Cardio 4 Valvular Heart Disease

Question 1

What is mitral stenosis (MS)?

Answer 1

Mitral stenosis is a condition where the mitral valve becomes narrowed, typically due to rheumatic heart disease. This causes increased left atrial pressure, leading to symptoms like dyspnea and pulmonary hypertension.

Question 2

What are the causes of mitral stenosis?

Answer 2

The most common cause is rheumatic heart disease, which leads to commissural fusion and thickening of the mitral valve leaflets. Other causes include congenital mitral stenosis and carcinoid syndrome.

Question 3

What are the symptoms of mitral stenosis?

Answer 3

Symptoms include:
- Exertional dyspnea due to increased left atrial pressure and pulmonary congestion.
- Hemoptysis due to rupture of pulmonary capillaries.
- Neurological symptoms due to thromboembolism from atrial fibrillation.
- Hoarseness due to left atrium pressing on the laryngeal nerve.

Question 4

What is the clinical examination finding in mitral stenosis?

Answer 4

Loud S1 and opening snap after S2.
- Rumbling mid-diastolic murmur heard at the apex (best with the patient in the left lateral position).
- Presystolic accentuation (murmur increases just before S1).
- Mitral facies: A characteristic malar flush seen in severe MS.
- Apex beat: Tapping but not displaced.

Question 5

How is mitral stenosis diagnosed?

Answer 5

Chest X-ray: May show left atrial enlargement, pulmonary edema, and signs of pulmonary hypertension.
- ECG: Atrial fibrillation (common), P mitrale (bifid P-wave), P pulmonale, and signs of right ventricular hypertrophy (RVH).
- Echocardiogram: Shows thickening and calcification of the mitral valve leaflets, and the severity of stenosis can be assessed by measuring the mitral valve area and pressure gradient.

Question 6

What is the treatment for mitral stenosis?

Answer 6

Medical management: Includes beta-blockers for rate control if atrial fibrillation is present, diuretics for fluid overload, and anticoagulation for preventing thromboembolic events.
- Surgical treatment:
- Percutaneous transseptal balloon valvotomy (TSBV) is the treatment of choice for symptomatic patients, especially if there is pulmonary hypertension.
- Mitral valve replacement is indicated in cases with LA thrombus, MR, or heavily calcified valves.

Question 7

What are the complications of mitral stenosis?

Answer 7

Complications include:
- Pulmonary hypertension.
- Right-sided heart failure.
- Acute pulmonary edema.
- Atrial fibrillation leading to systemic embolization.
- Endocarditis.

Question 8

What is mitral regurgitation (MR)?

Answer 8

Mitral regurgitation is a condition where the mitral valve fails to close properly, leading to backflow of blood into the left atrium during systole.

Question 9

What are the causes of acute mitral regurgitation?

Answer 9

Causes include:
- Myocardial infarction with papillary muscle rupture or dysfunction.
- Mitral valve prolapse (MVP) with ruptured chordae tendineae.
- Infective endocarditis or rheumatic heart disease with ruptured chordae or cuspal perforation.

Question 10

What are the causes of chronic mitral regurgitation?

Answer 10

Chronic mitral regurgitation is most commonly caused by:
- Mitral valve prolapse (MVP): Myxomatous degeneration, often seen in conditions like Marfan syndrome.
- Dilated cardiomyopathy: Leading to annular dilatation.
- Rheumatic heart disease (RHD): Causing thickening and fibrosis of the mitral valve leaflets.

Question 11

What are the symptoms of mitral regurgitation?

Answer 11

Symptoms of chronic MR include:
- Palpitations, especially with exertion.
- Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue as left ventricular failure develops.
- Pulmonary hypertension and right-sided heart failure in severe cases.

Question 12

What are the signs of mitral regurgitation on clinical examination?

Answer 12

Signs include:
- Soft S1 (due to the failure of proper valve closure).
- S3 gallop (due to rapid filling of a dilated left ventricle).
- Pansystolic murmur heard at the apex, radiating to the axilla.
- Mid-systolic click in MVP, followed by a late systolic murmur.

Question 13

How is mitral regurgitation diagnosed?

