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MD2 Cardio > Heart Valve Disease > Flashcards

Heart Valve Disease Flashcards

1
Q

What forms of valvular disease are rarer?

A

Tricuspid stenosis

Pulmonary valve disease

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2
Q

Pathophysiology of rheumatic fever

A

Type II HS (Ab cross-reactivity to M protein) 2-3 weeks post-Strep pyogenes infection

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3
Q

How does infection with Strep pyogenes most commonly manigest?

A 
Pharyngitis
Scarlet fever (sore throat and rash)
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4
Q

What is the most common age group affected by rheumatic fever?

A

6-15 years

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5
Q

List 6 clinical features of rheumatic fever

A

Fever
Migratory polyarthritis of the large joints
Erythema marginatum
Subcutaneous nodules overlying bones and tendons
Murmur
Sydenham’s chorea (St Vitus Dance)

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6
Q

What is erythema marginatum?

A

Pink rings on the trunk and limbs, found primarily on extensor surfaces

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7
Q

How are the “Jones criteria” used to diagnose rheumatic fever?

A

Where there is evidence of GAS infection (i.e. positive cultures, rising ASO titre), 2 major criteria OR 1 major + 1 minor criteria are required for diagnosis

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8
Q

What is Sydenham’s chorea?

A

Movement disorder characterised by rapid, uncoordinated jerking movements primarily affecting the face, hands and feet; more common in females, usually with onset before puberty
https://www.youtube.com/watch?v=RnxqqW_nH0k

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9
Q

Major Jones criteria

A 
J: joints (migratory polyarthritis of the large joints)
O: a heart (carditis)
N: nodules (subcutaneous)
E: erythema marginatum
S: Sydenham's chorea

NB The 2 C’s meet the diagnostic criteria alone (carditis and chorea)

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10
Q

Minor Jones criteria

A

REAL Heart Failure
R: raised ESR/CRP
E: ECG with features of heart block (if no clear carditis)
A: arthralgia (if no clear polyarthropathy)
L: leukocytosis
H: Hx of rheumatic fever or heart disease
F: fever

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11
Q

How is rheumatic fever treated?

A

Abx (penicillin)
NSAIDs
Long term Abx prophylaxis to prevent recurrence

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12
Q

When is TOE indicated over TTE?

A

To look at valve details (esp mitral)
Where atrial thrombus is suspected
Where endocarditis is suspected

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13
Q

What structural and functional features of the heart can be examined on echocardiography?

A 
Chamber size and function (including EF)
Wall thickness
Cardiac structure
Valve morphology
Flow velocities (if Doppler; can be used to quantify stenosis, regurgitation, RV systolic pressure)
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14
Q

Describe the LV response to regurgitation

A

EDV, SV and EF all increase

ESV remains constant

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15
Q

Describe the irreversible change in LV function with decompensation in severe regurgitation. What does this correspond with clinically?

A

EDV increases markedly, ESV increases, EF decreases

Onset of symptoms occurs at this time

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16
Q

When is a surgical intervention indicated for regurgitation?

A

On echo criteria (before onset of symptoms as this indicates severe disease)

WHAT ECHO CRITERIA?

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17
Q

Volume overload

A

Regurgitation

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18
Q

Pressure overload

A

Stenosis

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19
Q

Effect of regurgitation on cardiac structure

A

Eccentric hypertrophy of the LV

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20
Q

Effects of stenosis on cardiac structure

A

AS: concentric hypertrophy of LV
MS: LA dilatation

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21
Q

Time of symptom onset with regurgitation

A

Coincides with irreversible LV changes

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22
Q

Time of symptom onset with stenosis

A

Trigger for surgery (LVH in AS is reversible with surgery)

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23
Q

Which valvular disorders may result in pulmonary HTN?

A

MR

MS

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24
Q

For each valve lesion, discuss causes, pathophysiology, symptoms, signs (peripheral as well as any murmurs), natural Hx and timing of intervention

A

AR:
MR:
AS:
MS:

