Heart Valve Disease Flashcards
If untreated, what does severe valve disease lead to?
Heart failure
What is rheumatic fever?
Type II hypersensitivity reaction to Streptococcus pyogenes
What infections does S pyogenes initially produce in the body?
Pharyngitis
Scarlet fever
When does rheumatic fever occur after S pyogenes infection?
2-3 weeks post-infection
In whom is rheumatic fever most common?
6-15 year-olds
What are the clinical features of rheumatic fever?
Fever Arthritis - Migratory polyarthritis - Large joints Rash - erythema marginatum Subcutaneous nodules over - Bones - Tendons Murmur Sydenham's chorea
How is rheumatic fever diagnosed?
On basis of clinical criteria: Jones criteria
What is the management for rheumamtic fever?
Abx
NSAIDs
Long-term Abx prophylaxis, as may recur
What is echocardiography?
High frequency US looking at
- Chamber size and function = EF
- Wall thickness
- Cardiac structure
- Valve morphology
What does transoesophageal echocardiography (TOE) show?
Valve details, especially mitral
Atrial thrombus
Endocarditis
What is the left ventricle’s response to regurgitation?
Compensation - Increased SV - Increased EF - Increased end diastolic volume If severe regurgitation > eventual irreversible deterioration in LV - High increase in end diastolic volume - Increased end systolic volume - Decreased ejection fraction
What chamber is affected in aortic regurgitation?
Left ventricle
What is the load on the heart in aortic regurgitation?
Volume
What is the effect of aortic regurgitation to the structure of the left ventricle?
Eccentric hypertrophy (enlargement)
When do symptoms occur in aortic regurgitation?
Coincide with irreversible LV changes
What chamber is affected in mitral regurgitation?
LV
What is the load on the heart in mitral regurgitation?
Volume
What is the effect of mitral regurgitation to the structure of the left ventricle?
Eccentric hypertrophy (enlargement)
When do symptoms occur in mitral regurgitation?
Coincide with irreversible LV changes
What are other effects of mitral regurgitation?
Pulmonary HTN
What is the chamber affected in aortic stenosis?
LV
What is the load on the heart in aortic stenosis?
Pressure
What is the effect of aortic stenosis on the structure of the left ventricle?
Concentric hypertrophy
What is the next step in treatment when symptoms occur in aortic stenosis?
Trigger for surgery
Is left ventricular hypertrophy due to aortic stenosis affected after surgery?
Yes, it regresses
What chamber is affected in mitral stenosis?
LA
What is the load on the heart in mitral stenosis?
Pressure
What is the effect of mitral stenosis on the structure of the heart?
LA enlargement
What is the next step in treatment when symptoms occur in mitral stenosis?
Surgery
What are the other effects of mitral stenosis?
Pulmonary HTN
What are the options for valve replacement?
Mechanical - Last forever - Need anticoagulants Bioprosthetic - Shorter lifespan - Don't need anticoagulants - Pig valve - Calf pericardium - Human valve
Can valves be repaired surgically?
Yes, especially if mitral valve prolapse
For what valve disease is valvuloplasty indicated?
Stenosis
What is the commonest valve lesion needing surgery?
Aortic stenosis
What are the causes of aortic stenosis?
Calcific - Commonest cause - Increases with age Congenital - Stenosed at birth - Bicuspid aortic valve may become stenotic later in life Rheumatic fever - Rare
What are the symptoms of aortic stenosis?
SOB on exertion
Chest pain on exertion
Syncope
When do symptoms of aortic stenosis appear?
When stenosis severe
What are the signs of aortic stenosis?
Carotid pulse - Slow upstroke = plateau pulse - Indicative of reduced systolic ejection Apex beat - Not displaced - Heaving Thrill - If loud murmur - Over upper R sternal edge
What are the characteristics of a murmur due to aortic stenosis?
Systolic
Crescendo-decrescendo = ejection systolic
Best heard at upper R sternal edge
Loud murmur may also be heard at apex
What is the management of aortic stenosis?
Mild-moderate/no symptoms
- Observe
Severe on echo + symptoms
- Replace valve
- Open operation: aortic valve replacement
- Transcatheter aortic valve implant (TAVI)
What are the causes of aortic regurgitation?
