Heart Valve Disease

Question 1

What are some of the common symptoms of patients with the different heart valve disease?

Answer 1

Aortic Stenosis: (may be asymptomatic)
Angina
Syncope (faintness/dizziness on exertion)
LVF aka exertional breathlessness (if severe)

Aortic regurgitation: (asymptomatic if mild)
If moderate - severe can cause LVF and associated symptoms.

Mitral Regurgitation: (asymptomatic if mild)
SOB due to congestion
Can cause LVF and symptoms
Makes patient more prone to AF due to atrial dilation due to congestion.

Mitral Stenosis:
Could cause atrial dilatation leading to AF
Reduced filling of ventricles could lead to cardiac remodeling and LVF
Cough/haemoptysis

Tricuspid Stenosis/Regurgitation: *much rarer than aortic and mitral murmurs

Signs of RVF:
Pulmonary oedema
Hepatomegaly
Raised JVP
Peripheral oedema

Pulmonary Stenosis: (v. rare usually always congenital)

Sob
Chest Pain
Exertional syncope
Sudden Death

Question 2

What non invasive investigations can be used to assess heart valves and give a brief description of how you could assess it?

Answer 2

Trans thoracic / trans oesophageal doppler flow echo-cardiograph can assess blood flow and assess extent of stenoses/regurgitations.

CXR: You could see an enlarged heart therefore assess whether heart valve disease may be contributing to cardiac failure.

ECG: Important for assessing arrhythmias which may be caused by heart valve diseases.

Question 3

What are the different causes of valvular heart disease?

Answer 3

Main causes are: congenital, degenerative, infective, rheumatic and ischaemic.

Congenital:

• Bicuspid aortic valve more prone to calcification therefore causes an aortic stenosis.
• Pulmonary atresia
• Tricuspid atresia

Infective:
Infective endocarditis causing inflammatory damage to valves.

Rheumatic:
Rheumatic fever is an immune mediated response following infection with group A streptoccoci.
Rheumatic fever can damage valves causing them to become thickened, fibrous and shrunken.

Degenerative:
Over time, the attachments of the mitral valve thin out or rupture and the leaflets become floppy and redundant causing a mitral regurgitation. Slow degenerative process affecting approximately 5% of people.

Calcification due to ageing most commonly affecting the aortic valve causing an aortic stenosis.

Ischaemia:
Following cardiomegaly there can be a functional mitral/tricuspid regurgitation due to hypertrophy of the ventricles meaning the valves no longer close properly.

Following an MI there can be papillary muscle dysfunction leading to mitral regurgitation.

Question 4

What is cardiac catheterisation?

Answer 4

It is the gold standard investigation for investigating haemodynamics aka intracardiac pressure, oxygen saturation and cardiac output.

Note angiography can also be performed at the same time.

Question 5

What are the indications for cardiac catheterisation?

Answer 5

It is an invasive procedure therefore the risks must be balanced against the benefits.

Indications for catheterisation are:

• Identification of the extent and severity of coronary artery disease (CAD) and evaluation of left ventricular function
• Assessment of the severity of valvular or myocardial disorders (aortic/mitral stenosis or insufficiency and cardiomyopathies)
• Determination of the presence of CAD in patients with confusing clinical presentations or chest pain of uncertain origin
• Determining the presence of cor pulmonale in right sided failure

This can help determine the need for surgery.

However as it is invasive patients must be relatively well aka not decompensated, not in ventricular arrhythmias etc. Quite a long list of contraindications.

Question 6

How can aortic stenosis be managed?

Answer 6

Medical management is just treating any underlying heart failure.

Surgery is indicated in:

• Severe symptomatic AS
• Patients with severe AS undergoing a CABG
• Asymptomatic severe AS with a LVF of less than 50%

Surgical options include:
Aortic valve replacement or Transcather Aortic Valve Implant (TAVI)

Question 7

How is aortic regurgitation treated medically?

Answer 7

ACE inhibitors are used in patients with severe AR that are not fit for surgery (helps with inevitable cardiac remodelling)

Question 8

What is the general basis for valvular surgery?

Answer 8

Essentially replace the valve either with a metallic or pig valve.

In Mitral regurgitation repair may be attempted.

In aortic regurgitation more modern surgeries which remove the need for a prosthetic valve.

Question 9

How is Mitral stenosis and regurgitation treated medically?

Answer 9

Stenosis: diuretics, nitrates and beta blockers. Anticoagulation if in AF.

Regurgitation: diuretics and nitrates (vasodilators). Treat heart failure if present.