Heart valves

Question 1

What makes 1st heart sound?

2nd?

Answer 1

Closure of mitral / tricuspid

Closure of aortic / pulm

Question 2

Which heart sounds are loudest on inspiration?

Expiration ?

Answer 2

Right in or left out

Right (P+T) - as increase in venous flow into right Atrium

Left (A+M) - increase in pulmonary venous return to Left heart

Question 3

What are the two loudest systolic murmurs

Answer 3

AS / MR

Question 4

Signs of AS

Answer 4

Ejection systolic murmur 
Radiates to carotids (sclerosis does not radiate)
If very severe – may not hear S2
Heaving apex beat
Narrow pulse pressure

Question 5

Signs of MR

Answer 5

Pansystolic because it leaks throughout systole
Radiates to Axilla
Displaced apex beat

Question 6

Usual cause of ejection systolic in >70?
<60?
any other causes?

Answer 6

Degenerative
bicuspid
Rheumatic, sclerosis, HCM

Question 7

Differential of MR ?>

Answer 7

VSD

Question 8

When do you hear AR?

Signs on auscultation?

Answer 8

Diastole
Radiates to left sternal edge leaning forwards
Displaced apex

Question 9

Murmur in MS?
Signs on auscultation?
Cause?
what other things do you often get?

Answer 9

Mid-diastolic murmur in apex in left lateral position
Tapping apex
Usually rheumatic cause –
classically get AF and pulmonary HTN due to increased LA pressure

Question 10

Signs with AR?

Name at least 3

Answer 10

Quincke’s – nail bed capillary pulsation
Collapsing pulse
Wide pulse pressure
Corrigan’s sign – pulsatile JVP/neck pulsation
De Mussett’s sign – head nodding
Duroziez’s sign – murmur on femoral artery compression
Traube’s – ‘pistol shot’ sound over femorals

Question 11

What is the criteria for severe AS?

Answer 11

Valve area <1cm
Mean valve gradient >40mmHg
EF <40% (heart failure)

Question 12

Compare mechanical vs Tissue/bioprothetic valve replacement?

Answer 12

Mechanical
Better for younger patients as lasts longer (20-25 years)
Lifelong Warfarin
Will hear ‘click’ as heart sound

Tissue
Older patients with higher bleeding risk
No Warfarin
Lasts ~10 years
Heart sounds normal

Question 13

Risks of valve replacement?

Answer 13

Bleeding
Thromboembolism/Stroke
Haemolysis – mechanical destruction against valve
Infective endocarditis – early usually staph infection from skin and later Strep. viridans
Atrial fibrillation
Bradyarrhythmia

Question 14

Why is Bradyarrhythmia more common with AV replacement?

Answer 14

AV node/bundle of his in aortic root (sinus node in RA at base of SVC).

Question 15

What is a TAVI?

What is main reason this might not be possible?

Answer 15

Transcatheter Aortic Valve Implantation

Cannot if calcified aortic root or calcified access

Question 16

Pros of TAVI?

Answer 16

Less invasive, better recovery
Better if high surgical risk (fraility)
Can be used even if Previous cardiac surgery
Over 75 years

HOWEVER
Long term outcomes uncertain

Question 17

What is BAV ? used when?

Answer 17

Balloon Aortic Valvuloplasty

Can be a bridging procedure, if unclear exact cause of Sx

May combine with percutaneous coronary intervention (PCI) or if has cardiogenic shock/very unstable

Question 18

What cardiomyopathy is in regurge? Stenosis?

Answer 18

Regurge -> Volume overload -> stretch -> DILATED

Stenosis - Muscular hypertrophy

Question 19

Hiw do you work out ejection fraction

Answer 19

(EDV-ESV) / EDV