Answer 13

Chest X-ray: Shows cardiomegaly due to left ventricular and atrial dilation.
- ECG: May show atrial fibrillation and signs of left ventricular hypertrophy (LVH).
- Echocardiogram: Key diagnostic test, showing a regurgitant jet, left ventricular dilation, and assessment of mitral valve anatomy.
- Doppler: Used to assess the severity of the regurgitation.

Question 14

What is the treatment for mitral regurgitation?

Answer 14

Medical management:
- ACE inhibitors, diuretics, and beta-blockers for symptom relief and to manage left heart failure.
- If atrial fibrillation is present, lifelong anticoagulation with warfarin.
- Surgical management:
- Acute MR: Requires emergency surgery, often valve replacement.
- Chronic MR: Surgical repair is preferred over replacement if possible. Indications for surgery include severe MR with symptoms, or when left ventricular dysfunction occurs (EF <60%, end-diastolic diameter >55mm).

Question 15

What are the complications of mitral regurgitation?

Answer 15

Complications include:
- Pulmonary hypertension and right heart failure.
- Acute pulmonary edema due to sudden worsening of regurgitation.
- Atrial fibrillation and systemic embolism due to thromboembolism.
- Endocarditis.

Question 16

What is mitral valve prolapse (MVP)?

Answer 16

Mitral valve prolapse is a condition where one or both mitral valve leaflets bulge into the left atrium during systole. It is often caused by myxomatous degeneration of the valve, leading to floppy, thickened leaflets.

Question 17

What are the symptoms of mitral valve prolapse (MVP)?

Answer 17

MVP may be asymptomatic or present with:
- Atypical chest pain not related to exertion.
- Palpitations, especially if there is associated mitral regurgitation.
- Fatigue and dizziness.
- Anxiety or panic-like symptoms in some cases.

Question 18

How is mitral valve prolapse diagnosed?

Answer 18

Echocardiogram: Confirms the prolapse of the mitral valve leaflets into the left atrium during systole.
- ECG: Can show non-specific changes, but is not diagnostic of MVP.
- Holter monitoring: May be used to detect arrhythmias associated with MVP, like premature ventricular contractions (PVCs).

Question 19

What is the treatment for mitral valve prolapse?

Answer 19

Beta-blockers: For chest pain and palpitations.
- Anticoagulants: If there is significant mitral regurgitation or atrial fibrillation to prevent thromboembolism.
- Surgery: If MR is severe or there is significant left ventricular dysfunction, valve repair or replacement may be necessary.

Question 20

What is aortic stenosis (AS)?

Answer 20

Aortic stenosis is the narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. This condition leads to left ventricular hypertrophy and can cause symptoms like angina, syncope, and dyspnea.

Question 21

What are the causes of aortic stenosis?

Answer 21

Causes include:
- Calcification: Most commonly in elderly patients with age-related degeneration. Bicuspid aortic valve is more common in younger patients.
- Rheumatic heart disease: A less common cause, often in younger individuals, particularly in developing countries.

Question 22

What are the clinical symptoms of aortic stenosis?

Answer 22

The classic triad of symptoms includes:
- Angina: Due to increased myocardial oxygen demand and reduced coronary perfusion.
- Exertional syncope: Due to decreased cardiac output during physical activity.
- Dyspnea: Due to heart failure and pulmonary edema caused by left ventricular failure.
- Other symptoms may include fatigue and lightheadedness.

Question 23

What are the signs of aortic stenosis on physical examination?

Answer 23

Signs include:
- Normal S1 and soft, muffled S2.
- S4 gallop: Due to atrial contraction against a stiff, hypertrophic left ventricle.
- Systolic ejection murmur: Harsh crescendo-decrescendo murmur, best heard at the right upper sternal border, radiating to the carotids.
- Parvus et tardus: A slow-rising, low-amplitude carotid pulse.
- Pulse pressure may be reduced due to the obstruction.

Question 24

How is aortic stenosis diagnosed?

Answer 24

Chest X-ray: May show calcification of the aortic valve and post-stenotic aortic dilation.
- ECG: May show signs of left ventricular hypertrophy (LVH) or strain patterns.
- Echocardiogram: The gold standard for diagnosis, showing a narrowed aortic valve orifice, elevated left ventricular pressure, and possibly left ventricular hypertrophy. Doppler studies can assess the severity of stenosis.
- Coronary angiography: May be done if coronary artery disease is suspected in patients requiring surgery.

