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2. Cardiovascular System > 23. Valvular Heart Disease > Flashcards

23. Valvular Heart Disease Flashcards

1
Q

What 2 valves are found on the right side of heart?

A
  1. tricuspid

2. pulmonary

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2
Q

What 2 valves are found on the left side of heart?

A
  1. mitral

2. aortic

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3
Q

To what structure is the mitral valve very closely related to?

A

to the left ventricle; it’s anchored to it ( what will affect the mitral valve will affect the l.ventricle and vice versa)

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4
Q

What is mitral valve anchored by?

A

anchored by cordae tendinae which are attached to papillary muscles

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5
Q

What is the aetiology for mitral stenosis? (3)

A
  1. rheumatic heart disease
  2. congenital mitral stenosis
  3. systemic conditions e.g. systemic lupus erythematosus (SLE) and rheumatoid arthritis
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6
Q

What is the main cause of mitral stenosis in the western world?

A

Mainly rheumatoid arthritis (rarely congenital defects)

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7
Q

What is the mitral valve orifice (opening) in cm?

A

<2cm^2

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8
Q

What effect does mitral stenosis have on:

  • AV pressure gradient
  • L.atrium pressure
  • Pulmonary venous and capillary pressures
  • Pulmonary vascular resistance
  • Pulmonary artery pressure
  • Right heart
A
  • AV pressure increases
  • L. atrium pressure increases
  • Pulmonary venous and capillary pressures increase
  • pulmonary vascular resistance increases
  • pulmonary artery pressure increases (and pulmonary hypertension develops)
  • right heart dilatation with tricuspid regurgitation and pulmonary regurgitation
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9
Q

What is the dynamic range for mitral stenosis for it to reach pathology?

A

dynamic range is relatively wide

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10
Q

What 2 features remain and function normally in mitral stenosis? (remain unaffected)

A
  1. l. ventricle pressures

2. systolic pressures

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11
Q

What determines mitral stenosis severity? (2)

A
  1. trans-valvular pressure gradient

2. trans-valvular flow rate (cardiac output and heart rate)

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12
Q

What factors affect heart rate (and therefore tachycardia)? (4)

A
  1. exercise
  2. acute illness
  3. pregnancy
  4. atrial fibrillation
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13
Q

What are clinical manifestations/ symptoms which indicate a mitral stenosis? (6)

A
  1. dyspnoea (mild exertional to pulmonary oedema)
  2. haemoptisis ( rupture of thin walled veins)
  3. systemic embolisation (left atrium and left atrial appendage enlargement or stroke)
  4. infective endocarditis
  5. chest pain
  6. hoarseness (compression of the l. recurrent laryngeal nerve)
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14
Q

What is found on examination in mitral stenosis patients? (6)

A
  1. mitral facies
  2. pulse (normal) since l.ventricle is normal
  3. JVP (prominent A wave)
  4. Tapping apex beat and diastolic thrill
  5. right ventricle heave
  6. auscultation
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15
Q

What might mitral facies signs look like in patients with mitral stenosis?

A
  • rosy cheeks

- other facial areas slightly blue due to cyanosis (especially in severe cases)

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16
Q

What will the first and second heart sounds sound like in mitral stenosis patients?

A

the first heart sound is increased in intensity and second heart sound is normal

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17
Q

What investigations are done for mitral stenosis patients to diagnose it?

A
  1. ECG
  2. cardiac
  3. chest x ray (shows l.atrium englargement)
  4. echocardiography (imaging)
  5. cardiac magnetic resonance (imaging)
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18
Q

What does an ECG show in a mitral stenosis patient?

A

l. atrium enlargement (pressure bigger than it should be)

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19
Q

What is the link between severity of the stenosis and the difference between l.atrial and l.ventricular pressures?

A

the bigger the pressure difference (pressure gradient) between l.atrium and l. ventricle, the more severer the mitral stenosis

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20
Q

What is seen on an echocardiograph in mitral stenosis patients?

A
  1. thickening and scarring of the leaflets

2. fusion of commissures (area where 2 valve leaflets abnormally came together)

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21
Q

How many leaflets/ cusps does each valve have?

A
  • tricuspid: 3
  • aortic: 3
  • pulmonary: 3
  • mitral: 2
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22
Q

What is the medical treatment for mitral stenosis?

