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Disease of heart valves Flashcards

1
Q

What are the causes of mitral stenosis?

A 
Rheumatic fever
Congenital
Mucopolysaccharidoses
Endocardial fibroelastosis
Malignant carcinoid
Prosthetic valve
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2
Q

What are mucopolysaccharidoses?

A

A group of metabolic disorders caused by the absence or malfunctioning of lysosomal enzymes

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3
Q

What is endocardial fibroelastosis?

A

A rare heart disorder usually associated with children two years old and younger characterized by a thickening of the endocardium due to an increase in the amount of supporting connective tissue and elastic fibers

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4
Q

What is the normal mitral valve orifice area? At what area do symptoms of stenosis begin?

A

Normal area= 4-6cm squared

Symptoms= <2cm squared

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5
Q

How does mitral valve stenosis present?

A 
Dyspnoea
Fatigue
Palpitations
Chest pain
Systemic emboli
Haemoptysis
Chronic bronchitis-like picture
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6
Q

What are the signs of mitral valve stenosis?

A

Malar flush on cheeks due to reduced cardiac output
Low-volume pulse
Atrial fibrillation is common
Tapping, non-displaced apex beat- palpable S1
On auscultation: loud S1; opening snap (pliable valve) rumbling mid diastolic murmur. Graham Steell murmur may occur

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7
Q

How is mitral stenosis best heard?

A

With the bell of the stethoscope
On expiration
With the stethoscope below the left axilla and the patient on their left side

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8
Q

What is a Graham Steell murmur?

A

An early diastolic murmur. EDMs are high pitched and easily missed and occur as ‘absence of silence’ in early diastole. An EDM occurs rarely in pulmonary regurgitation. If the pulmonary regurgitation is secondary to pulmonary hypertension resulting from mitral stenosis, then the EDM is called a Graham Steell murmur.

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9
Q

How do auscultation sounds change as mitral stenosis becomes more severe?

A

The more severe the stenosis, the longer the diastolic murmur and the closer the opening snap is to S2

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10
Q

What signs might be seen on an ECG in mitral stenosis?

A

Atrial fibrillation
RV hypertrophy
Progression right axis deviation
In sinus rhythm, bifid P waves (P mitrale)

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11
Q

What signs might be seen on a CXR in mitral stenosis?

A

Left atrial enlargement
Pulmonary oedema
Mitral valve calcification

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12
Q

What is the diagnostic test for mitral valve stenosis?

A

Echocardiography

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13
Q

When is significant stenosis said to exist in mitral stenosis?

A

When the valve orifice is <1cm square per 1m squared of the body surface area

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14
Q

How is mitral stenosis managed?

A
  1. If in AF rate control is crucial
  2. Anticoagulate with warfarin
  3. Diuretics to reduce pre-load and pulmonary venous conjestion
  4. If this fails to control symptoms, balloon valvuloplasty- if pliable, non-calcified valve, open mitral valvotomy or valve replacement
  5. Infective/subacute bacterial endocaritis prophylaxis for GI/GU infected procedures
  6. Oral penicillin as prophylaxis against recurrent rheumatic fever
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15
Q

What are complications of mitral stenosis?

A
  1. Pulmonary hypertension
  2. Emboli
  3. Pressure from larger left atrium on local structures e.g. recurrent laryngeal nerve causing hoarseness, the oesophagus causing dysphagia,
  4. Bronchial obstruction
  5. Infective endocarditis
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16
Q

What are the causes of mitral regurgitation?

A 
Functional (LV dilatation)
Annular calcification (elderly)
Rheumatic fever
Infective endocarditis
Mitral valve prolapse
Ruptured chordae tendinae
Papillary muscle dysfunction/rupture
Connective tissue disorders (Ehlers-Danlos; Marfan's)
Cardiomyopathy
Congenital
Appetite supressents e.g. fenfluramine
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17
Q

What are the symptoms of mitral regurgitation?

A

Dyspnoea
Fatigue
Plapitations
Infective endocarditis

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18
Q

What are the signs of mitral regurgitation?

A

Atrial fibrillation
Displaced, hyperdynamic apex beat
RV heave
Pansystolic murmur

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19
Q

Where does the murmur heard in mitral regurgitation radiate?

A

The axilla

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20
Q

What is the sign of increasing severity of mitral regurgitation?

A

The more severe, the larger the left ventricle

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21
Q

What signs might be seen on an ECG of a patient with mitral regurgitation?