Question 25

What is the treatment for aortic stenosis?

Answer 25

Surgical treatment: - Aortic valve replacement (AVR) is the treatment of choice for symptomatic patients or those with severe stenosis. - Transcatheter aortic valve replacement (TAVR) may be an option for high-risk surgical patients. - Medical management: No specific medical treatment can reverse aortic stenosis, but symptoms can be managed with: - Beta-blockers for controlling heart rate and reducing myocardial oxygen demand. - Diuretics for managing heart failure symptoms.

Question 26

What are the complications of aortic stenosis?

Answer 26

Complications include: - Heart failure: Due to left ventricular overload and diastolic dysfunction. - Arrhythmias: Including atrial fibrillation due to atrial dilation. - Sudden cardiac death: Particularly in patients with severe stenosis and syncope. - Endocarditis: Due to altered blood flow and turbulence across the stenotic valve.

Question 27

What is aortic regurgitation (AR)?

Answer 27

Aortic regurgitation is a condition where the aortic valve fails to close properly, allowing blood to flow back from the aorta into the left ventricle during diastole. This causes volume overload in the left ventricle.

Question 28

What are the causes of aortic regurgitation?

Answer 28

Causes of AR include: - Acute AR: Infective endocarditis, acute rheumatic fever, aortic dissection, failed prosthetic valve, and myocardial infarction. - Chronic AR: Rheumatic heart disease, bicuspid aortic valve, Marfan syndrome, Ehlers–Danlos syndrome, rheumatoid arthritis, syphilis, and osteogenesis imperfecta.

Question 29

What are the symptoms of aortic regurgitation?

Answer 29

Symptoms of chronic aortic regurgitation include: - Exertional dyspnea and fatigue due to left ventricular failure. - Orthopnea and paroxysmal nocturnal dyspnea as heart failure progresses. - Acute AR (such as from aortic dissection or infective endocarditis) presents with shock, cyanosis, and rapid deterioration.

Question 30

What are the signs of aortic regurgitation on physical examination?

Answer 30

Signs of aortic regurgitation include: - Widened pulse pressure: Due to increased stroke volume and decreased diastolic pressure. - Collapsing (water-hammer) pulse: A strong, rapid pulse that collapses quickly, best felt at the wrist. - S3 gallop: Due to volume overload in the left ventricle. - Early diastolic murmur: Best heard at the left sternal border, louder when the patient is sitting forward and holding their breath in expiration. - Austin Flint murmur: A mid-diastolic murmur caused by the regurgitant flow affecting the mitral valve. - Signs of severe AR: - Quincke’s pulse: Pulsation in the nailbeds. - Head bobbing: Due to the large stroke volume. - Hill’s sign: Increased systolic blood pressure in the popliteal artery compared to the brachial artery by >60 mmHg.

Question 31

How is aortic regurgitation diagnosed?

Answer 31

Chest X-ray: May show left ventricular enlargement and dilated aorta. - ECG: May show left ventricular hypertrophy (LVH). - Echocardiogram: The gold standard for diagnosis. It shows the regurgitant jet and left ventricular dilation, as well as the aortic root size and function. - Doppler ultrasound: To assess the severity of the regurgitation.

Question 32

What is the treatment for aortic regurgitation?

Answer 32

Acute AR (e.g., from aortic dissection or endocarditis): Requires emergency surgery, often with valve replacement. - Chronic AR: - Medical management: - Vasodilators (e.g., nifedipine, ACE inhibitors) to reduce afterload and improve symptoms. - ACE inhibitors and diuretics for heart failure management. - Surgical treatment: - Aortic valve replacement (AVR) is indicated for symptomatic patients or those with significant left ventricular dysfunction.

Question 33

What are the complications of aortic regurgitation?

Answer 33

Complications of AR include: - Heart failure: Due to left ventricular dilation and dysfunction. - Arrhythmias: Atrial fibrillation and ventricular arrhythmias. - Sudden cardiac death: Especially in cases with severe regurgitation and left ventricular dysfunction. - Endocarditis: Due to the altered hemodynamics and turbulent blood flow across the valve.

