transducer on it and it can measure pressures in the different chambers and pressures across the different valves that separate the chambers and there are standards for these measurements and depending on what the measurements are on the particular patient the cardiologists can use the results from this and different pressure tracings to actually diagnose valvular heart disease and this is very accurate but slightly more invasive usually patients don't need this to diagnose valvular heart disease so now that we've pretty much diagnosed valvular heart disease in a patient we need to know what our treatment options are and again they're different based on what the actual valve condition is but in general you have medical treatment and you have surgical treatment so for medical treatment because these are all very different conditions there's no one regimen that works for everyone but in general what we're trying to do with medical therapy is to just optimize the cardiac physiology so that we can stop the condition from progressing and you'll hear people talk about all the common cardiac drugs such as beta blockers and calcium channel blockers and ACE inhibitors and diuretics and a lot of these are really aimed at optimizing physiology so that these conditions don't progress so lowering the pressure that the heart has to contract against or decreasing the amount of fluid that returns to the heart so that it doesn't contract as hard in terms of surgical treatment you can have what's called a balloon valvuloplasty and what they do there is in a similar way to the cardiac catheterization they put a catheter up through one of the major arteries and say for instance it's the aortic valve they can actually go and pass the catheter across the aortic valve and then blow up a balloon on that catheter and what that does is that actually increases the opening or the opening size of the valve and can actually reduce symptoms although this is not as permanent of a solution now you also have the option of open heart surgery and so this is a pretty invasive strategy but they go in and they cut out the old valve and they replace it with either a metallic valve made out of metal or a bio prosthetic valve and this is usually made from the sac that surrounds the heart of either a pig or a cow and there are different advantages to one versus the other that's a little bit beyond the scope of what we're talking about here and so let's show a picture of open-heart surgery and just to orient you a little bit the patient's head is up here and their feet are going to be down there and this is the heart right here and then you'll notice this tube coming out of the heart and then this tube coming out of the heart and what that is is those are actually connected to the heart-lung machine so a machine is actually taking out all the on oxygen ated blood oxygenating it and then putting it back into the body and so it's kind of playing the role of your heart and your lungs hence the heart-lung machine or the more formal name cardio pulmonary bypass now there's a newer intervention that's been kind of hot in the recent years and this is called Tavor or transcatheter aortic valve replacement and so this is specific to the aortic valve but newer technologies are coming along to help with other valve problems but specifically this is when you take a catheter again and put it through the femoral artery and that catheter goes all the way up to the heart and they cross the aortic valve and they basically deploy a valve that has been pretty brilliantly placed onto the catheter in a condensed form and they deploy this valve over the old valve without ever having to make a large incision in you and so this is a minimally invasive form of valve replacement so I hope that you have a better idea of a general way to diagnose and treat valvular heart disease