A
  1. diuretics and restriction of Na intake (atrial fibrillation; sinus rhythm restoration or ventricular rate control)
  2. anticoagulation; all those with atrial fibrillation but debatale in sinus rhythm
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23
Q

When are diuretics used in mitral stenosis? What do they do?

A
  • used when there is atrial fibrillation
  • restore sinus rhythm
  • restore ventricular rate control
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24
Q

When are anticoagulation drugs used in mitral stenosis?

A
  • when patient has atrial fibrillation but debatable in sinus rhythm patients
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25
Q

What are 2 interventional medical treatments for mitral stenosis?

A
  1. valvotomy (balloon vs surgical)

2. MVR; mitral valve replacement

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26
Q

What is the most important form of treatment for mitral stenosis patients?

A

anticoagulation as it prevents possible emboli which can lead to strokes

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27
Q

What is the aetiology for mitral regurgitation?(5)

A
  1. rheumatic heart disease
  2. mitral valve prolapse (MVP)
  3. infective endocarditis
  4. degenerative
  5. functional mitral regurgitation due to l.ventricle and annular dilatation
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28
Q

What is the most common cause of mitral regurgitation in the world?

A

rheumatic heart disease

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29
Q

What is the most common cause of mitral regurgitation in the DEVELOPED world?

A

mitral valve prolapse (chord tendinae snaps and no longer valve is attached)

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30
Q

What population group often suffers from mitral valve prolapse leading to mitral regurgitation?

A

men in 40-50s

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31
Q

Why does l. ventricle enlargement cause mitral regurgitation?

A

In MI for example, when ventricle enlarges, the anchors of the mitral valve will also enlarge seal no longer created and mitral valve become incompetent

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32
Q

What is meant by stenosis?

A
  • narrowing of the oriffice of the valve

- thickening of the cusps occurs

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33
Q

What is meant by regurgitation?

A
  • valve doesn’t close properly when it pumps blood out

- leaky valve

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34
Q

How does effective regurgitant orrifice/ opening have on mitral regurgitation? (refer to preload, afterload and l.ventricle contractility)

A 
Annular enlargement in: 
-preload
-afterload
- l. ventricle contractility 
(regurgitant volume increases)
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35
Q

What occurs in left ventricular compensation in ACUTE mitral regurgitation?

A
  • end systolic pressure and end systolic volume decreases

- decrease in wall tension

36
Q

What occurs in left ventricular compensation in CHRONIC mitral regurgitation?

A
  • increase in end diastolic volume
  • end systolic volume returns to normal
  • ecentric/off centre left ventricular hypertrophy develops
37
Q

What 2 types of regurgitation are most severe and why?

A
  • ACUTE aortic and mitral regurgitation most severe
  • this is because ventricle has no time to adapt to sudden change (striking emergencies) leading to decrease in end systolic pressures and volume leading to left ventricular compensation and leaving patient in a difficult position
38
Q

Why is acute regurgitation more dangerous than chronic regurgitation?

A
  • in chronic, there is time to see what the situation is, the ventricle can adapt slowly and gradually to changes to accommodate this extra volume of blood over time
  • in acute, it occurs suddenly and l. ventricle isn’t able to deal with more blood coming into l. ventricle spontaneously
39
Q

What happens to l. atrium compliance in mitral regurgitation?

A
  1. compliance REDUCED
    but also…
  2. compliance INCREASE
    (combination of two occurs in l. atrium during mitral regurgitation)
40
Q

Why is l. atrium compliance REDUCED in mitral regurgitation? (4)

A
  • marked pressure rise
  • thickening of atrial myocardium
  • increase in pulmonary vascualar resistance
  • remodelling of the pulmonary vasculature with pulmonary hypertension
41
Q

Why is l. atrium compliance INCREASED in mitral regurgitation?

A
  • marked volume enlargement

- lesser changes in pulmonary vasculature but develop atrial fibrillation

42
Q

Describe clinical features/ manifestations of ACUTE mitral regurgitations. (valve perforation; small hole inside valve and chordal/papillary muscle) (5)

A
  1. breathlessness
  2. pulmonary oedema
  3. cardiogenic shock
  4. no previous or little history f cardio problems and symptoms presented only for a few days
  5. only once murmurs heard can diagnosis be made
43
Q

Describe the clinical features/ manifestations of CHRONIC mitral regurgitations. (5)

