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Module 103: The Heart, Lungs and Blood > Theme 3: Lecture 4 - Valvular dysfunction > Flashcards

Theme 3: Lecture 4 - Valvular dysfunction Flashcards

1
Q

Where do you auscultate for the aortic valve

A

2nd intercostal space on the right sternal edge

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2
Q

Where do you auscultate for the tricuspid valve

A

4th intercostal space on the left sternal edge

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3
Q

Where do you auscultate for the pulmonary valve

A

2nd intercostal space on the left sternal edge

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4
Q

Where do you auscultate for the mitral valve

A

5th intercostal space in the mid clavicular line

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5
Q

Atrial septal defect

A

hole between atria

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6
Q

Ventral septal defect

A

hole between ventricles

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7
Q

What sounds can you hear in the heart

A

-Opening and closing of the heart valves
-Filling of the heart
-Valvular pathology
-Structural heart disease
Turbulent blood flow:
-Through the heart
-Across the valves

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8
Q

What causes S1

A

Closing of the mitral and tricuspid valves at the start of systole

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9
Q

What causes S2

A

Closing of pulmonary and aortic valves at the start of diastole

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10
Q

What causes a mid systolic murmur

A
  • Aortic stenosis
  • Pulmonary stenosis
  • Atrial septal defect
  • Hypertrophic obstructive cardiomyopathy (HOCM)
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11
Q

What causes a holosystolic/pansystolic murmur

A
  • Mitral regurgitation
  • Tricuspid regurgitation
  • Ventricular septal defects
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12
Q

What does a holosystolic/pansystolic murmur sound like

A

high pitched and continuous

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13
Q

What causes a late systolic murmur

A

mitral valve prolapse

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14
Q

What causes an early diastolic murmur

A
  • Aortic regurgitation

- Pulmonary regurgitation

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15
Q

What causes a mid/late diastolic murmur

A
  • Mitral stenosis

- Tricuspid stenosis

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16
Q

Causes of other rare murmurs

A

-patent ductus arteriosus

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17
Q

What is patent ductus arteriosus

A

Where the ductus arteriosus (between aorta and pulmonary artery) fails to close after birth

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18
Q

Can you hear sound in laminar flow

A

No

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19
Q

Can you hear sound in turbulent flow

A

Yes

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20
Q

What causes valvular heart disease

A
  • Degenerative valve disease
  • Rheumatic valve disease
  • Infective valve disease
  • Congenital valve disease
  • Secondary to loss of supporting structures
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21
Q

What are rheumatic diseases

A

rheumatic diseases are autoimmune and inflammatory diseases that cause your immune system to attack your joints, muscles, bones, and organs

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22
Q

Epidemiology of degenerative valve disease

A
  • More calcium deposits on the valve making it harder to open or close properly
  • Reflects aging population
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23
Q

Epidemiology of rheumatic valve disease

A
  • Post Streptococcal Rheumatic Fever
  • Children and young adults
  • Disease of poverty, overcrowding
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24
Q

Epidemiology of infective valve disease

A
  • Most common on ‘abnormal’ valves
  • Virulent organisms – normal valves, Staph/strep
  • Immunocompromised
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25
Q

Epidemiology of congenital valve disease

A

Low static incidence in all populations

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26
Q

Which valves does degenerative valve disease affect

A
  • Aortic and mitral

- Affects aortic more than mitral

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27
Q

Which valves does rheumatic valve disease affect

A
  • Aortic and mitral

- Affects mitral more than aortic

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28
Q

Which valves does infective valve disease affect

A
  • Any valve (left heart more than right)
  • Right (atypical organisms, IVDU)
  • Bacterial, Fungal, Culture –ve (autoimmune)
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29
Q

Which valves does congenital heart disease affect

A

any valve

30
Q

What causes valves to become pathological

A
  • Calcification (immobility of leaflets)
  • Fibrosis (fusion of leaflets)
  • Dilation of valve ring
31
Q

Describe valve stenosis

A
  • Narrowing of valve leaflets
  • Valve leaflets fail to open completely
  • Leads to build of back pressure and loss of stroke volume
32
Q

Describe valve regurgitation

A
  • Failure of leaflets to meet in systole
  • Leaflets fail to close completely
  • Allows reverse flow of blood during relaxation of the heart
  • Also called “incompetence”
33
Q

