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CARDIO > old valvular disease > Flashcards

old valvular disease Flashcards

1
Q

what are the causes of aortic stenosis?

A

1) senile calcification >60yo most common
2) congenital- bicuspid valve 40-60yo, William’s syndrome
3) rheumatic fever

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2
Q

what are teh symptoms of aortic stenosis?

A

1) triad- SAD syncope, angina, dyspnoea (exp with exercise)
2) LVF- PND, orthopnoea, frothy sputum
3) arrhythmias
3) systemic emboli if endocarditis
4) sudden death

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3
Q

what are the signs of AS?

A

1) slow rising pulse with narrow PP
2) aortic thrill
3) apex- forceful, non-displaced (pressure overload)
4) heart sounds- quiet A2, early styolic ejection click if pliable (young) valve, S4 (forceful A contraction vs hypertrophied V)
5) murmur- ESM, right 2nd ICS, sitting forward in end-expiration, radiates to carotids

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4
Q

what are the clinical indicators of severe AS?

A

quiet/absent A2
S4
narrow pulse pressure
decompnesation- LVF

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5
Q

what ddx for AS?

A

1) coronary artery disease
2) MR
3) aortic sclerosis- valve thickening, no pressure gradient, turbulence leads to murmur, ESM with no radiation and normal pulse
4) HOCM- ESM which increases in intenstiy with valsalva (in AS it decreases)

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6
Q

what investigatons would you do for AS?

A 
bloods- FBC UE, lipids, glucose
ECG
CXR
ECHO + doppler
cardiac catherisaton + angiography 
exercise stress test - CI if symptomatic AS, useful to assess capacity in asymptomatic
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7
Q

what is the diagnostic investigation in AS?

A

ECHO + doppler

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8
Q

what would you see on ECG for AS?

A

LVH
LV strain- tall R, ST depression, T inversion in V4-V6
LBBB or complete AV block (septal calcification)- may need pacing

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9
Q

what would you see on CXR for AS?

A

calcified AV esp on lateral films
LVH
evidence of HF- ABCDE
post-stenotic aortic dilatation

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10
Q

what can you see on ECHO + doppler for AS?

A

1) thickened calcified immobile valve cusps
2) severe AS (AHA/ACC 2006 guidelines)
- pressure gradient >40
- jet velocity >4m/s or increase by 0.3m/s in a year
- valve area <1cm

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11
Q

what does cardiac catheterisation and angiography do in AS?

A

assesses valve gradient and LV function

assesses coronaries in all patients planned for surgery

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12
Q

what is the medical management of AS?

A

1) optimise RFs- statins, anti-HTN, DM
2) monitor- regular f/up with echo
3) angina- beta blockers
4) HF- ACEi + diuretics
avoid nitrates

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13
Q

what is the surgical management of AS?

A

valve replacement

  • young- mechanical valves with anticoagulation
  • older- bioprosthetic last 10-15yrs
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14
Q

what are the indications for surgical management of AS?

A

severe symptomatic AS
severe asymptomatic AS with decrease EF <50%
severe AS undergoing CABG or other valve operation

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15
Q

what suggests poor prognosis in surgical management of AS?

A

angina/syncope 2-3 years

LVF 1-2 years

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16
Q

what options are there for surgically unfit patients?

A

1) balloon valvuloplasty- complication rate high >10% and restenosis occurs in 6-12 months
2) TAVI transcather aortic valve implantation - folded valve deployed in aortic root
- higher perioperatie stroke risk but less risk major bleeding.

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17
Q

what are the acute causes of aortic regurgitation?

A

infective endocarditis

type A aortic dissection

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18
Q

what are the chronic causes of AR?

A

1) congenital- bicuspid aortic valve
2) rhuematic heart disease
3) connective tissue- marfans, EDS
4) autoimmune- ank spond, RA

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19
Q

what are the symptoms of AR?

A

1) LVF- exertional dyspnoea, PND, orthopnoea
2) arrhythmia (esp AF)- palpitations, forceful heart beats
3) angina

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20
Q

what are the signs of AR?

A

1) collapsing pulse- corrigan’s pulse
2) wide pp
3) apex- displaced (volume overload)
4) heart sounds- soft/absent S2 +/- S3
5) murmur- EDM, URSE + 3rd left IC parasternal. sitting forward in end-expiration +/- ejection systolic flow murmur +/- austin-flint murmur
6) underlying cause- high-arched palate, spondyloarthropathy, embolic phenomena

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21
Q

what is corrigan’s sign

A

carotid pulsation

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22
Q

what is de musset’s

A

head nodding

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23
Q

what is quincke’s

A

capillary pulsation in nail beds

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24
Q

what is traube’s

A

pistol-shot sound over femorals

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25
Q

what is austin-flint murmur

A

rumbling MDM at apex due to regurgitant jet fluttering the anterior mitral valve cusp

means severe AR

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26
Q

what is duroziez’s

A

systolic murmur over femoral artery with proximal compression
diastolic murmur with distal compression

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27
Q

what are the clincal indicators of severe AR?