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25
What are the pros and cons of mechanical vs bioprosthetic replacement valves?
Mechanical: last longer, require long term anticoagulation Bioprosthetic: shorter life, no need for anticoagulation
26
Give 3 examples of materials typically used for bioprosthetic valves
Pig valve Calf pericardium Human valve
27
What kinds of procedures can be performed as part of the surgical intervention in valvular disease?
Repair Valvuloplasty (surgical or balloon; for stenosis) Stent valves (Transcatheter Aortic Valve Implant, TAVI) Mitral valve clips
28
What is the most common valve lesion requiring surgery?
AS
29
What are the 3 most common causes of AS?
Calcific (increases with age) Congenital (AS or bicuspid, which may become stenotic later in life) Rheumatic fever
30
What are the symptoms of AS? When do these appear?
Exertional chest pain and SOB Syncope Symptoms appear when stenosis is severe; no symptoms if stenosis is mild-moderate
31
What examination findings are seen in AS?
Carotid pulse has slow upstroke ("plateau pulse") Apex beat heaving but not displaced Thrill over upper R sternal edge if loud murmur
32
What murmur is heard in AS? Where is it heard best?
Ejection systolic crescendo-decrescendo | Best heard at upper R sternal edge
33
What examination findings are suggestive of severe AS?
Murmur heard over wider area Delayed carotid upstroke LV heave on apex beat
34
How is severity of AS best determined? What findings indicate severe AS?
Echocardiography | Gradient of >50mm and an aortic valve area ≤0.7cm2 indicates severe disease
35
How is mild-moderate or asymptomatic AS managed?
Observation
36
How is severe or symptomatic AS managed?
Valve replacement (open operation or TAVI)
37
What are the 2 main mechanisms underlying AR?
Aortic leaflet damage | Dilated aortic root
38
List 6 causes of AR
Aortic leaflet damage: endocarditis, rheumatic fever | Aortic root dilation: Marfan's syndrome, aortic dissection, collagen vascular disorders, syphilis
39
Give some examples of collagen vascular disorders
``` RA SLE Ankylosing spondylitis Scleroderma Psoriatic arthritis ```
40
What are the symptoms of AR?
Even severe AR causes no symptoms unless the LV decompensates (in which case there are symptoms of HF, e.g. SOB, ankle oedema)
41
What are the clinical signs of AR?
High volume pulse: "collapsing pulse", wide pulse pressure | Early diastolic murmur
42
How is severe AR managed?
Follow-up with echocardiography 6-12 monthly When echo shows indicators of early LV decompensation (LVH, decreased LV function), surgical intervention is indicated BEFORE onset of symptoms
43
List 7 causes of MR
Valves: myxomatous degeneration (prolapse), infective endocarditis, rheumatic fever, collagen vascular disease Chordae tendinae: rupture (flail leaflet) Papillary muscle: rupture due to MI Ventricular: cardiomyopathy causing change in shape
44
What are the symptoms of MR?
Even severe MR causes no symptoms unless the LV decompensates (in which case there are symptoms of HF, e.g. SOB, ankle oedema)
45
What murmur is heard in MR?
Pansystolic murmur
46
Where is the murmur in MR heard best?
Usually confined to apex; if severe, may also be heard at upper R sternal edge
47
How is severe MR managed?
Follow-up with echocardiography 6-12 monthly When echo shows indicators of early LV decompensation (LVH, decreased LV function) or pulmonary HTN, surgical intervention (replacement or repair) is indicated BEFORE onset of symptoms
48
What is the most common lesion caused by rheumatic fever?
MS
49
What is the most common cause of MS and who is more commonly affected?
Rheumatic fever | Women more commonly affected
50
What are the symptoms of MS?
SOB and oedema if severe
51
What are the signs of severe prolonged MS?
``` Mitral facies (facial flushing: https://o.quizlet.com/swGxPssFWHbvUPPCHBzk0A_m.png) "Tapping" apex beat (correlates with loud S1) ```
52
Characterise the murmur heard in MS
Opening snap followed by a diastolic "rumbling" murmur with pre-systolic accentuation due to atrial systole
53
Where is the murmur heard best in MR? Diaphragm or bell?
Over the apex with the bell
54
What are the possible sequelae in MS?
``` Atrial dilatation AF Thrombo-embolic risk Pulmonary HTN and oedema RHF ```
55
How is MS managed?
Follow-up with echocardiography looking at mitral gradient, L atrial size and pulmonary artery pressure Anticoagulation (esp if AF; treatment if relevant) Diuretics Mitral valve intervention (valvotomy, valvuloplasty or replacement)
56
What are the options for surgical intervention in MS?
Mitral valvotomy (closed or open via L atrial incision) Balloon valvuloplasty Replacement
57
What are the 3 most common causes of TR?
``` RV failure (e.g. in pulmonary HTN due to lung disease or LHF) Endocarditis Pacemaker lead interference with valve ```
58
What are the symptoms and signs of TR?
Peripheral oedema Elevated JVP Hepatomegaly (due to hepatic congestion)
59
How is TR managed?
Symptoms usually controlled with diuretics | Surgery required only occasionally
60
What are the 4 most common organisms causing infective endocarditis?
Strep viridans Strep bovis Staph aureus Staph epidermidis
61
How does IE typically present?
Fever +/- murmur | Splinter haemorrhages, Osler's noes etc now rare (signs of inflammation and embolisation)
62
How is IE diagnosed?
Blood cultures Echocardiogram (esp TOE) Blood results may indicate inflammation (elevated WCC, ESR, CRP, evidence of anaemia and microhaematuria)
63
How is IE managed?
By a multidisciplinary team (cardiologist, ID, cardiac surgeon) Prolonged course of Abx via PICC (usually HitH) Valve replacement if HF or uncontrolled infection
64
Dukes criteria for endocarditis
Major: positive blood culture for IE, evidence of endocardial involvement (on echo) Minor: predisposition, fever, vascular phenomena, immunologic phenomena, microbiological evidence, echocardiographic findings

MD2 Cardio (11 decks)

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