What is the SAD triad

A

-

  • Syncope upon exertion,
  • Angina (chest pain)
  • Dyspnoea (Shortness of breath - especially on exertion),
34
Q

What does aortic stenosis cause

A
  • Obstruction to flow leading to decreased cardiac output

- Pressure overload

35
Q

What are the symptoms of aortic stenosis due to obstruction to flow leading to reduced cardiac output

A 
If severe: 
-SAD Triad
-fatigue
-palpitations
-Sudden death (rare in asymptomatic) due to arrhythmias from pressure overload
Mild-moderate: 
-Asymptomatic
-Murmur discovered on routine physical exam
36
Q

Describe what happens in pressure overload in aortic stenosis

A
  • Generation of high LV systolic pressure to force blood through the obstruction
  • Results in left ventricular hypertrophy
  • Eventual LV decompensation/dilatation
37
Q

When are the heart sounds heard in aortic stenosis

A
  • Systolic crescendo/decrescendo murmur

- soft second heart sound (in more severe cases)

38
Q

Why are these heart sounds heard in aortic stenosis

A

For systolic crescendo/decrescendo murmur:

  • The valve doesn’t open fully, producing turbulence as blood passes across it.
  • This occurs at the beginning of systole where the pressure gradually rises, and as a result the amount of blood and therefore the amount of turbulence gradually rises, peaks and then falls as the ventricle begins to relax

soft second heart sound:

  • In more severe cases
  • If the valve is stiff and thickened, it doesn’t close properly
39
Q

Aetiology of aortic stenosis

A
  • Congenital syndromes
  • Bicuspid valve (has 2 leaflets) instead of the normal three in the aortic valve
  • Degenerative
  • Post rheumatic fever
40
Q

Aetiology of aortic regurgitation (9)

A

Aortic dilatation:

  • loss of support
  • connective tissue disease (e.g. rheumatoid arthritis)
  • hypertension
  • aortic dissection
  • degenerative
  • cystic medial necrosis
  • syphilis

Valvular:

  • Bicuspid valve
  • Infective endocarditis
41
Q

What is an aortic dissection

A

occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart

42
Q

What is cystic medial necrosis

A

a disorder of large arteries, in particular the aorta, characterized by an accumulation of basophilic ground substance in the media with cyst-like lesions

43
Q

What is infective endocarditis

A

infection in the heart valves or endocardium. The endocardium is the lining of the interior surfaces of the chambers of the heart. This condition is usually caused by bacteria entering the bloodstream and infecting the heart.

44
Q

What does aortic regurgitation cause

A
  • Volume overload in the ventricle because blood falls back into LV during diastole
  • LV dilatation to accommodate volume, typical result of volume overload
45
Q

Pathophysiology f aortic regurgitation

A
  • Aortic regurgitation
  • Leads to LV dilation and failure
  • Leads to LA enlargement
  • Leads to pulmonary vein hypertension
  • Leads to pulmonary oedema
46
Q

What are the heart sounds heard in aortic regurgitation

A
  • Early diastolic murmur

- Concomitant systolic murmur

47
Q

Why are these sounds heard in aortic regurgitation

A

For early diastolic murmur:

  • At the end of systole the pressure in the ventricle drops and the aortic (and pulmonary) valves close.
  • If the aortic valve leaflets fail to come together and are damaged, blood under high pressure in the aorta rushes back into the ventricle (with turbulence)
  • This happens the most when the pressure in the ventricle is the lowest at the beginning of diastole

Concomitant systolic murmur:

  • Often, not always
  • Because in this disorder the aortic valve is often structurally abnormal, there is often turbulence as the blood exits the ventricle during systole
48
Q

Symptoms of aortic regurgitation

A
  • Often asymptomatic
  • Chest pain (due to decreased coronary perfusion and diastolic BP reduces)
  • Breathlessness
  • Syncope – uncommon
  • Catastrophic decompensation if acute – fulminant (sudden onset) pulmonary oedema
49
Q

Aetiology of mitral regurgitation

A

Valvular:
Prolapse, infective, degenerative

Chordal rupture/papillary muscle failure

Annular dilatation
Secondary to left ventricular dilatation

50
Q

What is annular dilation

A

The annular circle where the valve leaflets are placed becomes dilated

51
Q

What does mitral regurgitation cause

A
  • Volume overload in left ventricle
  • Pressure overload of right heart
  • Left ventricular dilatation (a response to volume overload)
  • Decompensation
52
Q

