Structural heart disease

Question 1

What gives rise to the first heart sound during S1?

Answer 1

Tricuspid & Mitral valves closing.

Question 2

What happens in the isovolumetric contraction phase of the cardiac cycle?

Answer 2

mitral and tricuspid valve close, Left ventricle contracts due to depolarisation, volume cannot increase due to mitral valve closing, LV pressure increases, pressure exceeds that of the aorta causing semilunar valve to open. Blood goes into aorta.

Question 3

What gives rise to the T-wave on the ECG cycle?

Answer 3

Re-polarisation wave.

Question 4

What causes the second heart sound (isovolumetric phase)?

Answer 4

Closure of the aorta and pulmonary valve.

Question 5

What is Left ventricular end systolic volume?

Answer 5

volume of blood that stays in the left ventricle at the end of systole.

Question 6

What is the Left ventricular end diastolic volume?

Answer 6

volume of blood left ventricle contains prior to ejection.

Question 7

How do you calculate Stroke volume?

Answer 7

By taking the end systolic volume from the end diastolic volume.

Question 8

What gives rise to the p wave on the ECG?

Answer 8

Atrial contraction

Question 9

What happens in the atria during diastole?

Answer 9

Mitral valve opens, blood from the atria pools in LV, Atrial contraction happens briefly towards the end of filling (10%) , and plays a larger role when you are exercising (40%).

Question 10

What are the two types of heart diseases?

Answer 10

Congenital heart diseases

Heart diseases that develop later in life

Question 11

What are some Congenital Heart diseases?

Answer 11

atrial septal defect (ASD), ventricular septal defect (VSD), coarctation of aorta, patent foramen ovale (PFO),Patent ductus arteriosus (PDA), Tetralogy of Fallot (TOF)

Question 12

What are some heart diseases that develop later in life?

Answer 12

can be due to valvular dysfunctions (Atrial stenosis /regurgitation or muscular (cardiomyopathies)

Question 13

What causes a Ventricular septal defect?

Answer 13

Happens when the wall between the two ventricles fail to develop normally, leading to a whole in the wall, this can lead to mixing of oxygenated and deoxygenated blood.
Some can close as the child grows but with others you will need surgery to close the whole

Question 14

What are the presentations for a Ventricular septal defect?

Answer 14

Poor weight gain, feeding.

Palpitations.

Question 15

What is present in the Tetralogy of Fallot?

Answer 15

4 different effects which happen together;
Ventricular septal defect
Pulmonary stenosis - pulmonary trunk is narrowed down.
Widening of the aortic wall - sits on both ventricles, mixes blood.
Right ventricular hypertrophy - thickening of the wall of the right ventricle.
Multiple surgeries needed for normal breathing.

Question 16

What is a Atrial Septal defect?

Answer 16

Whole in the wall between the 2 atria, develops due to failure of the walls development during pregnancy.

Question 17

What is Coarctation of the Aorta?

Answer 17

Narrowing of the arterial wall in the descending aorta, during ventricular systole blood has to be forced through, requiring greater ventricular effort, this can cause thickening of the ventricle or heart failure.

Question 18

What can happen due to a Aortic valve defect?

Answer 18

Aortic Stenosis

Aortic regurgitation

Question 19

What can happen due to a Mitral valve defect?

Answer 19

Mitral Stenosis

Mitral Regurgitation

Question 20

What is the biggest cause of valvular heart disease later on in life?

Answer 20

Rheumatic Heart disease

Question 21

What age group is Calcific aortic valve disease most present?

Answer 21

> 80

Question 22

What usually precedes aortic stenosis?

Answer 22

Aortic sclerosis - thickening of the aortic valve with flow limitations.

Question 23

What gives an early suspicion of Aortic stenosis?

Answer 23

It is often suspected by the presence of an early-peaking, systolic ejection murmur, and confirmed by echocardiography.

Question 24

What are the risk factors for Aortic stenosis?

Answer 24

Hypertension, LDL levels, smoking, elevated C-reactive protein, Congenital bicuspid valves, CKD, radiotherapy, old age.

Question 25

What are the causes of Aortic stenosis?