A

Atrial fibrillation
P-mitrale if in sinus rhythm
Left ventricular hypertophy

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22
Q

What signs might be seen on a CXR in a patient with mitral regurgitation?

A

Big LA and LV
Mitral valve calcification
Pulmonary oedema

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23
Q

As well as an ECG, what other tests may be performed on a patient with suspected mitral regurgitation

A

Echo: to assess LV function and aetiology (trans-oesophageal to assess severity and suitability for repair rather than replacement)

Coppler echo to assess size and site and regurgitant jet.

Cardiac catheterization to confirm diagnosis, exclude other valve disease and assess coronary artery disease

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24
Q

How is mitral regurgitation managed?

A
  1. Control rate if atrial fibrillation
  2. Anticoagulate if: AF; history of embolism; prosthetic valve; additional mitral stenosis
  3. Diuretics to improve symptoms
  4. Surgery for deteriorating symptoms
  5. Aim to repair or replace the valve before LV irreversibly impaired
  6. SBE/IE prophylaxis for GI/GU infected procedures
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25
What is the most common valvular abnormality?
Mitral valve prolapse
26
What is mitral valve prolapse?
Displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. "Mitral valve prolapse means that one or more of the mitral flaps are floppy and don't close tightly, often leading to backflow of blood- mitral regurgitation. Most people with a mitral valve prolapse will not have symptoms, unless the problem causes severe mitral regurgitation, and it is usually discovered by chance during echocardiography carried out for a different reason."
27
What other diseases may occur with mitral prolapse?
``` ASD Patent ductus ateriosus Cardiomyopathy Turner's syndorme Marfan's syndrome Osteogenesis imperfecta Pseudoxanthoma elasticum WPW ```
28
What are the symptoms of mitral valve prolapse?
May be asymptomatic May occur with atypical chest pain and palpitations Some patients have symptoms of autonomic dysfunction- anxiety, panic attack, syncope
29
What signs may be auscultated in a patient with mitral valve prolapse?
Mid systolic click and/or late systolic murmur
30
What are the complications of mitral valve prolapse?
Mitral regurgitation Cerebral emboli Arrhythmias Sudden death
31
What is the diagnostic test for mitral valve prolapse?
Echo
32
What is the treatment for mitral valve prolapse?
Beta-blockers may help palpitations and chest pain | If there is severe mitral regurgitation, surgery may be needed
33
What are the causes of aortic stenosis?
Senile calcification is the commonest cause | Other causes are congenital (bicuspid valve, Williams syndrome) and rheumatic fever
34
What triad of symtoms is characteristic of aortic stenosis?
Angina Syncope Heart failure
35
What other symptoms may be seen in aortic stenosis?
``` Dizziness Faints Dyspnoea Systemic emboli Sudden death ```
36
What are the signs of aortic stenosis?
Slow rising pulse with narrow pulse pressure LV heave Aortic thrill Ejection systolic murmur (crescendo de-crescendo)
37
How is an aortic stenotic murmur best heard?
Heard at the base, left sternal edge and aortic area. Radiates to the carotids.
38
What might an ECG of a patient with aortic stenosis look like?
P-mitrale Left ventricular hypertrophy Left axis deviaiton- left anterior hemiblock LBBB or complete AV block (calcified ring)
39
When is aortic stenosis classified as severe?
Peak pressure gradient across the aortic valve is >50mmHg and valve area <1cm squared
40
What is the differential diagnosis for aortic stenosis?
Hypertrophic cardiomyopathy
41
What is the best treatment for aortic stenosis?
Valve replacement
42
What is aortic sclerosis
Senile degeneration of the valve- may be a precursor of aortic stenosis
43
How can aortic sclerosis be differentiated from aortic stenosis on auscultation?
Both have ejection systolic murmur but in sclerosis there is no radiation to the carotids. There is a normal pulse- character and volume- and S2 is normal
44
What are the causes of acute aortic regurgitation?
Infective endocarditis Ascending aortic dissection Chest trauma
45
What are the causes of chronic aortic regurgitation?
``` Congenital Connective tissue disorders- Marfan's, Ehlers-Danlos Rheumatic fever Rheumatoid arthritis SLE Hypertension Osteogenesis imperfecta ```
46
What are the symptoms of aortic regurgitation?
