lecture 4 - valvular heart diseases Flashcards
AS leads to
concentric LVH
post-stenotic dilatation of aorta
relative fixed cardiac output
Valvular AS aetiology
Valvular AS (99% of AS):
congenital AS
bicuspid aortic valve
rheumatic AS
calcific (senile) AS – commonest
Aortic Stenosis (AS) Symptoms
Asymptomatic – symptoms generally only appear when AS is severe Angina Breathlessness Dizziness on exertion Syncope on exertion Sudden death
Aortic Stenosis (AS) Signs
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)
Aortic Stenosis (AS) Investigations
CXR
calcified aortic valve
signs of HF if complicated
ECG
LVH voltage criteria
prolonged PR interval
Echocardiography
confirms diagnosis, aetiology
and severity
Aortic Stenosis (AS) Treatment
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
Aortic Regurgitation (AR) Pathophysiology
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
Aortic Regurgitation (AR) Aetiology
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
Aortic Regurgitation (AR) symptoms
Asymptomatic – symptoms generally
only appear when AR is severe
Breathlessness
Aortic Regurgitation (AR) signs
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
Aortic Regurgitation (AR) Investigations
CXR
dilated aorta
signs of HF if complicated
ECG
LVH voltage criteria
Echocardiography
confirms diagnosis, aetiology
and severity
Aortic Regurgitation (AR) treatment
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
Mitral Stenosis (MS) Pathophysiology
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
Mitral Stenosis (MS) Aetiology
Rheumatic (almost always)
Congenital
Mitral Stenosis (MS) Symptoms
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)
Mitral Stenosis (MS) signs
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
Mitral Stenosis (MS) Investigations
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
Mitral Stenosis (MS) Treatment
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
Mitral Regurgitation (MR) Pathophysiology
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
Mitral Regurgitation (MR) Aetiology
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
Mitral Regurgitation (MR) Symptoms
Asymptomatic
Symptoms of left heart failure
Symptoms of atrial fibrillation
Symptoms of LA enlargement
Ortner’s syndrome
dysphagia
bronchiectasis
Mitral Regurgitation (MR) signs
Pan-systolic murmur
Signs of complications signs of atrial fibrillation signs of pulmonary hypertension e.g. malar flush and heave signs of heart failure
Mitral Regurgitation (MR Investigations
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
Mitral Regurgitation (MR) Treatment
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)
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
Tricuspid Regurgitation (TR) Symptoms
Symptoms of right heart failure
Symptoms of atrial fibrillation
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
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
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)
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
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
what are Osler’s nodes
Osler’s nodes are small tender
subcutaneous nodules in pulp
of digits, persisting for hours to days
what are Splinter haemorrhages
Splinter haemorrhages are
small linear subungal
haemorrhages
what are Janeway lesions
Janeway lesions are small
erythematous/haemorrhagic
non-tender macules on palms
and soles
what are roth’s spots
Roth’s spots are retinal hemorrhages with white or pale centers.
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).
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
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)