Answer 25

Rheumatic Heart Disease Congenital Heart Disease Calcium build up

Question 26

What is the Pathophysiology of Aortic stenosis?

Answer 26

Valvular endocardium is damaged due to abnormal blood flow or unknown cause. Inflammatory response leads to leaflet fibrosis & calcium deposits on the valve. This limits aortic leaflet motility and cause stenosis.

Question 27

What does Aortic Stenosis lead to?

Answer 27

LV Hypertrophy | Left ventricular wall stress increases causes systolic function to decline with resultant heart failure.

Question 28

What is the presentation for Aortic stenosis?

Answer 28

Exertional dyspnoea and fatigue Chest pain Ejection systolic murmur (≥3/6 is present with a crescendo-decrescendo pattern that peaks in mid-systole and radiates to the carotid) H/O Rheumatic fever, high lipoprotein, high LDL, CKD, age >65

Question 29

What investigations can be done to confirm Aortic stenosis?

Answer 29

Transthoracic echocardiography ECG Chest X ray (LVH) Cardiac catheterisation Cardiac MRI

Question 30

What is the treatment for Aortic stenosis?

Answer 30

The primary treatment of symptomatic AS Asymptomatic patients with severe AS who have an LVEF <50% or who are undergoing other cardiac surgery. AVR may be considered in asymptomatic patients with very severe AS or severe AS with rapid progression, an abnormal exercise test, or elevated serum B-type natriuretic peptide (BNP) levels Balloon aortic valvuloplasty Antihypertensive ACE inhibitors Statins

Question 31

What happens in Aortic regurgitation?

Answer 31

Aortic regurgitation (AR) is the diastolic leakage of blood from the aorta into the left ventricle. It occurs due to incompetence of valve leaflets resulting from either intrinsic valve disease or dilation of the aortic root

Question 32

What are the two types of Aortic regurgitation?

Answer 32

It can be chronic culminate into congestive cardiac failure It can be acute  medical emergency, presenting with sudden onset of pulmonary oedema and hypotension or cardiogenic shock

Question 33

What are the risk factors for Aortic regurgitation?

Answer 33

``` Rheumatic heart disease Infective endocarditis Aortic valve stenosis Congenital heart defects Congenital bicuspid valves ```

Question 34

What are the causes of Aortic regurgitation?

Answer 34

``` Marfan’s Syndrome Connective tissue disease/collagen vascular diseases idiopathic Ankylosing spondilytis Traumatic ```

Question 35

What is the cause of Acute Aortic regurgitation?

Answer 35

Infective endocarditis can lead to rupture of leaflets/ paraventricular leaks. Vegetation on valvular cusps can cause inadequate leaflets closure. Chest Trauma can cause a tear in the ascending aorta.

Question 36

What is the cause of Chronic Aortic regurgitation?

Answer 36

Bicuspid Aortic Valve. Rheumatic Fever - fibrotic changes causing thickening & retraction of leaflets.

Question 37

What is the Pathophysiology of Acute Aortic regurgitation?

Answer 37

Increase blood volume in LV during systoleLV end diastolic pressure increases increase in pulmonary venous pressure dyspnea and pulmonary oedemaheart failure cardiogenic shock

Question 38

What is the Pathophysiology of Chronic Aortic regurgitation?

Answer 38

 gradually increase in LV volumeLV enlargement and eccentric hypertrophy Early stages Ejection fraction normal or slightly increase after some time Ejection fraction falls and LV end systolic volume rises Eventually LV dyspnoea lower coronary perfusion  ischaemia, necrosis and apoptosis

Question 39

What are the presentations for Aortic Regurgitation?

