Cardiology Flashcards
Mitral regurgitation - aetiology?
Primary:
- Degenerative (eg. myxomatous degeneration, mitral valve prolapse, partial flail, flail leaflet).
- Infective endocarditis
- Rheumatic disease
- Congenital - possible complication of repairs
Seconday:
- Functional secondary to LV dilatation (dilated cardiomyopathy)
- Papillary muscle ischaemia
Physical findings in chronic mitral regurgitation
- Atrial fibrillation
- Displaced, dyskinetic/diffuse apex beat
- Loss of S1
- Split S2
- Added S3
- Apical pansystolic murmur that radiates to axilla, immediately after S1 and up to/obscuring S2.
- +/- apical thrill
Chronic MR - signs of severity
Soft S1
Split S2
Presence of S3
LV dilatation (laterally displaced apex beat) Pulmonary hypertension (loud P2 component) LV failure and LV dysfunction (gallop sounds) Early diastolic rumble (increased flow in diastole)
Small pulse volume (v. severe)
MR - indications for surgery
Acute MR: prompt/early surgical intervention is indicated in acute non-ischaemic MR. In patients with acute ischaemic MR, treatment depends upon the exact aetiology of valve dysfunction. Surgical intervention is necessary to treat papillary muscle rupture.
- Chordal rupture
- Infective endocarditis
- Papillary muscle rupture
- Myocardial ischaemic (PCI may lead to resolution of MR)
Chronic MR:
-
Primary chronic MR:
- Symptomatic (NYHA III/IV) with LVEF ≥30% and LVESD ≤55 mm
- Asymptomatic with LVEF 30-60% and/or LVESD ≥40 mm
-
Secondary MR (ie MR that is a consequence of LV dysfunction with normal MV and chords)
- First line therapy is medical management of HFrEF, including pharmacologic and CRT.
- Patients with persistent symptoms despite OMT.
- Consideration of surgical intervention may be indicated
- Consideration of surgical intervention if patient is having concurrent CTHR surgery (eg. CABG + ischaemic MR).
MR - indications for transcatheter mitral valve repair (MitraClip)
Transcatheter mitral vale repair may be consdiered for patients with primary MR who meet all of the following criteria:
- Chronic moderate to severe or severe MR (3 to 4+)
- Severely symptomatic (NYHA III or IV) depspite OMT
- Favourable anatomy for the repair procedure
- Life expectancy ≥2 years
- Prohibitive surgical risk due to comorbidities
Contraindications include:
- Patients who cannot tolerate procedural anticoagulation or antiplatelet agents post-procedure
- Active endocarditis of the mitral valve
- Rheumatic MV disease or other causes of mitral stenosis
- Thrombus of the femoral vein, IVC or intracardiac thrombus
MV prolapse - physical findings
Symptoms: Non-specific. Including palpitations, dyspnea, exercise intolerance, dizziness.
Murmur: Systolic click-murmur syndrome
- Non-ejection (mid or late) systolic click
- Murmur of MR, which in MVP is usually high pitched, late systolic crescendo-decrescendo occasionally “whooping or honking”, best heard at apex
Manoeuvres:
- Valsalva (decreases pre-load): murmur longer, click earlier
- Handgrip (increases after-load) or squatting (increases pre-load): murmur shorter
What does valsalva do?
Valsalva decreases pre-load
What does handgrip do?
Handgrip increases after-load
What does squatting do?
Squatting increases pre-load
Mitral stenosis - aetiology?
Rheumatic
Congenital (rare)
Mitral stenosis - mitral valve area?
Normal: MVA 4-6 cm^2
Significant MS: MVA 2 cm^2
Severe MS: MVA 1.5 cm^2
Very severe MS: 1 cm^2
Mitral stenosis - physical findings?
Malar flush
Pulse: AF
JVP: prominent a wave
Apex beat: tapping
Palpable S1 (at apex), palpable P2
RVH/parasternal lift
Auscultation:
- Accentuated/snapping S1
- OS
- Mid-diastolic rumbling murmur ?Pre-systolic accentuation (SR)
- Loud P2
Mitral stenosis - signs of severity?