``` Exertional dyspnoea Orthopnoea PND Palpitations Angina Syncope CCF ```
47
What are the signs of aortic regurgitation?
Collapsing pulse Wide pulse pressure Displaced, hyperdynamic apex beat High pitched early diastolic murmur
48
How is the murmur of aortic regurgitation best heard?
With the bell of the stethoscope In expiration With the patient sitting forward
49
What is Corrigan's sign?
Carotid pulsation
50
What is de Musset's sign?
Head nodding with each heart beat
51
What is Quincke's sign?
Capillary pulsations in nail bed?
52
What is Duroziez's sign?
In the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur. If 2cm distal, it gives a diastolic murmur as blood flows backwards.
53
What is Traube's sign?
Pistol shot sound over the femoral arteries
54
What is an Austin Flint Murmur?
Mid diastolic murmur heard in mitral stenosis due to the fluttering of the anterior mitral valve cusp caused by the regurgitant stream. Denotes severe AR
55
What is the main goal of therapy in aortic regurgitation?
To reduce systolic hypertension
56
Describe the management of aortic regurgitation
1. Reduce systolic hypertension using ACEis 2. Echo every 6-12 months to monitor 3. Surgery if indicated
57
What are the indications for surgery in aortic regurgitation?
Increasing symptoms Enlarging heart on CXR/echo ECG deterioration- T wave inversion in lateral leads IE refractory to medical therapy
58
What are the predictors for poor post operative survival in aortic regurgitation?
Ejection fraction 12 months
59
What causes tricuspid regurgitation?
Functional- RV dilatation e.g. due to pulmonary hypertesion induced by LV failure Rheumatic fever Infection endocarditis Carcinoid syndrome Congenital Drugs- ergot-derived dopamine antagonists e.g. bromocriptine
60
What are the symptoms of tricuspid regurgitation?
``` Fatigue Ascites Oedema Hepatic pain on exertion Dyspnoea Orthopnoea ```
61
What signs might be seen on the JVP wave in tricuspid regurgitation?
Giant V waves and prominent y descent
62
What are the signs of tricuspid regurgitation?
``` RV heave Pansystolic murmur Pulsatile hepatomegaly Jaundice Ascites ```
63
How is the murmur of tricuspid regurgitation best heard?
At the lower sternal edge in inspiration
64
How is tricuspid regurgitation managed?
1. Treat underlying cause 2. Drugs- diuretics, digoxin, ACEi 3. Valve replacement
65
What are the causes of tricuspid stenosis?
Rheumatic fever is the main cause | Also congenital, IE
66
What are the symptoms of tricuspid stenosis?
Fatigue Ascities Oedema
67
What are the signs of tricuspid stenosis?
Giant a wave and slow y descent in JVP OPening snao Early diastolic murmur AF can occur
68
How is tricuspid stenosis treated?
diuretics | surgical repair
69
What are the causes of pulmonary stenosis?
Usually congenital | Acquired causes: rheumatic fever, carcinoid syndrome
70
What are the symptoms of pulmonary stenosis?
Dyspnoea Fatigue Oedema Ascites
71
What are the signs of pulmonary stenosis?
Dysmorphic facies (congeintal causes) Prominent a wave in JVP RV heave Ejection click, ejection systolic murmur radiating to the left shoulder
72
What signs of pulmonary stenosis might be seen on an ECG?
Right axis deviation Peaked P waves- P pulmonale RVH RBBB
73
What is the diagnostic test for pulmonary stenosis?
Cardiac catheterization
74
What is the treatment of pulmonary stenosis?
pulmonary valvuloplasty or valvotomy
75
What causes pulmonary regurgitation?
Any cause of pulmonary hypertension
76
What is valulopasty?
A balloon catheter is inserted across a stenotic valve and inflated
77
When can valvuloplasty be used?
In mitral or pulmonary stenosis when the valve is pliable and non-calcified with no regurgitation
78
What is valvotomy?
Incision into a stenosed cardiac valve to relieve the obstruction. Rarely performed
79
What are the different types of mechanical valves?
Ball-cage, tilting disc or double tilting disc
80
What is the major risk of mechanical valves? How is this risk managed?
Thrombosis | Life-long anticoagulation
81
What are homografts? When are they used?
Cadaveric valves. Used in young patients and for the replacement of infected valves
82
What are xenografts? What is their disadvantage? What is their advantage?
Valves made from porcine valves or pericardium Do not require anticoagulation Less durable- need replacement after 8-10 years
83
What are the complications of prosthetic valves?
``` Systemic embolism IE Haemolysis Structural valve failure Arrhythmias ```

Cardiology (18 decks)

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