Valvular Emergencies And Endocarditis

David M. Cline MitraLStenosis

Pathophysiology

Clinical ...Features

MitraUncompetence

.Pathophysiology C!in,ica!, . .Features

Mitral..Vaive..Proiaps.e

Pathophysiology Clinical ..Features

AorticStenosis .Pathophysiology

Clinical ..Features

Aortic. .Incompetence Pathophysiology

CliniicaLFeatu.res

Hypertrophic .Cardiomyopathy (Idiopathic. .Hype^rtrophic.Subao^rtic.. Stenosis)

ClinMLFeatures

Right-sided..Va!vu!ar.Heart..Disease Pathophysiology

ClinjcaLFeatures

Multivalvular.. Disease Pathophysiology

ClinicaLFeatures

Diagnosis. . of. Valvular . Heart . Disease

Emergency Department Care.. of ..Symptomatic Valvular HeartDisease

Admission.Considerations

Discharge.. .Instructions

Prosthetic ..Valve. .Disease Pathophysiology

ClinicaLFeatures

Diagnosis.. of.Prosth.etic. .Valve. .Dysfunction

Emergency. .Department ..,Manag,e,m,ent..an,d,.. Admission. .Indication5

Infective..Endocarditis Pathophysiology CNnicalFeatures Diagnosis

Emergency. .Department ..Care

Admissionindications

AmbMlato^ry...Ireatm£n!

Nonvalvular.. Infectionspf .t,h.e...H.eart .Pathophysiology

Diagnosis

Emergency. .Department .„Management

Chapter.. .References

Ninety percent of valvular disease is chronic, with decades between the onset of the structural abnormality and symptoms. The emergency physician most commonly encounters patients with valvular disease after the diagnosis has been made but is occasionally the first to suspect valvular dysfunction based on the patient's symptoms and examination. Through chronic adaptation by dilation and hypertrophy, cardiac function can be preserved for years, which may delay the diagnosis for one to two decades until a murmur is detected on auscultation. In contrast to the more common chronic presentations, acute rupture of a cardiac valve presents with dramatic symptoms.

The four heart valves prevent retrograde flow of blood during the cardiac cycle, allowing efficient ejection of blood with each contraction of the ventricles. The mitral valve has two cusps, while the other three heart valves normally have three cusps. The right and left papillary muscles promote effective closure of the tricuspid and mitral valves, respectively. The papillary muscles are attached to the cusps of the atrioventricular valves by tendinous cords, the chordae tendineae. Abnormalities of the valvular cusps, the papillary muscles, the chordae tendineae, or the cardiac chambers themselves can cause valvular dysfunction.

The pathophysiology of and clinical findings for each of the classic valvular disorders are presented below. Following these descriptions, the treatment of the disorders is presented collectively. When important differences occur in the indicated management, these recommendations are contrasted and explained.

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