7. Valvular Heart Disease and Bacterial Endocarditis Flashcards
How do stenotic valves cause pathology?
How do regurgitant valves cause pathology?
What is the basic path for assessing valve disease?
Put chamber under pressure -> hypertrophy followed by dilation and reduced function.
Volume overload -> dilation -> reduced function.
Histoy, exam, ECG, echo (mainstay of dx), CXR, cardiac catheterization +/- angiography.
What are some causes of aortic stenosis?
What are some causes of aortic regurgitation?
What are some symptoms of aortic valve disease?
1) Acquired: degenerative calcific AS, rheumatic fever, Paget’s disease
2) Congenital: bicuspid aortic valve (1-2% live births)/other congenital abnormality
1) Valvular: rheumatic heart disease (often combined with AS), infective endocarditis, degenerative calcific (with AS), bicuspid aortic valve
2) Aortic root disease: aortic (root) dissection, dilated aortic root - Marfan’s syndrome (genetic, leads to dilated root and floppy mitral valve)
Chest pain (like angina), dyspnoea, syncope (exercise induced), symptoms of CCF (e.g. pulmonary oedema).
What would you hear in auscultation for:
a) aortic stenosis?
b) aortic regurgitation?
What are some echo parameters in aortic valve disease?
What are indications for intervention?
a) Slow rising carotid pulse. S4 +/- ejection click. Ejection systolic murmur. May feel thrusting apex b/c hypertrophied.
b) Rapidly rising carotid pulse. Early diastolic murmur - aortic backflow (L sternal edge). Ejection murmur - turbulent ejection from volume loaded LV (L sternal edge).
Valve appearance (e.g. calcified/bicuspid/thick). Valve gradient/valve area. Severity of AR based on colour flow and CW (cont. wave) Doppler. LV size and function. Associated or coincidental pathology.
Symptoms, irreversible changes in cardiac function, improve prognosis.
Describe the following heart sounds:
1) S1
2) S2
3) S3
4) S4
1) M1 (mitral valve closure) and T1 (tricuspid valve closure). Normally M1 precedes T1 slightly. Caused by closure of AV valves at beginning of systole. S1 results from reverberation within the blood associated with the sudden block of flow reversal by the valves. Delay of T1 even more than normal causes split S1 - heard in RBBB.
2) A2 (aortic valve closure) and P2 (pulmonary valve closure). Normally A2 precedes P2 especially during inhalation where a split of S2 can be heard. Caused by closure of semilunar valves at the end of ventricular systole and the beginning of ventricular diastole.
3) At beginning of diastole after S2 and lower in pitch than S1 or S2 as it’s not of valvular origin. Benign in youth, some trained athletes, and sometimes pregnancy but if re-emerges later in life it may signal cardiac problems, such as failing left ventricle as in dilated congestive heart failure (CHF). S3 is caused by oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from the atria. S3 indicates increased volume of blood in the ventricle.
4) Just after atrial contraction at the end of diastole and immediately before S1. When audible in adult = atrial gallop, produced by blood forced into a stiff/hypertrophic ventricle. Sign of pathologic state, usually a failing/hypertrophic L ventricle, as in systemic hypertension, severe valvular aortic stenosis, and hypertrophic cardiomyopathy.
Label A-G of this heart valve image.
A) anterior leaflet (concave shape, 1 cusp)
B) posterior leaflet (moon shape, 3 cusps)
C) primary chords
D) papillary muscle
E) coronary sinus
F) circumflex coronary artery
G) L and R coronary cusps
What are the causes of mitral stenosis?
Explain how the Jones Criteria is used.
Almost always rheumatic fever. Often associated with regurgitation (calcified valve sticks half open). Frequently associated with other valve disease and PHT (pulm hypertension). Other rare causes incl. congenital (e.g. ASD association), calcification, valvulitis.
Diagnosis of rheumatic fever can be made when 2 of the major criteria (or 1 major + 2 minor) are present along with evidence of streptococcal infection (elevated or rising antistreptolysin O ab titer or DNAase).
What are the causes of mitral regurgitation?
What do the following pictures show?
What are the symptoms of mitral regurgitation?
What symptoms may you see with mitral stenosis?
Acute: infective endocarditis, acute MI
Chronic: mitral valve prolapse (myxomatous or degenerative), rheumatic heart disease.
Ischaemic heart disease, functional mitral insufficiency.
A) Ruptured chord (centre), usually degenerative
B) Papillary muscle rupture
Dyspnoea, fatigue, dizziness, other symptoms of CCF (b/c backpressure through lungs -> swollen legs), palpitations (2o to atrial arrhythmias, b/c LV dilates -> AF)
MS: liver dilates b/c backpressure so high so can get pulsatile liver, huge JVP, ascites…
What would you hear in auscultation for:
a) mitral stenosis?
b) mitral regurgitation?
What do these 2 CXRs show?
What are some echo parameters in mitral valve disease?
a) Rarely produces a soft rumbling mid-diastolic murmur +/- presystolic murmur (SR only). Loud S1 opening snap. ‘Tapping apex’.
b) Mitral valve closed through systole, pansystolic murmur S3 (often louder in late systole), heard at apex
* NB: pansystolic: murmur occupying the entire systolic interval, from 1st to 2nd heart sounds*
L: Severe mitral stenosis. Dilated L atrium, little bit of cardiomegaly
R: Acute mitral regurgitation. Acute pulmonary oedema, batswing
Valve appearance (prolapse/rupture etc.), LA size, LV size and function, various Doppler parameters to assess severity of stenosis and regurgiataion. R heart size and function.
NB: ECG may show hypertrophy of L atrium (pic)
How is valve disease treated?
What are some indications for intervention?
What does endocarditis look like?
What is the Duke Criteria?
Pharmacology.
β-blockers (slow heart), ACE-I (vasodilators), diuretics, CCBs.
Mechanical interventions.
Symptoms. Irreversible changes in cardiac function. Improve prognosis.
Vegetations on valves - mass of blood cells, abs, bacteria and fibrinogen stick on valves.
Pathological diagnosis of definite infective endocarditis requires microorganisms to be demonstrated in tissue. Clinical dx of definite infective endocarditis requires 2 major, 1 major and 3 minor, or 5 minor criteria.
Describe 4 signs that could fulfill the “positive echo” major criteria of the Duke Criteria.
What different types of surgery can be used to treat valve disease?
Oscillating intracardiac mass on valve or supporting structures, in the path of a regurgitant jet or on implanted material in the absence of another explanation.
An abscess.
New partial dehiscence of a prosthetic valve (comes away from tissue it’s sewn to).
Completely new valvar regurgitation.
- *Balloon valvuloplasty** = balloon through valve - blow it up and stretch it.
- *Valve replacement**: tissue (deteriorate after 10-15yrs) / mechanical (lasts longer but lifelong anticoagulants and clot risk).
- *Valve repair** e.g. annuloplasty ring
- *Stented valves**
What is this ECG suggestive of?
Large voltages/QRS in lateral leads (e.g. V6). T wave inversion, sinus rhythm.
= LV hypertrophy.
What do these 2 pictures show?
L: Janeway patch.
R: splinter haemorrhages. Clubbing (most common in pts with lung cancer and bacterial endocarditis)