Question 34

What is tricuspid stenosis (TS)?

Answer 34

Tricuspid stenosis is the narrowing of the tricuspid valve, leading to increased right atrial pressure and right-sided heart failure.

Question 35

What are the causes of tricuspid stenosis?

Answer 35

Tricuspid stenosis is almost always.

Question 36

What are the causes of tricuspid stenosis?

Answer 36

Tricuspid stenosis is almost always caused by rheumatic heart disease, often in combination with mitral and aortic valve disease.

Question 37

What are the symptoms of tricuspid stenosis?

Answer 37

Symptoms of tricuspid stenosis include: - Right-sided heart failure symptoms: Peripheral edema, ascites, hepatomegaly. - Elevated JVP: With a prominent “a-wave” due to impaired right atrial filling. - Fatigue and dyspnea due to reduced right ventricular output.

Question 38

What are the signs of tricuspid stenosis on clinical examination?

Answer 38

Signs include: - Elevated JVP with a prominent a-wave due to impaired right atrial contraction. - Hepatomegaly: The liver may be pulsatile and tender due to increased venous pressure. - Peripheral edema and ascites due to fluid retention. - Diastolic murmur heard at the left lower sternal border.

Question 39

What is the treatment for tricuspid stenosis?

Answer 39

Treatment involves: - Medical management: Diuretics for fluid overload and heart failure symptoms. - Surgical treatment: Tricuspid valve replacement or repair, especially if severe symptoms are present.

Question 40

What is tricuspid regurgitation (TR)?

Answer 40

Tricuspid regurgitation is the backflow of blood from the right ventricle into the right atrium due to improper closure of the tricuspid valve during systole.

Question 41

What are the causes of tricuspid regurgitation (TR)?

Answer 41

Causes of TR include: - Secondary to pulmonary hypertension: Conditions like mitral stenosis, left heart failure, or chronic obstructive pulmonary disease (COPD) can cause right-sided heart failure and dilate the tricuspid annulus. - Post-myocardial infarction (MI): Right ventricular infarction can lead to tricuspid annular dilatation. - Congenital: Ebstein’s anomaly, a congenital malformation of the tricuspid valve. - Infective endocarditis: Can damage the tricuspid valve, especially in intravenous drug users. - Dilated cardiomyopathy: Can lead to ventricular enlargement and tricuspid valve incompetence.

Question 42

What are the symptoms of tricuspid regurgitation?

Answer 42

Symptoms of tricuspid regurgitation include: - Peripheral edema due to right-sided heart failure. - Ascites and hepatomegaly due to increased venous pressure. - Fatigue and dyspnea. - Elevated jugular venous pressure (JVP).

Question 43

What are the clinical signs of tricuspid regurgitation on examination?

Answer 43

Signs include: - Pan-systolic murmur heard at the lower left sternal border, which increases in intensity with inspiration. - Elevated JVP with a prominent v-wave due to blood regurgitating into the right atrium during systole. - Pulsatile tender hepatomegaly (liver pulsation due to increased right atrial pressure). - Severe peripheral edema and ascites.

Question 44

How is tricuspid regurgitation diagnosed?

Answer 44

Echocardiogram: The gold standard for diagnosing TR. It shows regurgitation through the tricuspid valve and any underlying causes like right ventricular dilation or pulmonary hypertension. Chest X-ray: May show signs of right heart failure (e.g., cardiomegaly, dilated right atrium). ECG: May show signs of right atrial enlargement or right ventricular hypertrophy.

Question 45

What is the treatment for tricuspid regurgitation?

Answer 45

Medical management: Diuretics to reduce fluid retention and manage symptoms of right heart failure. Surgical management: Tricuspid valve repair or replacement is indicated in severe cases, especially if there is symptomatic right-sided heart failure or severe regurgitation.

Question 46

What is pulmonary stenosis (PS)?

Answer 46

Pulmonary stenosis is a congenital condition where the pulmonary valve is narrowed, leading to obstruction of blood flow from the right ventricle to the pulmonary artery.

Question 47

What are the causes of pulmonary stenosis?

