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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
what is austin-flint murmur
rumbling MDM at apex due to regurgitant jet fluttering the anterior mitral valve cusp means severe AR
26
what is duroziez's
systolic murmur over femoral artery with proximal compression diastolic murmur with distal compression
27
what are the clincal indicators of severe AR?
``` wide pulse pressure and collpasing pulse S3 Long murmur austin-flint murmur decompensation - LVF ```
28
what investigations would you do in AR?
1) bloods- fbc u+e lipids glucose 2) ECG- LVH (R6 +S1>35mm) 3) CXR 4) ECHO 5) cardiac catherisation
29
what can be seen on CXR with AR?
cardiomegaly dilated ascending aorta pulmonary oedema
30
what can be seen on echo with AR?
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
31
what can cardiac catherisation do in AR?
coronary artery disease assess | assess severity, LV function + root size
32
what is the medical management of AR?
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
33
what is the surgical management of AR?
aortic valve replacement
34
when is surgical management indicated in AR?
in severe AR if: - symptoms of HF - asymptomatic with LV dysfunction: decreased EF/increased ES dimension
35
what are the causes of mitral stenosis?
rheumatic fever prosthetic valve congenital-rare
36
what is the pathophysiology of mitral stenosis?
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
what are the symptoms of mitral stenosis?
``` dyspnoea fatigue chest pain AF-> palpitations + emboli haemoptysis: rupture of bronchial veins ```
38
when do symptoms of mitral stenosis manifest?
symptoms manifest when orifice <2cm2 (norm 4-6)
39
what are the signs of mitral stenosis?
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
what are the clincal indicators of severe mitral stenosis?
mitral facies longer murmur opening snpa closer to 2nd heart sound- high LA pressure forcing valve open early decompensation- RVF
41
what are the complicaitons of mitral stenosis?
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
what investigations would you do in mitral stenosis?
``` bloods- FBC, UE, LFT, glucose, lipids ECG CXR Echo + doppler cardiac catherisation ```
43
what would you see on ECG in mitral stenosis?
AF P mitrale if in sinus RVH with strain- ST depression + T wave inversion in V1-V2
44
what would you see on CXR in mitral stenosis?
LA enlargement pulmonary oedema- ABCDE mitral valve calcification
45
what would you see on echo + doppler in mitral stenosis?
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
what do you use cardiac catherisation for in mitral stenosis
to assess coronary arteries
47
what is the medical management of mitral stenosis?
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
when is surgical management indicated in mitral stenosis?
moderate-severe mitral stenosis (asymptomatic and symptomatic)
49
what is the surgical treatment of choice for mitral stenosis?
percutaneous balloon valvuloplasty
50
what makes a suitable valve to do percutaneous balloon valvuloplasty in mitral stenosis + when CI?
pliable minimally calcified CI- left atrial mural thrombus
51
what other surgical management options are there for mitral stenosis?
surgical valvotomy/commissurotomy - valve repair valve replacement if repair not possible
52
what are the causes of mitral regurgitation?
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
what are the symptoms of MR?
dyspnoea fatigue AF-> palpitations + emboli pulmonary congestion-> HTN + oedema
54
what are the signs of MR?
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
what are the clinical indicators of severe MR?
larger LV decompensation- LVF AF
56
what are ddx for MR?
AS TR VSD
57
what investigations would you do for MR?
1) bloods- FBC UE, glucose, lipids 2) ECG 3) CXR 4) doppler ECHO 5) cardiac catherisation
58
what could you see on ECG in MR?
AF p mitrale unless in AF LVH
59
what could you see on CXR in MR?
LA+LV hypertrophy mitral valve calcification pulmonary oedema
60
what would you use echo for in MR + what criteria points are there?
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
what do you use cardiac catherisation for in MR?
confirm dx | assess CAD
62
what is the medical management of MR?
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
what is the surgical management for MR?
valve replacement or repair
64
what are the indications for surgical management of MR?
severe symptomatic MR | severe asymptomatic MR with diastolic dysfunciton: decreased EF
65
what are the causes of mitral valve prolapse (barlow syndrome)
primary- myxomatous degernation- often young women MI marfan's, EDS turner's syndrome
66
what are the symptoms of mitral valve prolapse (barlow syndrome)
usually asymptomatic autonomic dysfx- atypical chest pain, palpitations, anxiety, panic attack MR: SOB, fatigue
67
what are the signs of mitral valve prolapse (barlow syndrome)?
mid-systolic click +/- late-systolic murmur
68
what are the complications of mitral valve prolpase (barlow syndrome)?
MR cerebral emb oli arrhythmias-> sudden death
69
what is the management of mitral valve prolapse (barlow syndrome)?
bb relieve palps+chest pain | surgery if severe- most common reason for MV surgery
70
what conditions are included in right heart valve disease?
tricuspid regurg + stenosis | pulmonary regurg + stenosis
71
what are the causes of TR?
functional- RV dilatation rheumatic fever infective endocarditis carcinoid syndrome
72
what are the symptoms of TR?
fatigue hepatic pain on exertion ascites, oedema
73
what are the signs of TR?
raised JVP with giant v waves RV heave murmur- psm, llse in inspiration (carvallo's sign) pulsatile hepatomegaly jaundice
74
what investigations would you do for TR?
LFTs | ECHO
75
what is the management of TR?
treat cause medical- diuretics, ACEi, digoxin surgical- valve replacement
76
what are the causes of TS?
rheumatic fever (with MV + AV disease)
77
what are the symptoms of TS?
fatigue ascites oedema
78
what are the signs of TS?
large a waves opening snap murmur- EDM, LLSE in inspiration
79
what is the management of TS?
medical- diuretics | surgical- repair, replacement
80
what are the causes of PR pulmonary regurgitation?
any cause of pulmonary HTN | PR secondary to mitral stenosis= graham-steell murmur
81
what are the signs of pulm regurg?
murmur- decrescendo EDM at ULSE
82
what are the causes of pulmonary stenosis PS?
usually congenital- turner's, fallot's rheumatic fever carcinoid syndrome
83
what are the symptoms of pulm stenosis?
dyspnoea fatigue ascites oedema
84
what are the signs of pulm stenosis?
``` dysmorphia large a wave RV heave ejection click, soft P2 murmur- ESM, ULSE -> L shoulder ```
85
what investigations would you do for pulm stenosis?
ECG- p pulmonale, RAD, RBBB CXR- prominent pulmonary arteries: post-stenotic dilatation catherisation- diagnostic
86
what is the management of pulm stenosis?
valvuloplasty or valvotomy

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