6: Vulvular heart disease

Question 0

S1

Answer 0

Mitral and Tricuspid

Question 1

Left side of the valves are more susceptible to disease

Answer 1

due to higher pressure

Question 2

S2

Answer 2

Aortic and Pulmonary

Question 3

S2 Splitting-

Answer 3

Physiological- during inspiration
Fixed- ASD or VSD (Higher: ASD, Lower: VSD)
Wide split- Pulmonary HTN, Right branch block
Reverse- Aortic stenosis, Systemic HTN

Question 4

S3

Answer 4

Turbulence

Question 5

S4

Answer 5

Blood hitting non-compliant ventricle wall

Question 6

Aortic stenosis- info

Answer 6

Systolic murmur
Causes
1: congenital (Unicuspid/Bicuspid valve) (3-4th)
2: Rheumatic fever (valves fuse together) (4-5th)
3: calcification (7-8th decade)

Concentric hypertrophy on LV-> LV failure

Question 7

Aortic stenosis- sx

Answer 7

1: angina (1: increased demand, decreased supply to coronary arteries. 2: Mechanical compression of coronary arteries by hypertrophied LV. 3: Calcium embolus. 4: Pre-existing coronary artery disease)
2: syncope at exertion (since CO cannot go up to meet the demand of exertion)
3: Dyspnea (Left heart failure)

Question 8

AS- exams

Answer 8

Apical impulse- shifted, and strong*
Weak delayed peripheral pulse* (Pulsus parvus tardus)
Soft single S2-> paradoxical split (reverse)
S4

Question 9

AS- murmur

Answer 9

L: Left 2nd ICS
I: 1--6
P: medium pitch
Q: Harsh
R: radiate to neck
S: crescendo- decrescendo
T: btw S1- S2
There is ejection click (calcification) [right before the murmur]
Murmur louder on expiration (Exception: hypertrophic cardiomyopathy, Mitral collapses) (Squating increase blood on both sides, Valsalva decrease blood on both sides)

Question 10

AS- severity

Answer 10

1: Pressure gradient across valve >70
2: Orifice <0.8cm2
3: paradoxical split
4: the murmur moves late/ closer to the S2

Question 11

AS- complication

Answer 11

Left heart failure (CHF)

V-fib

Question 12

AS- dx

Answer 12

Eco-cardiogram (exam of choice)
EKG (show LV hypertrophy; left axis deviation [V5, V6: Tall R. V1, V2: Deep S. the SUM of tall R and deep S should be more than 35 boxes])*

Question 13

AS- tx

Answer 13

Valvular replacement (best results out of all 4 valve disease)
Balloon aortic valvuloplasty 
Ross's operation (give pulmonary valve to aorta and give prostatic to pulmonary since pts own valve lasts longer)

Question 14

Mitral stenosis- info

Answer 14

Diastolic murmur
Pressure buildup in left atrium-> hypertrophy of LA
Pulmonary HTN-> hemoptysis*
RVF* (whereas AS leads to LVF)

Question 15

MS- causes

Answer 15

Rheumatic fever- MCC*
Congenital
SLE
Calcification
Rheumatic arthritis

Question 16

MS- sx

Answer 16

L atrium hypertrophy compress local structures-> Ortner’s syndrome (hoarseness of voice)*
Dysphasia
A-fib-> mural thrombus-> cerebral embolus*
sx of RVF (JVD, Liver cirrhosis, hemoptysis)
Central cyanosis
S1- delayed and loud*
Palpitations- A-fib

Question 17

MS- murmur

Answer 17

L: 5th ICS mid clavicular
I: 1-6
P: low pitch
Q: Rumble
R: no radiation
S: decrescendo
T: diastolic

PSA; Pre-systolic accentuation (atrial contraction)

Question 18

MS- severity

Answer 18

Smaller the gap btw S2 and murmur, more severe it is.

Orifice: <1cm: severe

Question 19

MS- Right heart regurge**

Answer 19

1: Tricuspid regurge (louder in inspiration): Corvello’s sign
2: pulmonary valve regurge (blowing decrescendo murmur): Graham Steel sign

Question 20

MS- exam

Answer 20

EKG-

• A-fib
• Bi-fib p wave (delay of LA p wave on LEAD II. on LEAD V1: RA is positive and LA is negative peaks on p wave)

Question 21

MS- tx

Answer 21

Correction is better than replacement on surgery-> thus repair the existing M valve first*

Question 23

MR- cause

Answer 23

any of 5 things can be damaged
Annulus
Leaflet
Chorda tendenie
Papillary muscle
Myocardium

Question 24

MVP- cause

Answer 24

Myxomatous degeneration; type 3 collagen degenerates-> posterior leaflet is more affected (posterior valve is supplied by single artery; R coronary)

Question 25

MR- heart sound

Answer 25

S3
S1- gets barried in murmur (No lov for MR)
Wide split of S2

Question 26

MR- murmur

Answer 26

L: Mitral area
I: 1-6
P: high pitch
Q: blowing
R: axilla
S: platau
T: systolic

Question 27

MVP- murmur

Answer 27

1- multiple click
similar to AS murmur
Crescendo-Decrescendo
Gets louder on valsalva, quieter on squating (to Ddx with AS)

Question 28

MR- exam

Answer 28

Eco-cardiogram

Question 29

MR- tx

Answer 29

symptomatic

Mvalve repair

Question 30

Aortic regurgitation- info

Answer 30

Eccentric hypertrophy by volume overload (much more than MR)
Extreme shift of apical impulse
Pulmonary HTN

Question 31

AR- sx

Answer 31

Pulse pressure: wide
Systole is very high, Diastole is very low
1: Corrigan pulse: strong pulse that rapidly collapses like water hammer
2: de Musset sign: each heart beat, pts head bob
3: Quinckie’s sign: Capillary pulsations when light is transmitted through the pts fingertip
4: Traube sign: pistol shot on femoral artery with stetho

Question 32

AR- cause

Answer 32

Takayasu
Syphyllus
Ankylosing spondilitis

Question 33

AR- murmur

Answer 33

L 
I: 1-6
P: high pitch
Q: blowing or musical
R: no
S: decrescendo
T: diastolic

Austin Flint murmur: the regurg blood hits anterior leaflet of Mitral valves

Question 34

Hand-grip exercise**

Answer 34

1: increase systemic resistance
2: increased left ventricular filling
Murmurs
AR: louder
AS: quieter
MR/ MS: louder
MVP/hypertrophic cardiomyopathy: quieter

Question 39

Mitral regurgitation- info

Answer 39

During systolie, blood regurge back into LA

1: Acute; Pressure build up in LA-> RVF (IE, RF, MI)
2: Chronic; blood all comes back into LV (S3)-> volume overload-> eccentric hypertrophy of LV (Myxomatous degeneration-> mitral valve prolapse, Calcification, RF)