Answer 39

``` Acute AR Cardiogenic shock Tachycardia Cyanosis Pulmonary edema Austin flint murmur Chronic AR Wide pulse pressure Corrigan (wate hammer pulse) Pistol shot pulse (Traube sign) ```

Question 40

What investigations can be done to diagnose Aortic regurgitation?

Answer 40

Transthoracic echocardiography Chest X ray Cardiac catheterisation Cardiac MRI/CT Scan

Question 41

What is the management for Aortic regurgitation?

Answer 41

Management (Aortic Valve replacement) Acute ARIonotropes/vasodilators & valve replacememt & repair Chronic asymptomaticIf LV function is normal can be managed by drugs or reassurance Chronic symptomatic--) First line is valve replacement with adjunct vasodilator therapy Prevention: Prevention is key: Treat Rheumatic fever and infective endocarditis.

Question 42

What happens in Mitral stenosis?

Answer 42

Obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve Leads to pulmonary Hypertension & right heart failure.

Question 43

What are the causes of Mitral stenosis?

Answer 43

``` Rheumatic fever Carcinoid syndrome Use of ergot/serotonergic drugs SLE Mitral annular calcification due to aging Amyloidosis Rheumatoid arthritis Whipple disease Congenital deformity of the valve ```

Question 44

What is the pathophysiology of Mitral stenosis?

Answer 44

Typically occurs decades after an episode of rheumatic fever, acute insult leads to the formation of multiple foci and infiltrates the endo and myocardium along the valves walls, these get calcified, thickened & contracted.

Question 45

What does Mitral stenosis cause?

Answer 45

Initially moderate exercise or tachycardia result in exertional dyspnoea due to increased left atrial pressure Severe mitral stenosis leads to increase in left atrial pressure , transudation of fluid into the lung interstitium leading to dyspnoea at rest or exertion Pulmonary hypertension may develop as the result of it The restricted orifice limits filling of left ventricle limiting cardiac output Hemoptysis if bronchial vein rupture

Question 46

What is the presentation for Mitral stenosis?

Answer 46

``` H/0 of Rheumatic fever Dyspnoea orthopnoea Diastolic murmur Loud P2 Neck vein distention Hemoptysis 40-50 years age ```

Question 47

What are the investigations required to diagnose mitral stenosis?

Answer 47

``` ECG Transthoracic echocardiography Chest X ray Cardiac catheterisation Cardiac MRI/CT Scan ```

Question 48

What is the management for mitral stenosis?

Answer 48

Progressive asymptomatic No therapy required Severe asymptomatic no therapy generally required adjuvant balloon valvotomy Severe symptomatic diuretic, balloon valvotomy, valve replacement & repair adjunct b blockers

Question 49

What happens in Mitral regurgitation?

Answer 49

Abnormal reversal of blood flow from the left ventricle to the left atrium. It is the most frequent valvular heart disease It is caused by the disruption in any part of the mitral valve apparatus

Question 50

What are the Acute causes of Mitral regurgitation?

Answer 50

``` Mitral valve prolapse Rheumatic heart disease Infective endocarditis Following valvular surgery Prosthetic mitral valve dysfunction ```

Question 51

What are the Chronic causes of Mitral regurgiataion?

Answer 51

``` Rheumatic heart disease SLE Scleroderma Hypertrophic cardiomyopathy Drug related ```

Question 52

What happens in Chronic Mitral Regurgitation?

Answer 52

progression leads to eccentric hypertrophy leading to elongation of myocardial fibres and increased left end diastolic volume Increase in preload & a decrease in afterload increase in end- diastolic volume and a decrease in end-systolic volume Eventually prolonged volume overload leads to left ventricular dysfunction and increased left ventricular end-systolic diameter

Question 53

How does Infective endocarditis lead to Mitral regurgitation?

Answer 53

Abscess formation, vegetations, rupture of chordae tendineae and leaflet perforation

Question 54

What is the presentation for Mitral regurgitation?

Answer 54

Dyspnea diminished S1, murmur high Fatigue pitched, blowing xx Orthopnea Chest pain Atrial fibrillation

Question 55

What are the investigations you can do for Mitral regurgitation?

Answer 55

``` ECG Transthoracic echocardiography Chest X ray Cardiac catheterisation Cardiac MRI/CT Scan ```

Question 56

What is the treatment for Mitral regurgitation?

Answer 56

Acute MR Emergency Surgery & preoperative diuretics & intra-aortic balloon counterpulsation Chronic asymptomatic 1st ACE inhibitors Beta blockers if left ventricular ejection fraction is less than 60% 1st line is surgery Chronic symptomatic1st surgery plus medical treatment If left ventricular ejection fraction is less than 30% 1st line is Intra-aortic balloon counterpulsation