Cardiology: Valvular Heart Disease: AS & AR

Question 1

Which is the most common valve lesion in the UK? [1]

Answer 1

Aortic stenosis

Question 2

What is the most common cause of symptomatic AS in children? [1]

Answer 2

unicuspid aortic valve

Question 3

Describe the three causes of AS [3]
State when they might occur in life [2]

Answer 3

1. Calcific (degenerative)
   Affects patients later in life (>65).
   Atherosclerosis plays a role in calcification
2. Bicuspid valve (congenital)
   Stenosis tends to appear at a younger age (< 65).
3. Rheumatic heart disease

Question 4

State 4 risk factors for aortic stenosis [4]

Answer 4

• Hypercholesterolaemia
• Hypertension
• Smoking
• Diabetes.

Question 5

Desribe the pathophysiology of AS

Answer 5

A pressure gradient develops across the valve

Initially, this leads to systolic dysfunction, the heart can not pump out a normal proportion of its end-diastolic volume and causes increased resistance to ejection and increases the systolic pressure gradient.

Compensatory mechanisms result in left ventricular (concentric) hypertrophy - hence, a sustained apex.

This then causes diastolic dysfunction by reducing ventricular filling during diastole

This reduces the compliance of the left ventricle and reduces overall myocardial contractility.

This causes left heart failure

ALSO: the back-pressure from the left ventricle also increases pulmonary artery pressure and can lead to pulmonary hypertension. This eventually progresses to right heart failure.

Question 6

Describe the effect of AS on coronary arteries [2]

Answer 6

The hypertrophied area has a higher oxygen demand due to fewer capillaries per muscle mass and the larger LV may also compress coronary arteries

The lower stroke volume also causes reduced coronary filling time

Question 7

Describe the symptoms of AS

Answer 7

Patients with aortic stenosis (AS) may be asymptomatic for a prolonged period of 10-20 years.

• Exertional dysopnea
  Most common complaint
• Exertional angina
  Increased o2 demand due to more LV mass and decreased perfusion pressure gradient due to elevated LV end diastolic pressure
• Exertional syncope or presyncope
  Due to exercise induced vasodilation and inability to increase CO
• Atrial fibrillation
• Epistaxis or bruising

Classical triad of ‘SAD’ is often described.
Syncope; Angina; Dysopnea

Question 8

Which clotting disease can AS lead to? [1]
Explain your answer [1]

Answer 8

Turbulent flow across the stenotic aortic valve can lead to an acquired von Willebrand deficiency

High shear forces inducing structural changes in the shape of the protein leading to clotting abnormalities.

Question 9

Describe the signs of AS [4]

Answer 9

Murmur:
* Loud mid-to-late peaking systolic ejection murmur
* Radiates to the carotids and becomes more prominent with sitting forward and in expiration
* Murmur becomes softer the more severe the stenosis
* Murmur radiates to carotids

Sustained apex
Slow rising pulse
Narrow pulse pressure
Soft S2
S4 - caused by the atria contracting against stiff, hypertrophied ventricles.

Question 10

What ECG changes would you expect in AS? [1]

Answer 10

Left ventricular hypertrophy:
- deep S-waves in V1 and V2
- tall R-waves in V5 and V6).

Question 11

How can you tell from a murmur in AS if it is mild-moderate c.f severe murmur? [2]

Answer 11

Early peaking is more consistent with mild or moderate AS and late peaking is consistent with severe AS

Murmur becomes softer the more severe the stenosis

Question 12

What GI symptom might AS patients present with? [1]

Answer 12

gastrointestinal bleeding due to angiodysplasia

Question 13

How do you determine if an asymptomatic patient has AS? [1]

Answer 13

Perform a Exercise stress testing (EST)

Question 14

What is a multi-slice CT (MSCT) test for AS? [1]

Answer 14

Used to assess extent of calcification to determine calcium score for severity of AS and may be used to detect CAD in patients who are not eligible for EST

Question 15

When is dobutamine stress echo indicated in AS patients? [1]

By what mmHg does AS gr

Answer 15

Dobutamine stress echocardiogram:
- useful for patients who have low-gradient AS
- patients may be symptomatic but have seemingly low pressures due to a low ejection fraction
- gradient will increase > 40 mmHg after administration of low dose dobutamine

Question 16

Describe the work conducted prior to a surgical aortic valve replacement {SAVR) or transcatheter aortic valve implantation (TAVI) [3]

Answer 16

• Coronary angiogram:
  to ID CAD and concomitant coronary revascularization if possible
• Trans-oesophageal echocardiogram (TOE):
  assess for endocarditis and mitral valve abnormalities as well as monitoring the TAVI procedure
• MSCT:
  assess the anatomy and dimensions of the aortic root, shape of the aortic valve annulus and the number of aortic valve cusps

Question 17

What is the definitive treatment for AS? [2]

Answer 17

The definitive treatment for AS is surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI).

