lecture 4 - valvular heart diseases Flashcards

1
Q

AS leads to

A

concentric LVH
post-stenotic dilatation of aorta
relative fixed cardiac output

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2
Q

Valvular AS aetiology

A

Valvular AS (99% of AS):

congenital AS
bicuspid aortic valve
rheumatic AS
calcific (senile) AS – commonest

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3
Q

Aortic Stenosis (AS) Symptoms

A
 Asymptomatic – symptoms generally
only appear when AS is severe
 Angina
 Breathlessness
 Dizziness on exertion
 Syncope on exertion
 Sudden death
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4
Q

Aortic Stenosis (AS) Signs

A
 Heaving apex beat (with LVH)
 Slow-rising low-volume pulse*
 Narrow pulse pressure
 Reduced splitting of S2
 Quiet or absent S2*
 Ejection click
 Ejection systolic murmur
 Signs of heart failure (as complication)
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5
Q

Aortic Stenosis (AS) Investigations

A

CXR
calcified aortic valve
signs of HF if complicated

ECG
LVH voltage criteria
prolonged PR interval

Echocardiography
confirms diagnosis, aetiology
and severity

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6
Q

Aortic Stenosis (AS) Treatment

A

No treatment needed for mild or moderate AS

Treatment options for severe AS:
aortic valve replacement (AVR) surgery – gold
standard
transcatheter aortic valve implantation
(TAVI) – alternative for high-risk surgical
candidates
balloon valvuloplasty – usually as palliative
approach and little used
medical treatment for heart failure – avoid
vasodilators

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7
Q

Aortic Regurgitation (AR) Pathophysiology

A
AR leads to:
 backward flow into LV
 increased forward flow into
aorta
 increased LV end-diastolic
dimension and stroke volume

Chronic AR usually tolerated well until severe
- Acute AR usually less well tolerated

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8
Q

Aortic Regurgitation (AR) Aetiology

A
 Dilatation of AV ring, e.g.
systemic hypertension (commonest
cause), aortic dissection, Marfan’s
syndrome, syphilis, giant cell arteritis,
seronegative spondarthropathies,
osteogenesis imperfecta
 Damage to AV cusps, e.g.
Libman-Sacks endocarditis, infective
endocarditis, rheumatic heart disease,
bicuspid aortic valve, direct trauma,
mucopolysaccharidoses,
pseudoxanthoma elasticum
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9
Q

Aortic Regurgitation (AR) symptoms

A

Asymptomatic – symptoms generally
only appear when AR is severe
Breathlessness

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10
Q

Aortic Regurgitation (AR) signs

A
Signs of wide pulse pressure:
 collapsing pulse
 Corrigan’s sign
 De Musset’s sign
 Quincke’s sign
 Muller’s sign
Signs of backward flow:
 early diastolic murmur
 thrusting apex beat (and often
displaced)
 Duroziez’s sign

Sign of increased forward flow:
aortic systolic flow murmur

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11
Q

Aortic Regurgitation (AR) Investigations

A

CXR
dilated aorta
signs of HF if complicated

ECG
LVH voltage criteria

Echocardiography
confirms diagnosis, aetiology
and severity

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12
Q

Aortic Regurgitation (AR) treatment

A

No treatment needed for mild or
moderate AR (other than ensuring BP is
normal or well controlled)

Treatment options for severe AR:
 aortic valve replacement (AVR)
surgery – gold standard
 medical treatment for heart failure
 role of TAVI unclear
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13
Q

Mitral Stenosis (MS) Pathophysiology

A
 Normal MV area is 4-6 cm2
 Progressive MS leads to LA enlargement,
then increased LA pressure and pulmonary
congestion
 Eventually leads to pulmonary
hypertension
 Increasing risk of atrial fibrillation with LA
dilatation
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14
Q

Mitral Stenosis (MS) Aetiology

A

Rheumatic (almost always)

Congenital

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15
Q

Mitral Stenosis (MS) Symptoms

A

Asymptomatic
Symptoms of left heart failure
Symptoms of atrial fibrillation

Symptoms of LA enlargement
 Ortner’s syndrome = hoarse
voice due to recurrent laryngeal
nerve palsy from compression by
enlarged LA
 Dysphagia (compression on
oesophagus)
 Bronchiectasis (compression on
bronchi)
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16
Q

Mitral Stenosis (MS) signs

A

Tapping apex beat
Loud S1
Opening snap
Late diastolic murmur

Signs of complications
 signs of atrial fibrillation
 signs of pulmonary hypertension
e.g. malar flush and heave
 signs of heart failure
17
Q

Mitral Stenosis (MS) Investigations

A

CXR
enlarged LA (straight left heart border =
mitralisation of left heart border)
signs of HF and PH if complicated

ECG
may be in AF

Echocardiography (TTE / TOE)
confirms diagnosis, aetiology and severity

18
Q

Mitral Stenosis (MS) Treatment

A

Medical treatment for heart failure
Medical treat for atrial fibrillation

Anticoagulation with warfarin if:
atrial fibrillation
moderate or severe MS
systemic embolism

Invasive options for severe MS:
mitral valvotomy (open or closed)
mitral valve replacement (MVR) surgery