A 
wide pulse pressure and collpasing pulse
S3
Long murmur
austin-flint murmur
decompensation - LVF
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28
Q

what investigations would you do in AR?

A

1) bloods- fbc u+e lipids glucose
2) ECG- LVH (R6 +S1>35mm)
3) CXR
4) ECHO
5) cardiac catherisation

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29
Q

what can be seen on CXR with AR?

A

cardiomegaly
dilated ascending aorta
pulmonary oedema

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30
Q

what can be seen on echo with AR?

A

1) aortic valve structure + morphology eg bicuspid
2) evidence of infective endocarditis eg vegetations
3) severity
- jet width >65% of outflow tract = severe
- regurgitant jet volume
- premature closing of mitral valve
4) LV function- ejection fraction, end-systolic dimension

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31
Q

what can cardiac catherisation do in AR?

A

coronary artery disease assess

assess severity, LV function + root size

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32
Q

what is the medical management of AR?

A

1) optimise RFs- statins, antiHTN, DM
2) monitor- regular f/up with echo
3) decrease systolic HTN- ACEi, CCB as decreasing afterload can decrease regurgitation

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33
Q

what is the surgical management of AR?

A

aortic valve replacement

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34
Q

when is surgical management indicated in AR?

A

in severe AR if:

  • symptoms of HF
  • asymptomatic with LV dysfunction: decreased EF/increased ES dimension
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35
Q

what are the causes of mitral stenosis?

A

rheumatic fever
prosthetic valve
congenital-rare

36
Q

what is the pathophysiology of mitral stenosis?

A

1) valve narrowing -> raised left atrial pressure -> loud S1 + atrial hypertrophy -> AF
2) ->pulm oedema + PHT -> loud P2, PR
3) -> RVH -> L parasternal heave
4) -> TR -> large v waves
5) -> RHF -> raised JVP, oedema, ascites

37
Q

what are the symptoms of mitral stenosis?

A 
dyspnoea
fatigue
chest pain 
AF-> palpitations + emboli 
haemoptysis: rupture of bronchial veins
38
Q

when do symptoms of mitral stenosis manifest?

A

symptoms manifest when orifice <2cm2 (norm 4-6)

39
Q

what are the signs of mitral stenosis?

A

1) AF, low volume pulse
2) malar flush as low CO -> backpressure + vasoconstriction
3) JVP raised late on:
prominent a waves- PTH
large v waves- TR
absent a waves- AF
4) L parasternal heave (RVH secondary to PHT)
5) apex- tapping (palpable S1), non-displaced
6) heart sounds- loud S1, loud P2 if PHT, early diastolic opening snap
7) murmur- rumbling MDM, apex, left lateral position in end expiration, radiates to axilla +/- graham steell murmur (EDM secondary to PR)

40
Q

what are the clincal indicators of severe mitral stenosis?

A

mitral facies
longer murmur
opening snpa closer to 2nd heart sound- high LA pressure forcing valve open early
decompensation- RVF

41
Q

what are the complicaitons of mitral stenosis?

A

1) pulmonary HTN
2) emboli- TIA, CVA, PVD, ischaemic colitis
3) hoarseness- rec laryngeal nerve palsy= ortner’s syn
4) dysphagia- oesophageal compression
5) bronchial obstruction

42
Q

what investigations would you do in mitral stenosis?

A 
bloods- FBC, UE, LFT, glucose, lipids 
ECG
CXR
Echo + doppler
cardiac catherisation
43
Q

what would you see on ECG in mitral stenosis?

A

AF
P mitrale if in sinus
RVH with strain- ST depression + T wave inversion in V1-V2

44
Q

what would you see on CXR in mitral stenosis?

A

LA enlargement
pulmonary oedema- ABCDE
mitral valve calcification

45
Q

what would you see on echo + doppler in mitral stenosis?

A

severe MS (AHA 2006 criteria)

  • valve orifice <1cm2
  • pressure gradient>10
  • pulmonary artery systolic pressure >50

use TOE to look for left atrial thrombus if intervention considered

46
Q

what do you use cardiac catherisation for in mitral stenosis

A

to assess coronary arteries

47
Q

what is the medical management of mitral stenosis?

A

1) optimise risk factors- statins, anti HTN, DM
2) monitor- regular follow up with echo
3) consider prophylaxis vs. rheumatic fever eg pen V
4) AF- rate control + anticoagulant
5) diuretics provide symptom relief

48
Q

when is surgical management indicated in mitral stenosis?

A

moderate-severe mitral stenosis (asymptomatic and symptomatic)

49
Q

what is the surgical treatment of choice for mitral stenosis?

A

percutaneous balloon valvuloplasty

50
Q

what makes a suitable valve to do percutaneous balloon valvuloplasty in mitral stenosis + when CI?

A

pliable
minimally calcified

CI- left atrial mural thrombus

51
Q

what other surgical management options are there for mitral stenosis?

A

surgical valvotomy/commissurotomy - valve repair

valve replacement if repair not possible

52
Q

what are the causes of mitral regurgitation?

A

mitral valve prolapse
LV dialtation- AR, AS, HTN
annular calcification-> contraction (elderly)

post MI- papillary muscle dysfx/rupture
rheumatic fever
connective tissue- marf, EDS

53
Q

what are the symptoms of MR?