A
  1. fatigue
  2. exhaustion (low cardiac output)
  3. right heart failure
  4. dysponoea or palpitations due to atrial fibrillations
  5. ventricles start to dilate and function declines
44
Q

What is found on examination in patients with mitral regurgitation? (5)

A
  1. pulse; normal or reduced in heart failure
  2. JVP; prominent if right heart failure present
  3. Brisk and hyperdynamic apex beat (loud)
  4. right ventricle heave
  5. auscultation; S1 reduced, split s2; holosystolic blowing radiating to axilla (no relationship between intensity and severity), systolic might be so loud that heart sounds might not even be heard
45
Q

What investigations are done for mitral regurgitation? (4)

A
  1. ECG
  2. Chest X ray
  3. cardiac catherisation (not used anymore)
  4. echocardiography
46
Q

What will be seen on ECG in mitral regurgitation? (2)

A
  • l. atrium enlargement (p>0.12 sec tall)

- right ventricular hypertrophy (prominent r wave in r precordial leads)

47
Q

What will be seen on chest x ray in mitral regurgitation? (2)

A
  • l. atrium enlargement

- calcification of mitral annulus

48
Q

What will be seen in cardiac catherisation in mitral regurgitation? (2)

A
  • l. ventricle angiography; obsolete (not used anymore)
49
Q

What will echocardiography show in mitral regurgitation patients? (4)

A
  1. l. ventricle dimensions
  2. cause of mitral regurgitations; e.g. leaflet dysfunction, chordae tendinae or papillary muscle fault, annular disease
  3. severity of mitral regurgitation and papillary muscles fault
  4. accurate cardiac volumes (volumetric determination of regurgitation)
50
Q

What looks abnormal in an echocardiograph?

A

left ventricle looks sphere shaped (abnormal)

51
Q

What is the medical treatment for an ACUTE mitral regurgitation? (4)

A
  • preload and afterload reduction may be life-saving
  • sodium nitroprusside
  • dobutamine
  • intra-aortic balloon pump (IABP)
52
Q

What is the medical treatment for a CHRONIC mitral regurgitation? (1)

A
  • mainly l. ventricle function preservation

- lack of evidence that any therapy is beneficial for haemodynamic improvement

53
Q

What is the interventional treatment for mitral regurgitation? (2)

A
  1. mitral valve apparatus repair

2. mitral valve replacement

54
Q

What is the difference between time duration for treatment of acute and chronic mitral regurgitation?

A
  • acute needs to be treated immediately since ventricle not used to the change
  • chronic can wait decades to treat, lots of time to control it since ventricle underwent adaptation
55
Q

Which valve is biggest; mitral or aortic?

A

Mitral (bigger orfices), 3-4cm^2

56
Q

What is the most common valve stenosis in the world? Why?

A

aortic stenosis; because subjected to highest velocities of blood and creates highest pressure

57
Q

What are 3 main causes for aortic stenosis?

A
  1. degenerative
  2. rehumatic heart disease
  3. bicuspid valve (instead of having 3 cusps like in normal)
58
Q

Is bicuspid aortic valve congenital?

A

Yes; some people develop complications into adulthood whereas other don’t at all

59
Q

What does rheumatic disease cause for aortic stenosis? (2)

A
  • fusion of the commissures and retraction

- stiffening of free cusp margins

60
Q

What does degenerative disease cause for aortic stenosis? (2)

A
  • linked to atherosclerosis

- slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins

61
Q

Describe steps that lead to l. ventricular failure from aortic stenosis? (6)

A
  1. aortic stenosis (narrowing) increases l. ventricular pressure
  2. severe concentric hypertrophy and left ventricular mass
  3. increased l. ventricular end diastolic pressure (l.atrial pressure increases pulmonary hypertension too)
  4. increased myocardial oxygen consumption
  5. myocardial ischaemia develops
  6. l. ventricular failure
62
Q

Describe the asymptomatic phase in aortic stenosis. What happens once person becomes symptomatic?