Aortic leaflet damage - Endocarditis - Rheumatic fever Aortic root dilated > leaflets don't close - Marfan's syndrome - Aortic dissection - Collagen vascular disorders - Syphilis
What are the symptoms of aortic regurgitation?
Even severe AR causes no symptoms unless LV decompensates
Then symptoms of heart failure
- SOB
- Ankle oedema
What are the signs of aortic regurgitation?
Collapsing pulse
Wide pulse pressure
Early diastolic murmur
What is the management of aortic regurgitation?
Severe
- Follow-up with echocardiography every 6-12 months
When echo indicates early LV decompensation = increased LV size, decreased LV function
- Trigger for operation
- Before symptoms occur
What are the causes of mitral regurgitation?
Myxomatous degeneration > mitral valve prolapse
Ruptured chordae tendinae > flail leaflet
Infective endocarditis
Myocardial infarct > ruptured papillary muscle
Rheumatic fever
Collagen vascular disease
Cardiomyopathy > change in ventricular shape
What are the symptoms of mitral regurgitation?
Even severe MR doesn’t cause symptoms unless LV decompensates
Then symptoms of heart failure
- SOB
- Ankle oedema
What are the characteristics of a murmur due to mitral regurgitation?
Pan-systolic
Best heard in 5th intercostal space in mid-clavicular line
Can radiate to axilla
What is the management for mitral regurgitation?
Follow-up with echocardiography every 6-12 months for severe MR
When echo indicates early LV decompensation: increased LV size, decreased LV function/pulmonary HTN
- Trigger for operation
- Mitral valve replacement
- Mitral valve repair
- Before symptoms occur
What are the causes of mitral stenosis?
Rheumatic fever
What is the most common lesion due to rheumatic fever?
Mitral stenosis, especially in women
What are the symptoms of mitral stenosis?
When severe
- SOB
- Oedema
What are the signs of mitral stenosis?
In severe prolonged MS
- Mitral facies = facial flushing
- Tapping apex beat - correlates with loud S1
What are the characteristics of a murmur due to mitral stenosis?
Diastolic rumbling - best heard with bell
What are the complications of mitral stenosis?
Atrial dilatation AF Thrombo-embolism Pulmonary congestion and oedema Pulmonary HTN - Chronic hypoxia > pulmonary vasoconstriction Right heart failure
What is the management for mitral stenosis?
Follow-up with echocardiography - Mitral gradient - L atrial size - Pulmonary artery pressure Anticoagulation, especially if AF Treat AF Diuretics Mitral valve intervention
What are the mitral valve interventions for mitral valve stenosis?
Mitral valvotomy - Surgical - Closed = without major open heart surgery - Open - via L atrial incision Balloon valvuloplasty Mitral valve replacement
What are the causes of tricuspid regurgitation?
Usually response to RV failure
- Pulmonary HTN
Endocarditis - especially in IVDU
Pacemaker lead interference with valve
What are the signs of tricuspid regurgitation?
Same as those for RV failure
- Peripheral oedema
- High JVP
- Liver congestion
How is tricuspid regurgitation managed?
Diuretics
Tricuspid surgery occasionally needed
What is infective endocarditis?
Bacterial infection on heart valve/pacemaker lead
What are the common organisms causing infective endocarditis?
Streptococcus viridans
Streptococcus bovis
Staphylococcus aureus
Staphylococcus epidermidis
What is the clinical presentation of infective endocarditis?
Fever +/- heart murmur
Signs of inflammation/embolisation now rare
- Splinter haemorrhages
- Osler’s nodes
How is infective endocarditis diagnosed?
Blood cultures
Echardiogram, especially TOE
What do blood results often indicate in infective endocarditis?
Inflammation
- High WCC
- High ESR
- High CRP
- Anaemia
- Microhaematuria
What is the management of infective endocarditis?
Specialist team - Cardiologist - Infectious disease physician - Cardiac surgeon Prolonged course of Abx - Via PICC - Often Hospital in the Home Valve replacement surgery - If heart failure/uncontrolled infection