Question 18

How do you classify AS as being severe? [3]

Answer 18

Severe AS classified as:
- aortic jet velocity ≥4 m/s,
- mean trans-valvular pressure gradient ≥ 40 mmHg
- aortic valve area ≤1 cm2.

Question 19

What indicates surgery for AS? [3]

Answer 19

If symptomatic

If asymptomatic but have:
- LVEF < 50%
- Undergoing other cardiac surgery
- low surgical risk factors

Question 20

Which treatment option is used for palliative measures / not suitable for surgery / young children with congenital AS? [1]

Answer 20

Percutaneous balloon valvotomy

Question 21

When is conservative management indicated in AS patients? [1]

Answer 21

Conservative management is indicated for patients with mild AS who are asymptomatic and have no risk factors.

Question 22

What is Heyde’ syndrome? [1]

Answer 22

Triad of
- AS
- Anaemia due to bleeding
- Acquired coagulopathy

Question 23

Explain why angiodysplasia in the intestine may occur for patients with AS? [2]

Answer 23

Von Willebrand multimers get sheared across the narrowed aortic valve as they pass through it with higher velocity.

This prevents them from mediating platelet adhesion at sites of angiodysplasia in the intestine.

Question 24

What is the difference between long term management in those who recieve a mechnical valve vs a bioprosthetic valve when treating AS? [2]

Which suits younger patients more? [1[

Answer 24

Mechanical valve
- require long-term anticoagulation,
- long lifespan reducing the need for a second operation.
- Suited to younger patients.

Bioprosthetic valve
- no need for long-term anticoagulation
- limited life span (around 10 years) and a repeat operation is more likely.
- Suited to older patients.

Question 25

State the different aetiologies of AR [6]

Answer 25

Can be split into:

aortic leaflet disease:
* rheumatic infection
* infective endocarditis
* congenital & degenerative disease

aortic root disease:
* aortic dissection
* CT diseases
* aortitis

Question 26

Describe the valve leaflet causes of AR [3]

Answer 26

• rheumatic infection
  Inflammation is a result of molecular mimicry to streptococcal infection: immune system produces antibodies that confuse foreign and self-antigens.
• infective endocarditis
  Infective causes include Strep. viridans, Staph. aureus, Enterococci.
• congenital & degenerative disease
  Congenital (e.g. bicuspid, quadcuspid valve).
  Degenerative (e.g. calcification).

Question 27

Describe the aortic root causes of AR

Answer 27

Connective tissue disorders
- Aortic regurgitation may feature in a number of connective tissue disorders. Aortic root diameter should be monitored in these individuals.
- Marfan’s syndrome - caused by a defect in the FBN1 gene.
Ehlers-Danlos syndrome - caused by collagen defects.

Aortitis
- inflammation of the aortic root.
- May be associated with chronic inflammatory conditions such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Aortic dissection
- Aortic regurgitation may complicate in Stanford A dissections, secondary to impaired leaflet coaptation or prolapse. Causes acute disease regurgitation and is a medical emergency.

Question 28

Which causes of AS are acute [3] and chronic [3]

Answer 28

Acute:
- Infective endocarditis
- Rheumatic fever
- Aortic dissection

Chronic
- RHD
- Bicuspid valve disease
- CT disorders

Question 29

Describe the pathophysiology of acute AR

Answer 29

MEDICAL EMERGENCY:

• Causes an acute right in left atrial pressure
• Causes pulmonary oedema and cardiogenic shock
• Also get reduced coronary flow - the coronaries fill predominantly during diastole, regurgitant flow at this time reduces filling. Results in angina or in severe cases myocardial ischaemia.

Question 30

Describe the pathophysiology of chronic AR [4]

Answer 30

Regurgitation of blood during diastole causes an increase in the left ventricular end-diastolic volume (essentially the preload).

