M103 T3 L4 Flashcards
In which areas do we auscultate? Draw a diagram and label them
Aortic area (right of sternal angle) Pulmonary area (left of sternal angle) Tricuspid area (left inferior of sternal angle) Mitral area (far left inferior of sternal angle)
What diseases can cause issues with the valves? (DR.Congo)
degenerative valve disease
rheumatic valve disease
congenital valve disease
infections in immunocompromised patients
Which valves do each of the four main valve diseases affect the most?
Degenerative - aortic
rheumatic - mitral
congenital - bicuspid aortic valve
infective - left more than right
What group are at high risk of getting an infective disease against the valves and why?
IVDUs - IV drug users
on injection, the drugs may not be clean
flow into the venous system, into the right atrium
the first valve it comes into contact will be the tricuspid valve
What is the most common cause of someone with triscupid valve infective endocarditis?
IVDUs / drugs
What is the effect of the loss of supporting structure?
vascular heart disease
What happens if the valves don’t open properly?
results in stenosis and lack of pressure and loss stroke volume
What is the most common form of presentation for aortic stenosis?
degenerative
presents in those aged 60+
What age do bicuspid valves tend to present in?
40-60 years
What are the symptoms of SEVERE aortic stenosis? (SAD)
Syncope upon exertion, Angina, Dyspnoea
fatigue
palpitations
Sudden death (rare in asymptomatic) due to arrhythmias from pressure overload
What are the symptoms of mild-moderate aortic stenosis?
Asymptomatic
Murmur discovered on routine physical exam
What is the effect of aortic stenosis on the left ventricle?
Pressure overload Generation of high LV systolic pressure to force blood through the obstruction Results in left ventricular hypertrophy Eventual LV decompensation/dilatation symptoms of heart failure
Which heart sounds are heard in aortic stenosis?
systolic murmur OR crescendo / decrescendo murmur
soft S2
How is a systolic or crescendo/decrescendo (diamond shaped) murmur produced?
The valve doesn’t open fully, producing turbulence as blood passes across it.
This occurs at the beginning of systole where the pressure gradually rises
AAR the amount of blood and turbulence gradually rises, peaks and then falls as the ventricle begins to relax
Why might the soft second heart sound not be heard?
because the valve is so stiff and thickened, it doesn’t close with its usual snap
can’t hear the second heart sound - indication of severity
What are the two other names for a systolic murmur?
crescendo / decrescendo murmur
diamond shaped
What are the two main causes of incompetence?
aortic dilatation
valvular
What are the causes of aortic dilatation?
high blood pressure aortic dissection loss of support connective tissue disease hypertension, degenerative, cystic medial necrosis, syphilis
What pain is associated with an aortic dissection?
a sudden onset of severe chest or back pain, often described as “tearing”
What are the causes of valvular dilatation?
Bicuspid valve
Infective endocarditis
How does an early diastolic murmur occur?
At the end of systole the pressure in the ventricle drops and the aortic (and pulmonary) valves close
If the aortic valve leaflets fail to come together and are damaged blood under high pressure in the aorta rushes back into the ventricle (with turbulence)
This happens the most when the pressure in the ventricle is the lowest at the beginning of diastole
How does an concomitant systolic murmur occur?
Because in this disorder the aortic valve is often structurally abnormal, there is often turbulence as the blood exits the ventricle during systole
What are the symptoms of aortic regurgitation?
Often asymptomatic
Chest pain (due to decreased coronary perfusion and diastolic BP reduces)
Breathlessness due to the pressure effect and the pumping vasculature and pulmonary oedema
Syncope – uncommon
Catastrophic decompensation if acute, there’s no time for the left ventricle and the left atria to become more compliant to take on this extra volume - causes fulminant pulmonary oedema
What are the symptoms of dilated cardiomyopathy?
can be asymptomatic feeling tired leg swelling shortness of breath chest pain fainting
What causes mitral regurgitation?
a problem with the valve apparatus itself
chordal rupture / papillary muscle failure
annular dilation
Why might leaflets not come together?
the valves are attached to papillary muscles in the left ventricle
if someone’s had a heart attack, the artery that’s supplying that territory (where that papillary muscle is)
becomes ischaemic and that muscle can rupture.
That will bring this leaflet down so it doesn’t work appropriately and therefore will not come together
What are the effects of mitral regurgitation?
Volume overload in left ventricle
Pressure overload of right heart
Left ventricular dilatation
Decompensation
What happens during pressure overload of the right heart?
During systole blood is ejected backwards into the left atrium
Extra blood in atrium leads to elevation of left atrial pressure and increased ventricular filling during subsequent diastole
What happens during pressure overload of left heart?
Pressure overload of right heart
Can lead to right ventricular hypertrophy or right heart failure
Transient elevation of left atrial pressure during systole
How is a pan-systolic murmur generated?
If the leaflets fail to coapt, either because the annulus is stretched (with a ‘hole’ in the middle), or because the leaflets are damaged or abnormal, blood leaks back into the left atrium with turbulence as it passes across the abnormal valve
Blood regurgitates back in atrium almost immediately and for the whole of systole because the left atrium is a low pressure chamber and during systole the left ventricle is under high pressure
What are the symptoms of mitral regurgitation?
Breathlessness due to back pressure of pulmonary circulation
Lethargy and reduced exercise tolerance due to breathlessness and reduced cardiac output
Palpitations – atrial fibrillation due to pressure overload in atrium
Peripheral oedema – decompensation
Chest pain – concomitant CAD
What happens to the lungs and the ventricles in mitral stenosis?
Lung / right heart - breathlessness, congestion, etc due to pressure back up because of failure of ejection of left atrial volume
the left ventricle physiology usually preserved
LV function compromised when atrial contraction lost (low LV filling) or when high circulating volume (high right heart pressure)
What are the heart sounds of mitral stenosis?
Mid-diastolic rumbling murmur
Opening snap
Loud first heart sound
What are the symptoms of mitral stenosis?
Breathlessness Peripheral oedema Haemoptysis Heart palpitations Systemic emboli Fatigue stridor dysphagia
How is valvular heart disease treated?
medical treatment - looks at treating heart failure and arrhythmia symptoms
surgical treatment - valve repair or replacement
percutaneous treatment - BAV / TAVI
What techniques can be used to determine the presence of valvular heart disease in asymptomatic patients?
clinical assessment (stress) echocardiography exercise testing MRI scan Multislice CT Cardiac catherisation
How can prosthetic (especially metallic) heart valves be identified?
if the first heart sound is metallic - mitral valve
if the second heart sound is metallic - aortic valve
For which type of patients was trans-catheter valve replacement initially used?
for patients who were turned down for having for being too high risk for surgical open heart surgery
What is aorto-valvuloplasty and how does it work?
where the balloon will be passed from the aorta across the aortic valve into the left ventricle
It will then be inflated and will break down the calcium, which can lead to improved opening of the aortic valve
What are the risks of aorto-valvuloplasty?
can damage the aortic valve leaflets
causing aortic regurgitation
What happens if the valves don’t meet properly?
regurgitation where the blood flows in the opposite direction
