PBL 4 - Heart Valve Disease Flashcards
what is heart valve disease?
diseases or abnormality of any one of the heart valves for any number of reasons
what is a murmur?
abnormal blood flow across a heart valve or across a structure within the heart
how is a HVD diagnosed?
- through auscultation of a murmur
- can also be picked up via an ECG or people having other cardiac tests
how is HVD most commonly treated and why?
watchful waiting as most people are asymptomatic — patients are just monitored in secondary care or in the community over time
if HVD becomes symptomatic and severe, how is it then treated?
either open heart surgery (cardiopulmonary bypass and valve replacement) or repair surgery, or increasingly transcatheter therapies for certain valve lesions
describe aortic stenosis and how it results in LV hypertrophy
- aortic valve becomes heavily calcified with reduced opening — valve becomes thicker
- heart has to pump with lots of extra force to get the valve to open
- LV becomes hypertrophied so has to pump harder to punish blood around the body (doesn’t become bigger but more muscular. apex is more forceful)
when is the abnormal blood flow in aortic stenosis and what effect does the thickened valve have on the blood ?
in systole — blood becomes turbulent and gets churned up by the thickened aortic valve
where can the aortic valve be auscultated?
right 2nd IC space parasternal
what kind of systolic murmur can be heard and where in aortic stenosis?
crescendo decrescendo ejection systolic murmur — harsh murmur best heard in the aortic area, radiating to the carotids
what is the pulse pressure like in aortic stenosis?
low
symptoms of aortic stenosis
- elevated LVEDP
- increased pressure in LA
- increased pressure in pulmonary veins
- SOB
- angina
- exertional dizziness/syncope
what is aortic stenosis most commonly caused by?
degenerative aortic valve disease — get calcification deposition on the aortic valve leaflets so it becomes thickened and calcified — usually associated with an ageing process
what other 2 things can aortic stenosis also be caused by?
- bicuspid aortic valve — 2 leaflets instead of 3 — these degenerate much more quickly
- rheumatic heart disease — rare
what are 2 methods of aortic stenosis treatment?
- surgical aortic valve replacement
- increasingly transcatheter approach = TAVI
briefly describe a TAVI (transcatheter aortic valve implantation)
go in the groin under local anaesthetic, valve loaded onto a national frame, goes into the femoral artery up into the aorta and crush the old valve out of the way
what is aortic stenosis characterised by?
obstruction of the left ventricular outflow —> decreased CO
which is the only valve that usually has 2 leaflets instead of 3?
mitral/bicuspid
S1 vs S2 heart sounds
S1 = AV valves close (blood in ventricles and ventricles begin to contract)
S2 = aortic/pulmonary valves close
when is systole in terms of S1 and S2?
in between S1 and S2
when is diastole in terms of S1 and S2?
in between S2 and S1
when is the murmur in aortic stenosis heard in terms of S1 and S2?
in between S1 and S2
what is mitral valve regurgitation?
when there is a leak of blood from the LV into the LA during systole due to incompetence of the mitral valve for various reasons
= 2nd most common cause of HVD after aortic stenosis
where is the mitral valve?
between LA and LV
what kind of murmur can be heard in mitral regurgitation? what does it sound like?
holosystolic/pan systolic murmur:
lub-whoooooo-dub (sounds like wind through tunnel)
where is the murmur heard best in mitral regurgitation? radiation?
loudest in the apex at the mitral region with radiation round to the axilla and a displaced apex beat
where is the mitral valve heard best?
5th IC space mid-clavicular line
why is murmur sometimes heard in apex in mitral regurgitation?
LA is quite a posterior structure so murmur often goes into the apex
is a murmur heard in the carotids in mitral regurgitation?
no
why do you get a displaced apex beat in mitral regurgitation?
ventricle becomes volume loaded — displaced apex beat away from the midclavicular line towards the axilla
why are patients sometimes in atrial fibrillation with mitral regurgitation?
often get a stretched left atrium — atrium becomes more electrically active as it stretches
symptoms of mitral regurgitation — how can it lead to SOB?
- elevation of the left atrial pressure that increases the pressure in the lungs — SOB
- no chest pain
what are some causes of mitral regurgitation?
what’s the most common cause of mitral regurgitation?
valvular degeneration
- ‘myxomatous disease’
how can endocarditis cause mitral regurgitation?
either eats away at the leaflet tips of causes a perforation within the body of the valve leaflet
can mitral regurgitation be congenital?
yes but rare
how can a functional MR cause mitral regurgitation?
baggy LV (eg. HF that has stretched the LV) causes the mitral valve annulus to stretch — valve leaflets pulled apart and unable to close
how can an ischaemic MR cause papillary muscle rupture hence causing mitral regurgitation?
abrupt lack of O2 supply to part of muscle supplying papillary muscle — can break off and rupture — nothing thethering the mitral valve = very severe and usually not survivable
what is hypertrophic obstructive cardiomyopathy and how can it cause mitral regurgitation?