Leads to systolic and diastolic dysfunction

LV dilatation occurs with eccentric hypertrophy

The dilation allows for an increased stroke volume compensating for regurgitant flow supported by the ventricular hypertrophy

These changes maintain ejection fraction, with a greater preload leading to greater contractility

Question 31

Describe the clinical features of a patient with acute [4] and chronic AR [5]

Answer 31

Acute AR
* Sudden dyspnoea
* Chest pain (consider angina, MI or aortic dissection)
* Bi-basal crackles
* Raised JVP

Chronic:
* Palpitations
* Angina
* Dyspnoea
* Water hammer pulse
* Wide pulse pressure
* Chest signs:
Displaced apex
Ejection diastolic murmur
Soft S1 and S2

Question 32

Describe the following signs of AR [5]

Answer 32

de Musset’s - head nodding with the heart beat.
Quincke’s - pulsation of nail beds.
Traube’s - pistol shot femorals.
Duroziez’s - to and fro murmur heard when stethoscope compresses femoral vessels.
Müllers’ - pulsation of uvula.

Question 33

Pulsation of uvula is a sign of AR. What is the name for this sign?

Answer 33

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Question 34

A patient presents with head nodding to each heart beat. What is this a sign of?
What is the name for this sign? [1]

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Answer 34

Sign of AR

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Question 35

What is the name for the sign of pulsating nail beds? [1]

Answer 35

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Question 36

What is the name for a pistol shot in the femoral pulses?

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Answer 36

What is the name for a pistol shot in the femoral pulses?

Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Question 37

to and fro murmur heard when stethoscope compresses femoral vessels
This refers to which sign?
.
Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Answer 37

to and fro murmur heard when stethoscope compresses femoral vessels
This refers to which sign?
.
Duroziez’s
Quincke’s
de Musset’s
Traube’s
Müller’s

Question 38

Describe the murmur seen in AR [3]

Answer 38

Early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
Collapsing pulse
Wide pulse pressure

Question 39

Describe the managment of acute AR

Answer 39

Acute AR is a surgical emergency: Aortic valve replacement or repair should be performed as soon as possible. It primarily occurs secondary to infective endocarditis or aortic dissection, both of which carry very high morbidity and mortality:

Aortic dissection (Stanford type A):
- management depends on the patients pre-morbid state and severity of presentation. If not already there, patients are transferred to the local on-call dissection centre. Emergency open surgery is typically required, management depends on the exact pattern of findings but may consist of root replacement and valve repair or replacement.

Infective endocarditis:
- management depends upon pattern of valvular involvement (multiple valves may be affected) and complications (e.g. annular/aortic abscess, septic emboli). Coronary angiogram may be performed in selected stable patients prior to operative management. AR is generally an indication for early surgery.

-

Question 40

What indicates surgery in chronic AR? [4]

Answer 40

Significant enlargement of the ascending aorta
or
Symptomatic severe AR
or
Severe AR with LVEF ≤ 50% or LVEDD > 70mm or LVESD > 50mm (may be adjusted for body size)

Marfan’s with aortic root disease with a maximal ascending aorta diameter ≥ 50mm

Question 41

Which is characterised by the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Answer 41

Mitral regurgitation

Question 42

Which is characterised by the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Answer 42

AS

Question 43

Which is characterised by the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Answer 43

MS

Question 44

Which is characterised by the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Answer 44

AR

Question 45

Eccentric hypertrophy is caused by which of the following? [2]

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitat

Answer 45

Eccentric hypertrophy is caused by which of the following? [2]

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Question 46

Concentric hypertrophy is caused by which of the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Answer 46

Concentric hypertrophy is caused by which of the following?

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

Question 47

Which of the following conditions would cause eccentric hypertrophy [2]?

Renal failure

Aortic stenosis

Aortic regurgitation

Increased BP

Answer 47

Which of the following conditions would cause eccentric hypertrophy [2]

Renal failure

Aortic stenosis

Aortic regurgitation

Increased BP

*Eccentric hypertrophy is caused by volume overload, so could be caused by renal failure (which increases blood volume). It could also be caused by valve regurgitation.

Aortic stenosis usually results in initial concentric hypertrophy, but this in itself can then leads to eccentric hypertrophy

Question 48

What valvular pathology would cause a murmur that radiates to the carotids?

