Classify the causes of valvular heart disease
Infective:
- Inflammation of the endocardium of heart valves (valvulitis) can result from immune mediated damage (e.g. in acute rheumatic fever) or direct infection (e.g. bacterial/fungal endocarditis)
- Valvular inflammation has two important consequences:
- Collagen exposure and thrombus development in the short-term
- Post-inflammatory scarring, leading to long-term functional impairment
- Left sided heart valves are more freuently the site of endocarditis, thus emboli from valve thrombosis classically produces infarcts in systemic organs
- Most common cause of chronic heart valve scarring is rheumatic fever - immune disorder
Congenital:
- Aortic stenosis is commonly due to calcification of a congenital bicuspid aortic valve
Ischaemic:
- Mitral regurgitation is often caused by papillary muscle dysfunction post-infarction
List the different types of murmers you can get
Are they systolic or diastolic?
Left hand side (oxygenated side_:
- Aortic stenosis - systolic murmer
- Mitral regurgitation - systolic murmer
- Aortic regurgitation - diastolic murmer
- Mitral stenosis - diastolic murmer
Right hand side:
- Tricuspid regurgitation - systolic murmer
- Pulmonary stenosis - systolic murmer
- Tricuspid stenosis - diastolic murmer
- Pulmonary regurgitation - diastolic murmer
Mitral stenosis - diastolic murmer
What is it?
Where is it best heard?
Causes?
Pathophysiology?
Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.
Mitral valve murmers are best heard with the patient on their left hand side
Causes:
- Post inflammatory scarring: history of rheumatic fever
Pathophysiology:
- The LA is unable to empty, leading to pulmonary hypertension
- The LA becomes dilated and hypertrophies
- Pulmonary hypertension leads to RHF (cor pulmonale - an alteration in the structure and function of the right ventricle)
Mitral stenosis - diastolic murmer
Symptoms and sign?
Symptoms:
- Dysponea & haemoptysis: pulmonary hypertension
- Fatigue, weakness and abdominal/lower limb oedema: Right heart failure
- Palpitations: secondary AF
Signs:
- Malar flush: dusky discolouration in malar distribution, due to vascular stasis
- Small volume regular pulse, or irregular irregular (AF)
- Jugular vein distension (RHF)
- Left parasternal heave, due to RV hypertrophy (aka right ventricular heave)
- Ausculation: ‘Rumbling’ mid-diastolic murmer heart loudest at apex, just prior to systole (also a loud first heart sound and ‘opening snap’
Mitral regurgitation - systolic murmer
Signs and symptoms?
Symptoms:
- Palpitations: increased stroke volume/AF
- Dyspnoea/orthopnoea: pulmonary hypertension
- Fatigue: reduced cardiac output
- Features of RHF/CCF
Signs:
- Laterally displaced apex beat with a systolic thrill
- Auscultation: Pansystolic murmer at apex radiating into the axilla
- Alo a soft first heart sound and prominent third heart sound (due to sudden rush of blood into dilated LV in diastole if decompensated)
- Signs of CCF develop in later disease
- AF can develop but is less common than in mitral stenosis
Mitral regurgitation - systolic murmer
What is it?
Where is it best heard?
Causes?
Mitral regurgitation a disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood.
Best heard with the patient on their left hand side
Causes:
- Post-inflammatory scarring: commonly rheumatic
- Post-infarction papillary muscle dysfunction
- LV dilation: i.e. in LVF hypertrophic cardiomyopathy
- Mitral prolapse: floppy mitral valve syndrome
Aortic stenosis - systolic murmer
What is it?
Causes?
Pathophysiology?
Aortic stenosis is a narrowing of the aortic valve in the heart.
Causes:
- Calcification of congential bicuspid valve: most common
- Post-inflammatory scarring: rheumatic fever
- Senile calcific degeneration: no known cause
Pathophysiology:
- Progressive outflow obstruction leads to left ventricular hypertrophy, which may lead to angina
- There is a risk of sudden cardiac death due to arrhythmias, and without surgical intervention prognosis is poor with death in 2-3 years
The most common cause of chronic heart valve scarring is rheumatic fever. What is rheumatic fever and how does it cause heart valve scarring?
It is an immune disorder that occurs in children, usually following tonsillitis/pharyngitis caused by group A ß-haemolytic streptococci (GAS)
- There is antibody production to GAS, yet these antibodies cross-reat with cardiac antigens to cause a self-limiting myocarditis/pericarditis
- Although this is self-limiting, there is damage to heart valves that heals by progressive fibrosis of the valve leaflets and chordae tendinae
- This leads to shrunken, fibrotic valve leaflets, often secondary calcification
- If there is no convincing history of rheumatic fever, the term ‘post inflammatory scarring’ is used instead
Aortic regurgitation - diastolic murmer
What is it?
Causes?
Aortic regurgitation is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.
Causes:
- Post-inflammatory scarring
- Infective endocarditis
- Age-related calcification
- Dilation of the aortic root to inflammatory diseae (syphilis, aortic stenosis)
Aortic regurgitation - diastolic murmer
Signs and symptoms?
Symptoms:
- Usually asymptomatic until acute left ventricular failure
- Symptoms may include angina pectoris (due to low diastolic BP) and dyspnoea if present
Signs:
- Bounding/collapsing pulse
- Wide pulse pressure (e.g. 140/40)
- Auscultation: early diastolic murmer with a ‘decresendo’ quality
- Signs of LVF
Certain other signs may be present in very severe disease:
- Quinke’s sign: capillary pulsation in nail beds
- De Musset’s sign: head nodding with each heartbeat
- Duroziez’s sign: murmer on the femoral arteries if pressure applied distally
- Pistol sht femorals: sharp bang in time with the heartbeat if femorals auscultated
Are pulmonary/tricuspid disease more rare than mitral/aortic disease?
What is pulmonary/tricuspid disease most commonly due to?
Yes
Most commonly caused by post-infalmmatory scarring in rheumatic disease, endocarditis associated with IV drug users, or carnoid syndrome can lead to pulmonary stenosis. Right-sided murmers are all louder on inspiration
What would you find on examination including auscultation of patients with heart valve disease?
Mitral stenosis
- mitral facies/flush, small volume pulse (possibly AF), raised JVP, thrill and heave, mid-diastolic rumble murmur.
Mitral regurgitation:
- laterally displaced, diffuse apex beat, pansystolic murmur, prominent 3 rd heart sound, signs of right sided heart failure and pulmonary congestion, AF.
Aortic stenosis:
- small volume, slow rising pulse, sustained/thrusting apex beat, aortic thrill, ejection systolic murmur radiating to carotids (crescendo/decrescendo).
Aortic regurgitation:
- Bounding or collapsing pulse. Quincke’s sign (pulsatile nailbeds), De Musset’s sign (head nodding), Duroziez’s sign (pistol shot femorals), Mueller’s sign (pulsatile uvula), Corrigan’s sign (prominent carotids), Hill’s sign (higher BP in legs), laterally displaced, forceful apex beat, and high pitched diastolic murmur.
How can you differentiate between systolic and diastolic murmurs?
Systolic murmur occurs between first and second heart sounds, Diastolic occurs after second heart sound. Feeling the pulse will allow to establish which sound is S1.
How can you diagnose common mitral and aortic murmurs and their common causes
- Aortic Stenosis: Ejection systolic murmur radiating to the carotids (age-related calcification)
- Aortic Regurgitation: Early diastolic decrescendo murmur
- Mitral Stenosis: Mid-diastolic murmur (Rheumatic fever)
- Mitral Regurgitation: Pan-systolic murmur