Answer 47

Congenital: The most common cause is congenital heart defects like Tetralogy of Fallot (TOF) or Noonan syndrome. Acquired: Less common, but it may be seen in conditions like rheumatic heart disease.

Question 48

What are the symptoms of pulmonary stenosis?

Answer 48

Symptoms in severe cases may include: - Exertional dyspnea. - Fatigue due to reduced blood flow to the lungs and the body. - Syncope and chest pain in severe cases or during physical exertion. - Cyanosis (in severe cases with right-to-left shunting, especially in TOF).

Question 49

What are the clinical signs of pulmonary stenosis on examination?

Answer 49

Signs include: - Systolic ejection murmur: Harsh and best heard at the left upper sternal border, often with a thrill. - Right-sided heart failure symptoms in severe cases, such as edema, hepatomegaly, and JVP elevation. - Prominent a-wave in the JVP due to right atrial contraction against a stenotic pulmonary valve.

Question 50

How is pulmonary stenosis diagnosed?

Answer 50

Echocardiogram: The gold standard for diagnosis, showing the degree of stenosis and the effect on right ventricular size and function. Chest X-ray: May show post-stenotic dilation of the pulmonary artery. ECG: Right ventricular hypertrophy may be evident. Cardiac catheterization: Sometimes used for assessing the severity of stenosis and for potential intervention.

Question 51

What is the treatment for pulmonary stenosis?

Answer 51

Mild to moderate cases: Often require no treatment, but should be monitored regularly. Severe cases: - Balloon valvuloplasty: The treatment of choice for most cases, where a catheter with a balloon is inserted into the pulmonary valve and inflated to widen the valve. - Surgical repair: May be required if balloon valvuloplasty is not successful or if there is significant pulmonary valve deformity.

Question 52

What is pulmonary regurgitation (PR)?

Answer 52

Pulmonary regurgitation is the backflow of blood into the right ventricle during diastole due to the failure of the pulmonary valve to close properly. It is often associated with pulmonary hypertension or dilatation of the pulmonary valve annulus.

Question 53

What are the causes of pulmonary regurgitation?

Answer 53

Pulmonary hypertension: Can lead to dilation of the pulmonary valve annulus, causing regurgitation. Infective endocarditis: Can damage the pulmonary valve. Congenital defects: Such as pulmonary atresia or Tetralogy of Fallot. Surgical repair of congenital defects: Can result in pulmonary valve insufficiency after surgical interventions.

Question 54

What are the symptoms of pulmonary regurgitation?

Answer 54

Symptoms of pulmonary regurgitation often develop in the context of pulmonary hypertension, including: - Exertional dyspnea. - Fatigue. - Right-sided heart failure symptoms: Including peripheral edema, ascites, and hepatomegaly. - Cyanosis may occur in severe cases, particularly when there is significant right-to-left shunting.

Question 55

What are the clinical signs of pulmonary regurgitation on examination?

Answer 55

Signs of pulmonary regurgitation include: - Early diastolic murmur: Best heard at the upper left sternal border, sometimes referred to as the Graham-Steell murmur. - Signs of right-sided heart failure: Elevated JVP, peripheral edema, and hepatomegaly. - Increased splitting of S2 due to prolonged right ventricular systole.

Question 56

How is pulmonary regurgitation diagnosed?

Answer 56

Echocardiogram: The most effective diagnostic tool for visualizing the regurgitant flow through the pulmonary valve, right ventricular size, and pulmonary artery pressures. Cardiac MRI: Can also assess the degree of regurgitation and right ventricular function. ECG: Right ventricular hypertrophy and right atrial enlargement may be seen.

Question 57

What is the treatment for pulmonary regurgitation?

Answer 57

Management of underlying pulmonary hypertension: Includes the use of pulmonary vasodilators like sildenafil or bosentan. Surgical repair: If the regurgitation is severe and symptomatic, surgical intervention may be necessary, such as pulmonary valve replacement. Diuretics for managing fluid retention and right-sided heart failure.

Question 58

What is the normal JVP waveform and what does it signify?