What does volume overload in the left ventricle lead to

A
  • During systole blood is ejected backwards into the left atrium
  • Extra blood in atrium leads to elevation of left atrial pressure and increased ventricular filling during subsequent diastole
53
Q

What can pressure overload of the right heart lead to

A
  • Can lead to right ventricular hypertrophy or right heart failure
  • Transient elevation of left atrial pressure during systole
54
Q

What heart sounds are heard in mitral regurgitation

A

Pan systolic murmur

55
Q

Why are these sounds heard during mitral regurgitation

A

Pan-systolic Murmur:
-The leaflets fail to coapt either because the annulus is stretched (with a ‘hole’ in the middle), or
because the leaflets are damaged or abnormal
-Blood leaks back into the left atrium with turbulence as it passes across the abnormal valve
-Blood regurgitates back in atrium almost immediately and for the whole of systole
-Because the left atrium is a low pressure chamber and during systole the left ventricle is under high pressure

56
Q

Symptoms or mitral regurgitation (5)

A
  • Breathlessness due to back pressure of pulmonary circulation
  • Lethargy and reduced exercise tolerance due to breathlessness and reduced cardiac output
  • Palpitations – atrial fibrillation due to pressure overload in atrium
  • Peripheral oedema – decompensation
  • Chest pain – concomitant CAD
57
Q

Describe a mitral valve prolapse

A

Initially valve shuts during the early part of systole but then, either because the leaflet is too ‘baggy’ or because of abnormal sub-valvar apparatus the leaflet prolapses back into the left atrium potentially allowing though a jet of regurgitation

58
Q

What are the heart sounds heard in mitral valve prolapse

A
  • Mid systolic click

- Late systolic murmur

59
Q

Why are these sounds heard in a mitral valve prolapse

A
  • Mid-systolic ‘click’ – as the leaflet prolapses back into the left atrium
  • Late systolic murmur - if blood then continues to flow into the left atrium after initial jet of regurgitation
60
Q

Aetiology of mitral stenosis (7)

A
  • Almost always due to rheumatic fever
  • Congenital
  • Storage diseases
  • Malignancy (e.g. carcinoid)
  • Previous endocarditis
  • Mitral valve calcification (i.e. degenerative)
  • Systemic disease
61
Q

What does mitral stenosis cause

A

Lung/right heart consequences:

  • Breathlessness, congestion, etc
  • Due to pressure back up because of failure of ejection of left atrial volume

Left ventricle physiology usually preserved

62
Q

When ventricle function compromised in mitral stenosis

A
  • atrial contraction lost (low LV filling) or

- when high circulating volume (high right heart pressure)

63
Q

What are the heart sounds heard in mitral stenosis

A
  • Mid diastolic rumbling murmur
  • Opening snap
  • Loud first heart sound
64
Q

Why are these sounds heard in mitral stenosis

A
  • Mid-diastolic rumbling murmur during diastole, stenosis restricts blood flowing across the mitral valve from the LA into LV
  • Opening snap as the restricted leaflets ‘snap’ open
  • Loud first heart sound if the leaflets are stiff but still relatively mobileas leaflets “slam” shut
65
Q

Symptoms of mitral stenosis

A
  • Lung (Breathlessness, Peripheral oedema, Haemoptysis)
  • Palpitations
  • Systemic emboli
  • Fatigue
  • Compressive symptoms (stridor, dysphagia)
66
Q

What is dysphagia

A

difficulty swallowing

67
Q

What is stridor

A

high pitched wheezing sound caused by disrupted airflow

68
Q

What are the surgical management options for valvular heart disease

A
  • Valve repair

- Valve replacement

69
Q

What are the percutaneous management options for valvular heart disease

A
  • Balloon aortic valvuloplasty (BAV)

- Transcatheter aortic valve implantation (TAVI)

70
Q

Advantages and disadvantages of mechanical valves

A
  • last 20/30 years

- need to be on long term anticoagulation

71
Q

Advantages and disadvantages of biological valves

A
  • Last 10/15 years

- Don’t need long term coagulation

72
Q

Describe the heart sounds with mechanical valves

A
  • First heart sound metallic = mitral
  • Second heart sound metallic = aortic
  • Systolic murmurs normal and not necessarily pathological
  • Diastolic murmurs usually pathological

Module 103: The Heart, Lungs and Blood (51 decks)

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