= genetic thickening of the heart muscle
- when the heart is in systole, the mitral leaflet is dragged towards the septum — causes a leak in the mitral valve
treatment of mitral regurgitation?
- mitral valve repair
- valve replacement
- transcatheter therapies (mitral clip = transcatheter edge-to-edge repair = clip valve leaflets together_
what is aortic regurgitation?
occurs when there is back flow of blood from the aorta into the LV as the ventricle relaxes
when is flow normal/abnormal in aortic regurgitation?
flow is normal in systole and abnormal in diastole
what kind of murmur is present in aortic regurgitation?
diastolic murmur — often hard to hear — lub-dub-hahhhhh
where and when is the murmur in aortic regurgitation best heard?
along left sternal edge in expiration = where the column of blood is falling
is there a displaced apex in aortic regurgitation?
yes
left ventricular volume loading — causes eventually dilation of the LV — displaced apex towards axilla
what kind of pulse is present in aortic regurgitation?
collapsing (water hammer) pulse (Carrogan’s pulse/ Watson’s water hammer pulse)
what is typical of aortic regurgitation in terms of pulse pressure?
= wide pulse pressure
- strange blood pressures eg. 180/60 — very big difference between the 2 numbers
signs/symptoms of aortic regurgitation
- visible pulsation of the neck vessels
- strange BPs (wide pulse pressure)
- SOB due to back pressure into LV
- elevated atrial pressure
- can cause pulmonary oedema: acute rise in LA pressure, acute rise in pressure in pulmonary capillaries, acute alveolar oedema
what is endocarditis?
infection of heart valve — valve eaten away so becomes incompetent
what are some causes of aortic regurgitation?
i
treatment of atrial regurgitation
- most asymptomatic with good LV function — no treatment required
- symptomatic:: aortic valve or aortic valve replacement — open surgical techniques
what is mitral stenosis?
= thickening of the mitral valve so it doesn’t open well — difficult to get blood into LV
what heart chamber does mitral stenosis affect the most and why?
left atrium — left atrial pressure has to be very high to push blood across the very stenosed and thickened mitral valve in diastole
when is flow abnormal in mitral stenosis?
diastole
what kind of murmur is present in mitral stenosis?
diastolic murmur which is difficult to hear
where and when is the murmur loudest in mitral stenosis and does it radiate anywhere? displacement?
- loudest at apex in the mitral region with radiation round to the axilla — no displacement of apex beat
- often best heard at the bowel or ask patients to sit on their side and lift their arm up above the head in order to spread the rib spaces out
- best heard on end expiration
what does the diastolic murmur in mitral stenosis sound like?
- very low pitched rumbling sound
- apex beat has a tapping character (not often felt in clinical practice)
- leaflet snap — can hear the valve leaflets snapping open — very difficult to hear
is mitral stenosis common?
no — rare
causes of mitral stenosis?
- rheumatic heart disease (rare in UK)
- occasionally degenerative calcification of the mitral valve in dry very elderly patients
signs of mitral stenosis?
- very high left atrial pressure — dilation of left atrium — becomes very electrically active — these patients are almost always in atrial fibrillation — irregular HB
- malar flush = reddening of the cheeks
- high pressures in lungs — present with SOB, possibly pulmonary oedema (esp. if there is another stressor present eg, pregnant, septic)
= irregularly irregular pulse, diastolic murmur and possibly malar flush
treatment of mitral stenosis
replacement of heart valve
what is Beckers signal? (aortic regurgitation)
retinal vessel pulsation on fundoscopy
what is De Mussets sign? (aortic regurgitation)
head bobbing in time with cardiac cycle
what is Dureozizs sign? (aortic regurgitation)
diastolic murmur heard over femoral pulses when partly occluded below stethoscope
what is Muellers sign? (aortic regurgitation)
uvula pulsation
what is Quickes sign? (aortic regurgitation)
capillary pulsation in nail bed
what is Traubes sign? (aortic regurgitation)
pistol shot systolic sound in femoral arteries
what valve diseases can be caused due to rheumatic heart disease vs rheumatic fever?
heart disease = stenosis
fever = regurgitation
AF is a sign in which valve diseases?
mitral regurgitation and mitral stenosis