19
Q

Mitral Regurgitation (MR) Pathophysiology

A
Initially leads to gradual
increase in left atrial size
Eventually leads to increase
in left atrial pressure and left
ventricular end-diastolic
pressure ®symptoms of
heart failure
20
Q

Mitral Regurgitation (MR) Aetiology

A
Dilatation of MV ring
 functional (any cause of LV dilatation)
 Marfan’s syndrome
 osteogenesis imperfecta
 acromegaly
Damage to valve cusps
 Libman-Sack endocarditis
 infective endocarditis
 rheumatic
 senile calcification
 floppy leaflets (mitral valve prolapse)

Damage to subvalvular apparatus
myocardial infarction (of papillary muscles)
ruptured / degenerative chordae

21
Q

Mitral Regurgitation (MR) Symptoms

A

Asymptomatic
Symptoms of left heart failure
Symptoms of atrial fibrillation

Symptoms of LA enlargement
Ortner’s syndrome
dysphagia
bronchiectasis

22
Q

Mitral Regurgitation (MR) signs

A

Pan-systolic murmur

Signs of complications
 signs of atrial fibrillation
 signs of pulmonary hypertension
e.g. malar flush and heave
 signs of heart failure
23
Q

Mitral Regurgitation (MR Investigations

A

CXR
enlarged LA (straight left heart border =
mitralisation of left heart border)
signs of HF and PH if complicated

ECG
may be in AF

Echocardiography (TTE / TOE)
confirms diagnosis, aetiology and severity
TOE may be needed to guide surgical
management, e.g. repair vs. replacement

24
Q

Mitral Regurgitation (MR) Treatment

A

Medical treatment for heart failure
Medical treatment for atrial fibrillation

Anticoagulation if:
atrial fibrillation
systemic embolism

Mitral valve repair or replacement
surgery in severe MR (depending on
aetiology)

25
Tricuspid Regurgitation (TR) Aetiology
Commonest cause is dilatation of TV ring due to right heart failure from pulmonary hypertension secondary to left heart disease or lung disease Other causes:  rheumatic heart disease  infective endocarditis (esp. in intravenous drug users)  carcinoid syndrome
26
Tricuspid Regurgitation (TR) Symptoms
Symptoms of right heart failure | Symptoms of atrial fibrillation
27
Tricuspid Regurgitation (TR) Signs
Pan-systolic murmur CV wave (if severe TR) Pulsatile liver (if severe TR) Signs of complications  signs of atrial fibrillation  signs of right heart failure
28
Tricuspid Regurgitation (TR) Treatment
TR due to pulmonary hypertension usually treated medically (with diuretics) Tricuspid valve replacement rarely may be considered in true valve disease
29
Infective Endocarditis (IE)
• Multisystem disease due to infection of the heart valves and/or adjacent endocardium • Incidence 3-10 per 100,000 person-years • Male-to-female ratio >2 (reasons unknown)
30
IE – Pathophysiology
``` •Bacteraemia – dental manipulation – intravenous drug use – intravenous cannulation – gastrointestinal, urogenital and oropharyngeal procedures ``` •Pre-existing valve lesion – congenital abnormality – acquired abnormality – prosthetic valve
31
IE – Clinical Features
``` Chronic infection symptoms: Fever, rigors, fatigue, weight loss, anorexia, myalgia, arthralgia. signs: Pyrexia, clubbing, splenomegaly, anaemia (pallor) ``` Cardiac - Symptoms of HF and arrhythmias. Murmur (present in 85%) Immunological - Splinter haemorrhages, Osler’s nodes, Janeway lesion, Roth spots, petechiae, haematuria Embolism - Symptoms and signs of stroke, MI, limb ischaemia, mesenteric ischaemia, mycotic aneurysm rupture, metastatic abscess, pneumonia
32
what are Osler's nodes
Osler's nodes are small tender subcutaneous nodules in pulp of digits, persisting for hours to days
33
what are Splinter haemorrhages
Splinter haemorrhages are small linear subungal haemorrhages
34
what are Janeway lesions
Janeway lesions are small erythematous/haemorrhagic non-tender macules on palms and soles
35
what are roth's spots
Roth's spots are retinal hemorrhages with white or pale centers.
36
what are Petechiae
A petechia is a small (1 - 2 mm) red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels).
37
IE – Investigations
 Blood cultures – ideally at least 3 sets from different veins before antibiotics  Venous bloods – U&Es, LFTs, CRP, FBC, blood film (risk of microangiopathic haemolytic anaemia), clotting screen, C3, C4  Urinaylsis – microscopic haematuria may be present  CXR – for signs of heart failure as complication  ECG – prolonged PR interval in aortic valve endocarditis is a sign of abscess formation  Echocardiography (TTE / TOE)  vegetations may be detected on TTE, but TOE is more sensitive, especially for prosthetic valve endocarditis  assessment of valvular and ventricular function  Other investigations guided by clinical presentation
38
IE – Treatment
Definitely need… Intravenous antibiotics (usually combination) – start empirically after cultures taken if high clinical suspicion and/or unwell; guided by culture results when available How long? At least 4-6 weeks – guided by microbiological advice ``` Anything else? Consider surgery (in appropriate cases) ```