Stenosis and regurgitation Flashcards
What is aortic regurgitation?
The diastolic leakage of blood from the aorta into the left ventricle (LV).
How does aortic regurgitation progress?
Chronic aortic regurgitation (AR) may be asymptomatic for years until overt symptoms of congestive heart failure develop.
Initial symptoms can include palpitations and uncomfortable awareness of the pounding heart when lying on the left side.
What is acute aortic regurgitation?
Acute AR is a medical emergency, presenting with sudden onset of pulmonary oedema and hypotension or cardiogenic shock.
May also present as myocardial ischaemia or aortic root dissection.
How would you diagnose aortic regurgitation?
- Presence of risk factors
- Diastolic murmur
Also: dyspnoea, fatigue, weakness, orthopnoea
What are risk factors for aortic regurgitation?
- Bicuspid aortic valve
- Rheumatic fever
- Endocarditis
- Marfan’s syndrome and related connective tissue disease
What are diagnostic investigations for aortic regurgitation?
- ECG
- CXR
- Echocardiogram
- M-mode and 2-dimensional imaging
How would you manage acute aortic regurgitation?
Inotropes + vasodilators + urgent aortic valve replacement or repair
What is rheumatic fever?
Rheumatic fever (acute rheumatic fever) is a disease that can affect the heart, joints, brain, and skin.
Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly.
What are the symptoms of rheumatic fever?
Fever
Painful tender joints
Symptoms of congestive heart failure, including chest pain, shortness of breath, fast heartbeat
Fatigue
Jerky, uncontrollable body movements (called “chorea”)
Novel heart murmurs, dilation, fluid in pericardium
What is the most common age for rheumatic fever?
5 through 15 years old
What organism causes rheumatic fever?
Group A strep infection
How would you manage mild to moderate chronic aortic regurgitation?
- Asymptomatic → no treatment
2. Symptomatic → Treatment underlying cause
How would you manage severe (EF < 50%) chronic aortic regurgitation?
- Aortic valve replacement
2. Vasodilation
What is aortic stenosis?
Aortic stenosis is obstruction of blood flow across the aortic valve due to aortic valve fibrosis and calcification.
How does aortic stenosis present?
Presentation includes fatigue; exertional symptoms including shortness of breath, angina, or syncope; and heart failure.
What are risk factors for aortic stenosis?
- Age > 60
- Congenitally bicuspid aortic valve
- Rheumatic heart disease
- Chronic kidney disease
What are key diagnostic factors for aortic stenosis?
- Characteristic murmur is systolic, mid-to-late peaking with a crescendo-decrescendo pattern, and radiates to the carotids.
- Doppler echo is essential to the diagnosis and will show a pressure gradient across the stenotic aortic valve.
- Presence of risk factors
- Exertional dyspnoea
- Fatigue
- Chest pain
What are diagnostic investigations for aortic stenosis?
- Doppler
- ECG
- Chest x-ray
How would you manage a clinically unstable aortic stenosis?
All patients need to be stabilised prior to surgery or transcatheter aortic valve replacement (TAVR).
Balloon valvuloplasty is a reasonable option as a bridge to recovery and subsequent evaluation for surgical aortic valve replacement (SAVR)
How would you manage a clinically stable symptomatic aortic stenosis?
- Surgical aortic valve replacement PLUS long-term infective endocarditis antibiotic prophylaxis
+ anticoagulants
In old patients you would do a transcatheter aortic valve replacement
How would you differentiate aortic stenosis vs sclerosis?
Signs and symptoms of heart failure or chest pain should prompt an echocardiogram but cannot by themselves reliably distinguish the two conditions.
What are causes of aotic stenosis?
Causes include being born with a bicuspid aortic valve, and rheumatic fever
What is the cardiac adverse effect of stenosis?
Initially: myocardial hypertrophy
Later stages: the left ventricle dilates, the wall thins, and the systolic function deteriorates
What is mitral stenosis?
Mitral stenosis is a narrowing of the mitral valve orifice, usually caused by rheumatic valvulitis producing fusion of the valve commissures and thickening of the valve leaflets.
What causes mitral stenosis?
Rheumatic heart disease
What are the symptoms of mitral stenosis?
Exertional dyspnoea Palpitations Chets pain Haemoptysis Ascites
What are the complications of mitral stenosis?
Atrial fibrillation is a common complication of resulting left atrial enlargement, which can lead to systemic thromboembolic complications like stroke
Causes decreased filling of the left ventricle, while simultaneously increasing left atrial pressure, producing the syndrome of right-sided heart failure.
How is mitral stenosis diagnosed?
- Loud first heart sound
- History of rheumatic feber
- Dyspnoea
- Orthopnoea
Where is the mitral valve located?
Left side
What are the diagnostic investigations for mitral stenosis?
- ECG: atrial fibrillation; left atrial enlargement; right ventricular hypertrophy
- CXR: double right heart border indicating an enlarged left atrium; prominent pulmonary artery; Kerley B lines
- Trans-thoracic echocardiography: hockey stick-shaped mitral deformity
How would you manage mitral stenosis?
In severe symptomatic disease:
- Diuretics
- Balloon valvotomy or valve replacement
What is mitral regurgitation?
A form of valvular heart disease in which the mitral valve does not close properly when the heart pumps out blood
Mitral regurgitation is the most common form of valvular heart disease
What murmur can be heard in mitral regurgitation?
Typically presents as a holosystolic blowing murmur at the apex, radiating to axilla.
What are the key diagnostic factors of mitral regurgitation?
- Exertional dyspnoea
- Decreased exercise tolerance
- Lower extremity oedema
What are risk factors for mitral regurgitation?
- Mitral valve prolapse
- History of rheumatic heart disease
- Infective endocarditis
- History of cardiac trauma
What diagnostic investigations would you perform for mitral regurgitation?
Transthoracic echo
ECG
Transthoracic echo is the diagnostic test of choice in identifying presence, severity, and mechanism of MR.
How would you manage mitral regurgitation?
In acute MR → emergency surgery
In asymptomatic chronic MR → ACE-I + beta-blockers
In symptoms MR → surgery and medication