Answer 58

The normal jugular venous pressure (JVP) waveform includes two primary waves: a-wave and v-wave. ## Footnote a-wave: Represents atrial contraction and occurs just before the carotid pulse. v-wave: Represents venous filling during ventricular systole, occurring after the carotid pulse. A normal JVP is less than 3 cm above the sternal angle.

Question 59

What causes prominent a-waves in the JVP?

Answer 59

Prominent a-waves in the JVP occur due to increased resistance to right atrial contraction, such as in: Tricuspid stenosis, Pulmonary hypertension, Right ventricular hypertrophy (RVH), Complete heart block.

Question 60

What is pulsus alternans and what does it indicate?

Answer 60

Pulsus alternans is an alternating strong and weak pulse. It is often a sign of severe left ventricular dysfunction and indicates poor cardiac output, commonly seen in patients with heart failure.

Question 61

What is pulsus bisferiens, and what does it signify?

Answer 61

Pulsus bisferiens is characterized by a double peak in the arterial pulse, usually felt in the carotid artery. It is seen in conditions like Hypertrophic cardiomyopathy (with left ventricular outflow obstruction) and Mixed aortic regurgitation and aortic stenosis.

Question 62

What is pulsus paradoxus, and what condition is it associated with?

Answer 62

Pulsus paradoxus is when the pulse weakens during inspiration and becomes stronger during expiration. It is associated with conditions that cause cardiac tamponade and is a classic sign of this condition.

Question 63

What is pulsus bigeminus, and what does it indicate?

Answer 63

Pulsus bigeminus is a pulse pattern where every other beat is a premature beat, creating a group of two beats separated by a longer interval. It is associated with premature ventricular contractions (PVCs) or ectopic heartbeats.

Question 64

What is pulsus parvus et tardus, and what does it indicate?

Answer 64

Pulsus parvus et tardus is a weak, slow-rising pulse that peaks late and is characteristic of aortic stenosis. The condition indicates that the left ventricle is struggling to pump blood through the narrowed aortic valve.

Question 65

What are the normal and abnormal apex beat findings on physical examination?

Answer 65

Normal apex beat: It is just palpable at the tip of the fingers at the 5th intercostal space (ICS) along the midclavicular line (MCL). Tapping apex beat: Felt in isolated mitral stenosis, represents a palpable S1. Heaving apex beat: Felt in conditions with hypertrophic pressure overload, such as aortic stenosis (AS), hypertrophic obstructive cardiomyopathy (HOCM), or systemic hypertension. Hyperdynamic apex beat: Felt in dilated and hypertrophic cardiomyopathies like mitral regurgitation (MR), aortic regurgitation (AR), patent ductus arteriosus (PDA), and ventricular septal defect (VSD).

Question 66

What are S3 and S4 heart sounds?

Answer 66

S3 (ventricular gallop): Occurs during rapid ventricular filling in early diastole. It is heard in conditions with volume overload such as heart failure with reduced ejection fraction (HF-REF), acute pulmonary edema, aortic regurgitation (AR), mitral regurgitation (MR), and dilated cardiomyopathy. S4 (atrial gallop): Occurs just before S1, when the atrium contracts against a stiff, non-compliant ventricle. It is always pathological and seen in conditions like heart failure with preserved ejection fraction (HF-PEF), aortic stenosis (AS), hypertrophic obstructive cardiomyopathy (HOCM), systemic hypertension, and coarctation of the aorta.

Question 67

How does the Valsalva maneuver affect heart murmurs?

Answer 67

The Valsalva maneuver involves forced exhalation against a closed airway, which decreases venous return to the heart and reduces preload: Decreases left-sided heart murmurs (such as those in aortic stenosis (AS), mitral regurgitation (MR), or aortic regurgitation (AR)). Increases right-sided murmurs (such as those in tricuspid regurgitation (TR) and pulmonary stenosis (PS)).

Question 68

How does squatting and standing affect heart murmurs?

Answer 68

Squatting increases venous return to the heart, which increases preload and the intensity of left-sided heart murmurs (e.g., aortic stenosis (AS), mitral regurgitation (MR)). Standing decreases venous return, which decreases preload and the intensity of left-sided heart murmurs. Conversely, it increases the intensity of murmurs from hypertrophic cardiomyopathy (HOCM) and mitral valve prolapse (MVP).