Cardio: Valvular heart disease Flashcards
Left sided murmurs
How does mitral stenosis progress? [3]
Pressure builds up in the Left Atrium [1] which backs up through the pulmonary circ causing pulmonary hypertension [1]
As a result the Right heart dilates with Tricuspid and pulmonary regurgitation. [1]
Left sided murmurs
What can cause mitral stenosis? [7]
- Mainly Rheumatic Heart Disease fibrosing the valve.
- Congenital Mitral Stenosis
- Autoimmune: SLE or rheumatoid arthritis, amyloid
- Mitral Valve Prolapse
- Infect. Endocarditis
- Degenerative Disease (annular calcification)
- Ventricle enlargement stretching the valve
Left sided murmurs
What are the symptoms of mitral stenosis? [5]
- Dyspnoea & Pulmonary Oedema (secondary to pulmonary HTN)
- Chest Pain
- Haemoptysis/pink frothy sputum due to pulmonary pressures, vascular congestion
- Systemic embolisation due to enlargement of LA & LAA (left atrial appendage)
- Hoarseness (enlarged heart compresses L Recurrent Laryngeal Nerve)
Left sided murmurs
What are the clinical signs of mitral stenosis? [6]
Tachycardia, Low volume pulse
A Diastolic Thrill & Tapping Apex Beat
A RV Heave due to dilatation
Mid-late diastolic murmur on expiration.
Loud S1, opening snap
Mitral Facies
Left sided murmurs
How do we investigate suspected Mitral Stenosis? [4]
An ECG, CXR - LA enlargement
Echocardiogram - Thickening/Scarring of mitral leaflets
CMR
Left sided murmurs
How can we treat mitral stenosis? [3]
- Atrial fibrillation > warfarin
- Asymptomatic - monitoring regular ECHO
- Symptomatic - percutaneous mitral balloon valvotomy, mitral valve surgery
Left sided murmurs
What would appear on an MS ECG? [2]
Tall P wave indicating LA enlargement
Prominent R wave showing RVH
Left sided murmurs
How do we treat Mitral Regurgitation? Acute [2] vs Chronic MR [2]
Acute MR: Use Na nitroprusside OR Dobatumine to lower preload/afterload
Chronic MR: Diuretics can reduce symptoms but will still need surgery ie MV repair/Replacement
Left sided murmurs
Rheumatic Heart Disease What is it triggered by? [3]
Describe histology seen in RHF
Rheumatic fever
- GABHS infection - streptococcus pyogenes
- Cross-reactive Immunological reaction to recent strep pyogenes infection - antigen presentation to T cells - molecular mimicry
- 2-6w ago
- the cell wall of Streptococcus pyogenes includes M protein, a virulence factor that is highly antigenic. It is thought that the antibodies against M protein cross-react with myosin and the smooth muscle of arteries
- Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever
Rheumatic Heart Disease Sequelae [5]
- Valvular stenosis + regurgitate *mitral stenosis
- LA dilation due to pressure overload > AF
- Large mural thrombi form
- Chronic venous congestion > LHF
- RV hypertrophy
RHD DX What criteria is used?
Jones criteria
RHD DX
List minor [3] and major [5] criteria
Major Criteria:
- Carditis
- Migratory polyarthritis
- Subcutaneous nodules
- Erythema marginatum skin rash
- Sydenham chorea/ St vitus dance
Jones Criteria Minor Criteria:
- Fever
- Arthralgias
- ECG changes
Left sided murmurs
Mitral valve prolapse associations
congenital heart disease: PDA, ASD
cardiomyopathy
Turner’s syndrome
Marfan’s syndrome, Fragile X
osteogenesis imperfecta
pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
long-QT syndrome
Ehlers-Danlos Syndrome
polycystic kidney disease
Left sided murmurs
Characteristic murmur for mitral valve prolapse
mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)
Left sided murmurs
Complications of MVP [3]
mitral regurgitation, arrhythmias (including long QT), emboli, sudden death
Left sided murmurs
How is MVP diagnosed
what other investigations are needed
Defined by imaging
Ant or post mitral valv leaflets cross valve plane by >2mm into left atrium during ventricular systole
Stress ECHO
Left sided murmurs
Mitral valve prolapse murmur characteristics
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Left sided murmurs
Mitral valve prolapse murmur characteristics, what is not typical of murmurs in MVP?
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Describe murmur characteristic in Mitral Regurgitation
- Pansystolic murmur (radiation to axilla) louder on expiration.
- Mid-late systolic murmur in MV prolapse (radn. to axilla, louder on inspiration).
