Structural and Valvular Abnormalities

Question 1

What are the features of HOCM?

Answer 1

Spectrum

Asymptomatic — Dyspnoea, angina, syncope, — sudden death (arrythmias and heart failure)

Signs: ejection systolic murmur, mitral regurg, assymetric hypertrophy, LVH, ecg : t-wave invention and LAD

Question 2

What can be found on examination of someone with coarctation of the aorta?

Answer 2

Systolic murmurs,
Weak foot pulses
Hypertension in upper limbs

Question 3

What is the genetics of HOCM?

Answer 3

Autosomal dominant

Gene mutation for B-myosin heavy chain protein.
Chromosome 14

Question 4

What can be seen on echo in HOCM?

Answer 4

• Systolic anterior motion of the mitral valve.
• asymmetric hypertrophy of the intraventricular septum.
• left ventricular outflow tract obstruction
• mitral regurgitation

Question 5

What is arrthymogenic right ventricular dysplasia?

Answer 5

Autosomal dominant cardiomyopathy
(Desmosome gene mutation)

Right ventricular becomes enlarged, fatty and hypotonic, with a thin free wall.

ECG: t wave invention V1-3, epsilon wave (terminal notch in QRS complex)

Question 6

Where and when is MS heard best?

Answer 6

5 intercostal space mid claviclar line in expiration

Mid-late diastolic murmur
Load S1- opening snap

Question 7

Causes of MS

Answer 7

Rheumatic fever

Question 8

What is seen on CXR in MS?

Answer 8

Left atrial enlargement - see double heart border

Question 9

Risk factors for AS?

Answer 9

Age (stress over time)
Bicuspid valve
Chronic rheumatic fever (commissural fusion)

Question 10

Treatment for AS

Answer 10

Valve replacement

Or balloon vavuloplasty for those unfit for surgery

Question 11

Causes of AR

Answer 11

Aortic root dilation (idiopathic, aortic dissection, aneurysms, syphillis)

Valvular damage (endocarditis, chronic rheumatic fever)

Question 12

What do you find on clinical examination of someone with AR?

Answer 12

Early diastolic murmur,

Wide pulse pressure leading to:

• bound/water hammer pulse
• head bobbing
• Quinckes sign (capillary beds in fingernails pulsate)

Eccentric left ventricular hypertrophy

Question 13

Indications for surgery in AS

Answer 13

Symptomatic

Asymptomatic with valvular gradient >40mm Hg and feature of left ventricular dysfunction

Question 14

Which murmurs are ejection systolic?

Answer 14

As
Ps
HOCM
ASD, Fallots

Question 15

Which murmurs are pansystolic?

Answer 15

Mitral/ tricuspid regurg, (high pitches blowing)

VSD (harsh in character)

Question 16

Late systolic murmurs?

Answer 16

Mitral valve prolapse,

Coarctation of aorta

Question 17

Early diastolic murmurs?

Answer 17

AR (high pitched and blowing)

Graham steel murmur (pulmonary regurg)

Question 18

Mid diastole murmurs?

Answer 18

MS (rumbling)

Austin flint murmur (severe aortic regurg - rumbling)

Question 19

Contiounous machinery murmur?

Answer 19

Patent ductus arteriosus

Question 20

Treatment for mitral stenosis

Answer 20

Supportive - control AF, symptoms
If get pulmonary hypertension then surgery is required
1) transepts balloon valvotomy (CI in severe calcification, severe regurgitation or LA thrombus)
2) closed valvotomy
3) open valvotomy
4) mitral valve replacement

Question 21

Criteria for aortic stenosis surgery

Answer 21

Symptoms during exercise test or drop in BP
LVEF <50%
Moderate-severe stenosis undergoing CABG, aortic or other cardiac surgery
AV gradient > 40 or symptoms — valve replacement

Question 22

Treatment for HOCM

Answer 22

Implantable defibrillator, amiodarone or dysoparamide

Surgery - myomectomy

Question 23

What are the features and findings of examination for bicuspid aortic valve?

Answer 23

Common, will probably be asymptomatic until later life when it can be calcified giving AS.
Sounds : early systolic click. Can be some AR/AS can hear a blowing diastolic murmur.