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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
Q

What are the pros and cons of mechanical vs bioprosthetic replacement valves?

A

Mechanical: last longer, require long term anticoagulation
Bioprosthetic: shorter life, no need for anticoagulation

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26
Q

Give 3 examples of materials typically used for bioprosthetic valves

A

Pig valve
Calf pericardium
Human valve

27
Q

What kinds of procedures can be performed as part of the surgical intervention in valvular disease?

A

Repair
Valvuloplasty (surgical or balloon; for stenosis)
Stent valves (Transcatheter Aortic Valve Implant, TAVI)
Mitral valve clips

28
Q

What is the most common valve lesion requiring surgery?

A

AS

29
Q

What are the 3 most common causes of AS?

A

Calcific (increases with age)
Congenital (AS or bicuspid, which may become stenotic later in life)
Rheumatic fever

30
Q

What are the symptoms of AS? When do these appear?

A

Exertional chest pain and SOB
Syncope
Symptoms appear when stenosis is severe; no symptoms if stenosis is mild-moderate

31
Q

What examination findings are seen in AS?

A

Carotid pulse has slow upstroke (“plateau pulse”)
Apex beat heaving but not displaced
Thrill over upper R sternal edge if loud murmur

32
Q

What murmur is heard in AS? Where is it heard best?

A

Ejection systolic crescendo-decrescendo

Best heard at upper R sternal edge

33
Q

What examination findings are suggestive of severe AS?

A

Murmur heard over wider area
Delayed carotid upstroke
LV heave on apex beat

34
Q

How is severity of AS best determined? What findings indicate severe AS?

A

Echocardiography

Gradient of >50mm and an aortic valve area ≤0.7cm2 indicates severe disease

35
Q

How is mild-moderate or asymptomatic AS managed?

A

Observation

36
Q

How is severe or symptomatic AS managed?

A

Valve replacement (open operation or TAVI)

37
Q

What are the 2 main mechanisms underlying AR?

A

Aortic leaflet damage

Dilated aortic root

38
Q

List 6 causes of AR

A

Aortic leaflet damage: endocarditis, rheumatic fever

Aortic root dilation: Marfan’s syndrome, aortic dissection, collagen vascular disorders, syphilis

39
Q

Give some examples of collagen vascular disorders

A 
RA
SLE
Ankylosing spondylitis
Scleroderma
Psoriatic arthritis
40
Q

What are the symptoms of AR?

A

Even severe AR causes no symptoms unless the LV decompensates (in which case there are symptoms of HF, e.g. SOB, ankle oedema)

41
Q

What are the clinical signs of AR?

A

High volume pulse: “collapsing pulse”, wide pulse pressure

Early diastolic murmur

42
Q

How is severe AR managed?

A

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
Q

List 7 causes of MR

A

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
Q

What are the symptoms of MR?

A

Even severe MR causes no symptoms unless the LV decompensates (in which case there are symptoms of HF, e.g. SOB, ankle oedema)

45
Q

What murmur is heard in MR?

A

Pansystolic murmur

46
Q

Where is the murmur in MR heard best?

A

Usually confined to apex; if severe, may also be heard at upper R sternal edge

47
Q

How is severe MR managed?

A

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
Q

What is the most common lesion caused by rheumatic fever?

A

MS

49
Q

What is the most common cause of MS and who is more commonly affected?

A

Rheumatic fever

Women more commonly affected

50
Q

What are the symptoms of MS?

A

SOB and oedema if severe

51
Q

What are the signs of severe prolonged MS?

A 
Mitral facies (facial flushing: https://o.quizlet.com/swGxPssFWHbvUPPCHBzk0A_m.png)
"Tapping" apex beat (correlates with loud S1)
52
Q

Characterise the murmur heard in MS

A

Opening snap followed by a diastolic “rumbling” murmur with pre-systolic accentuation due to atrial systole

53
Q

Where is the murmur heard best in MR? Diaphragm or bell?

A

Over the apex with the bell

54
Q

What are the possible sequelae in MS?

A 
Atrial dilatation
AF
Thrombo-embolic risk
Pulmonary HTN and oedema
RHF
55
Q

How is MS managed?

A

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
Q

What are the options for surgical intervention in MS?

A

Mitral valvotomy (closed or open via L atrial incision)
Balloon valvuloplasty
Replacement

57
Q

What are the 3 most common causes of TR?

A 
RV failure (e.g. in pulmonary HTN due to lung disease or LHF)
Endocarditis
Pacemaker lead interference with valve
58
Q

What are the symptoms and signs of TR?

A

Peripheral oedema
Elevated JVP
Hepatomegaly (due to hepatic congestion)

59
Q

How is TR managed?

A

Symptoms usually controlled with diuretics

Surgery required only occasionally

60
Q

What are the 4 most common organisms causing infective endocarditis?

A

Strep viridans
Strep bovis
Staph aureus
Staph epidermidis

61
Q

How does IE typically present?

A

Fever +/- murmur

Splinter haemorrhages, Osler’s noes etc now rare (signs of inflammation and embolisation)

62
Q

How is IE diagnosed?

A

Blood cultures
Echocardiogram (esp TOE)
Blood results may indicate inflammation (elevated WCC, ESR, CRP, evidence of anaemia and microhaematuria)

63
Q

How is IE managed?

A

By a multidisciplinary team (cardiologist, ID, cardiac surgeon)
Prolonged course of Abx via PICC (usually HitH)
Valve replacement if HF or uncontrolled infection

64
Q

Dukes criteria for endocarditis

A

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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