In which would you see left heart failure? Mitral Stenosis or Mitral regurgitation
MR - you would see signs of LHF
Management of Rheumatic heart fever [3]
- Early IV antibiotics benzylpenicillin G or ceftriaxone. Follow on doses of 4-weekly IM benzylpenicillin or oral penicillin V should be continued daily for up to 0 years or into adulthood after an episode of ARF to reduce the risk of late complication with rheumatic heart disease.
- Acute carditis: oral prednisolone treatment ( mg/kg daily) to a maximum of 80 mg daily.
- Acute arthritis responds to high-dose aspirin.
Left sided murmurs
How does Aortic Stenosis lead to Heart failure?
Pressure backs up in the LH causing it to hypertrophy. This increases myocardial O2 demand eventually leading to LVF
What causes Aortic Stenosis?
Calcific degenerative disease - A slow inflammatory process thickens and calcifies the cusps (senile calcification, linked to atherosclerosis)
Rheumatic disease
Congenital Bicuspid Valve
What is the symptoms of aortic stenosis?
A long time is spent asymptomatic then suddenly:
Angina - Syncope - SOBOE - Heart Failure
What are the clinical signs of aortic stenosis?
Pulse is slow rising with narrow pulse pressure
Heaving Apex Beat, LV Heave
Aortic Thrill
Ejection systolic crescendo, descrescendo murmur with radiation to carotids
How do we investigate aortic stenosis? [4]
ECG - CXR - Echo - CMR
ECG - LV Strain pattern showing LVH (ST depression & T inversion)
CXR - LVH, calcified aortic valve
Echo then Cardiac catheterization
How do we treat Aortic Stenosis? [3]
Medical mx: HF symptomatic treatment
Valve replacement - surgical replacement or transcatheter + warfarin long term
Balloon valvuloplasty: palliative in highly symptomatic
How does Aortic Regurgitation progress?
The blood backs up so LV volume & pressure increases -> LVH -> increased O2 demand -> Ischaemia & LV failure`
What can cause aortic regurgitation?
Acute [3]
Chronic [7]
Acute:
- Infective endocarditis
- Ascending aortic dissection
- Chest trauma
Chronic:
- Atherosclerosis, HTN
- CTD eg Marfans
- Rheumatic heart disease
- Takayasu’s arteritis
- RA, SLE
- Myxomatous disease
- Osteogenesis imperfecta
- Syphilia aortitis
What are the symptoms of aortic regurgitation?
IF it happens acutely then LV failure, cyanosis and dyspnoea
If its chronic there will be a long time without symptoms with SOBOE and eventual RVF
What are the signs on examination of Aortic Regurgitation? [5]
A large collapsing pulse
A wide pulse pressure
Water hammer pulse palpated
Corrigans pulse - visible carotid pulsation
A hyperdynamic & displaced apex beat
A soft, early diastolic murmur on auscultation of the AV.
What would appear in an Aortic Regurgitation ECG?
An LV strain pattern of ST depression & T wave inversion. Signifying LVH
What would show up on an Aortic Regurgitation CXR? [3]
Cardiomegaly in chronic AR
Dilated ascending aorta
Pulmonary edema
What would an Echo show us in Aortic Regurgitation? [3]
AV thickening, prolapse, bicuspid and/or vegetations.
Also LV function, dilatation & hypertrophy.
A Doppler-Echo would show the regurgitant flow.
How can we treat Aortic Regurgitation? [3]
ACEi
6-12m ECHO monitoring
Aortic valve sparing or replacement surgery
Pulmonary stenosis O/E [4]
- raised JVP
- Left parasternal heave of RV hypertrophy
- End diastolic murmur at upper L sternal border
- signs of RHF, cyanosis
Pulmonary regurgitation murmur
end-diastolic murmur heard along left sternal border, signs of right heart failure may be seen
Tricuspid stenosis
- raised JVP
- mid-diastolic murmur at lower left sternal border
Tricuspid regurgitation O/E [3]
- pansystolic murmur at lower left sternal border, severe RHF, pulsatile liver
Valve replacement
Bioprosthesis or mechanical valves
◆ Bioprosthesis: xenogenic material (e.g. bovine/porcine pericardium)
◆ Mechanical prosthesis - last longer but require anticoagulation, recommended for younger patients.
Catheter based tehcniques
Describe 3 types and their indications
◆ Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis.
◆ Transcatheter balloon valvuloplasty for MS (and to palliate AS).
◆ Percutaneous (catheter deployed) mitral valve intervention (i.e. mitral clipping) for severe mitral
regurgitation.
Medical management in valve disease [3]
◆ Treating symptoms/complications of valve disease.
◆ Secondary prevention of cardiovascular risk factors.
◆ Palliation where intervention is not possible.