- Small pulse pressure
- OS close to S2 (increased LA pressure)
- Long diastolic murmur (present as long as there is a gradient between LA and LV)
- Pulmonary hypertension
- Apical diastolic thrill
Signs of Aortic Regurgitation
Collapsing pulse Widened pulse pressure
Central signs of AR ?
Soft A2 - loss of normal splitting of S2 on inspiration Volume loaded apex beat, displaced apex beat Decrescendo diastolic murmur, loudest when sitting forward on expiration
AR murmur
Decrescendo diastolic murmur Loudest on expiration when sitting forward
Causes of AR?
ACUTE Infective endocarditis Dissecting aneurysm HTN Trauma CHRONIC Rheumatic heart disease Congenital bicuspid AV Ank spon Marfan/ehlers Danlos syndromes Aortitis
Mitral stenosis murmur?
Low pitched mid diastolic murmur Best heard at apex in left lateral position
Aortic regurgitation - physical findings
Water-Hammer/Collapsing pulse
Femoral artery “Pistol shot” murmur
Widened artery pressure (severe AR may not have a wide pulse pressure as LV end-diastolic pressure rises)
Displaced apex beat
Diastolic thrill at left sternal edge
S3 “ventricular gallop”
Decrescendo diastolic murmur
Austin Flint murmur: mid-diastolic murmur (regurgitant jets directed at the LV free wall)
Auscultatory features accentuated by exercise
Aortic regurgitation - signs of severity
Wide pulse pressure
Collapsing pulse
Long decrescendo diastolic murmur
S3
Soft A2
Austin-Flint murmur
LVF
Natural history of AR?
Chronic AR generally evolves slowly with a long asymptomatic compensated phase, with some patients developing worsening regurgitation that may progress to severe AR with LV dilation, LV systolic dysfunction, and heart failure
When is AVR recommended for AR?
Symptomatic patients with severe AR, regardless of LV systolic function
Asymptomatic patients with chronic severe AR and LVEF <50%
Asymptomatic patients with normal LVEF but end-systolic dimension >50 mm.
Asymptomatic patients with normal LVEF but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low
Patients with moderate or severe AR while undergoing cardiac surgery for other indications.
Tricuspid regurgitation - Peripheral signs
TR is diagnosed on the basis of peripheral signs
JVP with prominent V wave and rapid Y descent
Pulsatile liver
Often RV heave
PHT, loud P2
Pansystolic murmur, left LSE, louder on inspiration
Murmur in hypertrophic obstructive cardiomyopathy (HOCM)?
Late ejection systolic murmur max LSE
Pansystolic murmur of MR at apex (systolic anterior motion)
S4 (“atrial gallop”)
Louder on Valsalva, softer with hand grip
HOCM - Apex beat character?
Apex beat typically double impulse (pre-systolic ventricular dilatation post atrial contraction)
VSD - Aetiology
Usually congenital
Ruptured myocardial infarct
VSD - Physical findings
PSM max at LSE (often louder with smaller defects)
S3/S4
Thrill
Softer with valsalva
Associated with MR, Down’s, Tetralogy of Fallot
Indication for surgery: Moderate to large shunt
ASD - Murmur
Mid-systolic pulmonary ejection murmur
Increases with inspiration
Fixed splitting of S2
A mid-diastolic rumbling murmur at LSE may indicate increased flow through TV
What is the definition of mitral valve prolapse?
MVP is a common cause of MR. Most patients with MVP have mild, trivial, or no MR.
MVP is the most common cuase of surgical MR in developed countries.
The definition of MVP is based on imaging alone (previously imaging + clinical findings):
- Billowing of any portion of the mitral leaflets ≥2 mm above the annular plane in a long axis view.
- Abnormal systolic displacement of one or both leaflets in to the LA (sustolic billowing) due to a disruption or elonation of leaflets, chordae, or papillary muscles.