A

dyspnoea
fatigue
AF-> palpitations + emboli
pulmonary congestion-> HTN + oedema

54
Q

what are the signs of MR?

A

1) AF
2) left parasternal heave (RVH)
3) apex- displaced. volume overload as ventricle pump forward SV + regurgicant volume -> eccentric hypertrophy
4) heart sounds- soft S1, S2 not heard separately from murmur, loud P2 if PTH
5) murmur- blowing PSM, apex left lateral position in end expiration, radiates to axilla

55
Q

what are the clinical indicators of severe MR?

A

larger LV
decompensation- LVF
AF

56
Q

what are ddx for MR?

A

AS
TR
VSD

57
Q

what investigations would you do for MR?

A

1) bloods- FBC UE, glucose, lipids
2) ECG
3) CXR
4) doppler ECHO
5) cardiac catherisation

58
Q

what could you see on ECG in MR?

A

AF
p mitrale unless in AF
LVH

59
Q

what could you see on CXR in MR?

A

LA+LV hypertrophy
mitral valve calcification
pulmonary oedema

60
Q

what would you use echo for in MR + what criteria points are there?

A

doppler echo to assess MR severity: multiple criteria:

  • jet width (vena contracta)>0.6cm
  • systolic pulmonary flow reversal
  • regurgiant volume >60ml

TOE to assess severity and suitablity of repair cf. replacement

61
Q

what do you use cardiac catherisation for in MR?

A

confirm dx

assess CAD

62
Q

what is the medical management of MR?

A

1) optimise RF- statins, antihtn, DM
2) monitor- regular follow up with echo
3) AF- rate control + anticoagulant (anticoag if history of embolism, prosthetic valve, additonal MS as well)
4) drugs to lower afterload can help symptoms- ACEi or bb carvedilol, diuretics

63
Q

what is the surgical management for MR?

A

valve replacement or repair

64
Q

what are the indications for surgical management of MR?

A

severe symptomatic MR

severe asymptomatic MR with diastolic dysfunciton: decreased EF

65
Q

what are the causes of mitral valve prolapse (barlow syndrome)

A

primary- myxomatous degernation- often young women
MI
marfan’s, EDS
turner’s syndrome

66
Q

what are the symptoms of mitral valve prolapse (barlow syndrome)

A

usually asymptomatic
autonomic dysfx- atypical chest pain, palpitations, anxiety, panic attack

MR: SOB, fatigue

67
Q

what are the signs of mitral valve prolapse (barlow syndrome)?

A

mid-systolic click +/- late-systolic murmur

68
Q

what are the complications of mitral valve prolpase (barlow syndrome)?

A

MR
cerebral emb oli
arrhythmias-> sudden death

69
Q

what is the management of mitral valve prolapse (barlow syndrome)?

A

bb relieve palps+chest pain

surgery if severe- most common reason for MV surgery

70
Q

what conditions are included in right heart valve disease?

A

tricuspid regurg + stenosis

pulmonary regurg + stenosis

71
Q

what are the causes of TR?

A

functional- RV dilatation
rheumatic fever
infective endocarditis
carcinoid syndrome

72
Q

what are the symptoms of TR?

A

fatigue
hepatic pain on exertion
ascites, oedema

73
Q

what are the signs of TR?

A

raised JVP with giant v waves
RV heave
murmur- psm, llse in inspiration (carvallo’s sign)

pulsatile hepatomegaly
jaundice

74
Q

what investigations would you do for TR?

A

LFTs

ECHO

75
Q

what is the management of TR?

A

treat cause
medical- diuretics, ACEi, digoxin
surgical- valve replacement

76
Q

what are the causes of TS?

A

rheumatic fever (with MV + AV disease)

77
Q

what are the symptoms of TS?

A

fatigue
ascites
oedema

78
Q

what are the signs of TS?

A

large a waves
opening snap
murmur- EDM, LLSE in inspiration

79
Q

what is the management of TS?

A

medical- diuretics

surgical- repair, replacement

80
Q

what are the causes of PR pulmonary regurgitation?

A

any cause of pulmonary HTN

PR secondary to mitral stenosis= graham-steell murmur

81
Q

what are the signs of pulm regurg?

A

murmur- decrescendo EDM at ULSE

82
Q

what are the causes of pulmonary stenosis PS?

A

usually congenital- turner’s, fallot’s
rheumatic fever
carcinoid syndrome

83
Q

what are the symptoms of pulm stenosis?

A

dyspnoea
fatigue
ascites
oedema

84
Q

what are the signs of pulm stenosis?

A 
dysmorphia
large a wave
RV heave
ejection click, soft P2
murmur- ESM, ULSE -> L shoulder
85
Q

what investigations would you do for pulm stenosis?

A

ECG- p pulmonale, RAD, RBBB
CXR- prominent pulmonary arteries: post-stenotic dilatation
catherisation- diagnostic

86
Q

what is the management of pulm stenosis?

A

valvuloplasty or valvotomy

CARDIO (10 decks)

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