Tricuspid regurgitation

Aortic stenosis

Mitral stenosis

Mitral regurgitation

Pulmonary stenosis

Answer 48

What valvular pathology would cause a murmur that radiates to the carotids?

Tricuspid regurgitation

Aortic stenosis

Mitral stenosis

Mitral regurgitation

Pulmonary stenosis

Think of the radiation of murmurs to occur in the direction of the blood flow (i.e. aortic stenosis the blood flows towards the carotids – therefore radiates there. In mitral regurgitation the blood flows backwards towards the left axilla – therefore radiates there.)

Question 49

You are asked by your consultant to examine a patient with a murmur. She asks you to feel the patient’s carotid pulse.

When you feel the pulse, it feels as though the blood is shot up under high pressure, then immediately disappears.

What valvular pathology would this stereotypical pulse indicate? [1]

Answer 49

• Aortic regurgitation

This rapidly increasing then collapsing pulse is typical of aortic regurgitation. The blood is forced through the systemic vascular system under high pressure during systole, then the incompetent aortic valve allows blood to flow straight back into the heart. this gives a collapsing feeling to the pulse

Question 50

What valvular pathology may cause a murmur that radiates to the left axilla?

Mitral regurgitation

• Mitral stenosis
• Aortic regurgitation
• Aortic stenosis
• Tricuspid regurgitation

Answer 50

What valvular pathology may cause a murmur that radiates to the left axilla?

Mitral regurgitation

• Mitral stenosis
• Aortic regurgitation
• Aortic stenosis
• Tricuspid regurgitation

Think of the radiation of murmurs to occur in the direction of the blood flow (i.e. aortic stenosis the blood flows towards the carotids – therefore radiates there. In mitral regurgitation the blood flows backwards towards the left axilla – therefore radiates there.)

Question 51

A 64 year old presents complaining of shortness of breath, worse on exertion and when lying flat at night.

He is known to have ischaemic heart disease and is on medication for angina. He has had two previous NSTEMIs.

On ausculatation you hear a grade 3, pan-systolic murmur loudest at the apex.

What is the most likely cause for his murmur?

• Mitral regurgitation
• Mitral stenosis
• Tricuspid regurgitation
• Aortic regurgitation
• Aortic stenosis

Answer 51

A 64 year old presents complaining of shortness of breath, worse on exertion and when lying flat at night.

He is known to have ischaemic heart disease and is on medication for angina. He has had two previous NSTEMIs.

On ausculatation you hear a grade 3, pan-systolic murmur loudest at the apex.

What is the most likely cause for his murmur?

• Mitral regurgitation
• Mitral stenosis
• Tricuspid regurgitation
• Aortic regurgitation
• Aortic stenosis

Question 52

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries.

Which of the following is this patient most likely to have?

Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Answer 52

Aortic stenosis

Question 53

The length of murmur that correlates to intensity of pathology occurs with which of the following?

Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Answer 53

The length of murmur that correlates to intensity of pathology occurs with which of the following?

Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Question 54

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble.

Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Answer 54

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble.

Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Question 55

An 82-year-old lady comes into see her GP. Over the past 8 months, she has become increasingly breathless, especially at night, and has found that her ankles have become swollen. She has a history of ischaemic heart disease but an echocardiogram shows normal valve function. The GP listens to her heart and hears a low-pitch sound at the beginning of diastole, just after S2. What is the most likely cause of this sound?

Rapid movement of blood entering verntricles from atria
Mitral stenosis
Aortic regurgitation
Forceful atrial contraction
PDA

Answer 55

Rapid movement of blood entering verntricles from atria

This is a description of S3, an abnormal sound that can be heard in some patients with heart failure. The cause of the sound is rapid movement and oscillation of blood into the ventricles.

Question 56

Soft S2 is/are most characteristically seen in:

Mitral regurgitation

Patent ductus arteriosus

Aortic regurgitation

Mitral stenosis

Aortic stenosis

Answer 56

Aortic stenosis

Question 57

A 70-year-old man presents with chest pain and dyspnoea. On examination he has an ejection systolic murmur which radiates to his carotids is a stereotypical history of:

Mitral regurgitation

Left ventricular aneurysm

Hypertrophic obstructive cardiomyopathy

Aortic stenosis

Dressler’s syndrome

Mitral stenosis

Answer 57

Aortic stenosis