A
  • long asymptomatic phase
  • progressive and slow over years
  • when patients become symptomatic, their survival rate drops instantly (fast treatment is needed immediately)
63
Q

What are cardinal symptoms for aortic stenosis? (4)

A
  1. chest pain (angina)
  2. syncope/ dizziness (exertional pre-syncope)
  3. breathlessness on exertion
  4. heart failure
64
Q

What is found on clinical examination in aortic stenosis patients? (5)

A
  1. pulse: small volume and slowly rising (cardiac output is low)
  2. JVP: prominent if r. heart failure present, low BP
  3. vigorous and sustained apex beat
  4. right ventricle heave
  5. auscultation; late peaking, loud at base, harsh murmur and radiating to carotids
65
Q

What investigations are needed for aortic stenosis? (4)

A
  1. ECG
  2. chest x ray
  3. cardiac catherisation (no longer used)
  4. echocardiography
  5. CMR: cardiovascular magnetic resonance imaging
66
Q

What does ECG show in aortic stenosis?

A
  • l. ventricular hypertrophy voltage criteria

- ST/T changes (l.ventricle stain)

67
Q

What does chest x ray show in aortic stenosis patients?

A

calcification of aortic valve

68
Q

What does cardiac catherisation show in aortic stenosis patients?

A
  • peak l. ventricle peak aortic gradient (obsolete/ no longer used)
69
Q

What does echocardiography show in aortic stenosis patients? (3)

A
  1. demonstrates aortic valve cusp mobility and severity of stenosis
  2. l. ventricle function and hypertrophy
  3. doppler haemodynamic assessment of pressure gradient and aortic valve area
70
Q

Who is limited to treatment for aortic stenosis?

A

patients who develop heart failure

71
Q

What is interventional treatment for aortic stenosis?

A

aortic valve replacement or repair

72
Q

What is 2 areas lead to aetiology for the aortic regurgitation?

A
  1. aorta

2. leaflets

73
Q

What aortic aetiology leads to aortic regurgitation? (2)

A
  1. dilated aorta (Marfan’s or hypertension)

2. connective tissue disorders

74
Q

What leaflet aetiology leads to aortic regurgitation? (4)

A
  1. bicuspid aortic valve
  2. rheumatic heart disease
  3. endocarditis
  4. myxomatous degeneration
    (leaflets become dysfunctional)
75
Q

Describe the steps that lead to l. ventricular failure from aortic regurgitation. (6)

A
  1. l. ventricle accommodates both stroke volume and regurgitant volume
  2. increased l.ventricle end diastolic volume and l. ventricle systolic pressure
  3. increased l. ventricular hypertrophy and l. ventricle dilatation
  4. increased myocardial oxygen consumption
  5. myocardial ischaemia develops
  6. l. ventricular failure
76
Q

What are symptoms for CHRONIC aortic regurgitation? Why can they be addressed over time?

A
  • long asymptomatic phase which means they take longer to develop and treatment phase is longer since ventricle adapted
  • exertional breathlessness
77
Q

Why are symptoms for ACUTE aortic regurgitation addressed immediately?

A
  • poorly tolerated as wall tension cannot acutely adapt

- l. ventricle pressure x l. ventricle radius / wall thickness

78
Q

What is seen on clinical examination in aortic regurgitation? (4)

A
  1. pulse: large volume and collapsing (Corrigan sign)
  2. wide pulse pressure
  3. hyperdynamic, displaced apex beat
  4. auscultations: normal s1 and normal s2, early diastolic, descrescendo and soft murmur heard
79
Q

What investigations are done for aortic regurgitation? (3)

A
  1. ECG
  2. chest x ray
  3. cardiac catherisation (obsolete/ no longer performed)
  4. echocardiography
  5. cardiovascular magnetic resonance imaging (CMR)
80
Q

What does ECG show in aortic regurgitation?

A

ST/T changes (l. ventricle strain seen on left anterior descending coronary artery_

81
Q

What does chest x ray show in arotic regurgitation?

A

cardiomegaly in chronic aortic regurgitation

82
Q

What is done prior to cardiac catherisation?

A

aortogram; cathether used to inject dye into aorta, rays taken as dye travels through aorta showing blood flow

83
Q

What does echocardiography allow us to see in aortic regurgitation? (echocardiogram= ulrtasound of heart, looking at it from different dimensions) (3)

A
  • shows AV cusp anatomy (thickening, prolapsing number of cusps, vegetations)
  • l. ventricle function, dilatation and hypertrophy
  • haemondynamic assessment of regurgitation flow
84
Q

What is the best medical treatment for aortic regurgitation?

A

vasodilator therapy (shown to delay timing for surgical intervention; 2-3 years)

85
Q

What is the best interventional treatment for aortic regurgitation? (2)

A
  • aortic valve replacement

- aortic valve repair

2. Cardiovascular System (42 decks)

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