Valve disease Flashcards
Describe the epidemiology of aortic regurgitation
3rd commonest valve disease
Increases w age
M > F
Describe the aetiology of aortic regurgitation
2 main groups of causes:
- Disease of aortic valve leaflets:
- Bicuspid aortic valve
- Rheumatic heart disease
- IE - Dilatation of aortic root:
- Marfan’s
- Aortitis
- Dissection
Describe the pathophysiology of aortic regurgitation
Blood flows back over aortic valve during diastole
- > LV pressure increases, LVH to compensate
- > eventually systolic dysfunction + CCF
Describe the presentation of chronic aortic regurgitation
- Usually asymptomatic for many years, detected on examination
- Awareness of heartbeat at night
- Palpitations
- Decreased exercise tolerance
- CCF
Describe the signs of aortic regurgitation
Hands: Corrigan’s pulse (collapsing), wide PP
Chest: displaced apex, EDM over aortic region w exacerbation leaning forward on end-exp at LSE
Eponymous signs:
-Quincke’s: nail bed pulsation
-De Musset’s: head bobbing
-Traube’s: pistol shot over femorals
Describe the investigations for aortic regurgitation
- ECG: LAD, LVH
- CXR: cardiomegaly
- Echo
- Extra special tests: exercise, catheterisation
Describe the management of aortic regurgitation (chronic)
Conservative:
-Most individuals will be managed conservatively w regular followup eg yearly echo
Medical:
-Management of any symptoms (end-stage)
Surgical/interventional:
- For any symptomatic/LV dysfunction/dilatation
- AV replacement or repair
Describe the epidemiology of aortic stenosis
Most common valve disease
Increases with age
Describe the aetiology of aortic stenosis
- Calcification of normal valves (age)
- Congenital biscuspid valve
- Rheumatic heart disease
- Connective tissue disease
Describe the pathophysiology of aortic stenosis
Impaired flow through the aortic valve during systole
- > LVH for compensation
- > systolic dysfunction (reduced CO) and CCF
Describe the presentation of aortic stenosis
May be detected when asymptomatic on exam Classic triad of symptoms: -Angina -Dizziness/syncope -SOB especially on exertion CCF symptoms
Describe the signs of aortic stenosis
Hands: slow-rising pulse, narrow PP
Chest: thrusting apex, ESM over aortic area radiating to the carotids +/- AR, quiet S2
Describe the investigations for aortic stenosis
ECG: LVH, LAD
CXR
Echo
Extra tests: stress etc
Describe the management of aortic stenosis
Conservative:
-Mild/mod disease can be Mx with regular monitoring
Medical:
-To relieve symptoms as needed/not suitable for intervention
Surgical/interventional:
- For symptomatic/severe disease/LV dysfunction
- AV replacement/repair or TAVI if frail (>80years)
Describe the epidemiology of mitral regurgitation
2nd commonest valve disease
F > M
Younger/middle aged
Describe the aetiology of mitral regurgitation
Chronic: mitral valve prolapse (young F), connective tissue disease, rheumatic heart disease
Acute: chordae tendonae or papillary muscle dysfunction (MI, rupture), IE
Describe the pathophysiology of mitral regurgitation
Back flow of blood over mitral valve
- > increased LA pressure + dilatation
- > pulmonary HTN + CCF
Describe the presentation of mitral regurgitation
- May be initially asymptomatic, detected on exam
- AF commonly occurs- palpitations, dizziness, syncope
- Exertional dyspnoea, fatigue
- CCF
Describe the signs of mitral regurgitation
Hands: irregularly irregular pulse
Chest: pansystolic blowing murmur at apex, radiation to axilla. Quiet S1, displaced apex
Describe the investigations for mitral regurgitation
ECG: AF, LVH
CXR: enlarged LA
Echo
Describe the management of mitral regurgitation
Conservative:
-Mild/mod disease, monitored with echo
Medical:
-If required for symptoms, AF
Surgical/interventional:
- Symptomatic disease/raised LA pressures/rEF
- Mitral valve replacement/repair (valvuloplasty)
Describe the epidemiology of mitral stenosis
Uncommon valve disease
More common in developing countries
Describe the aetiology of mitral stenosis
- Rheumatic heart disease by far most common
- Carcinoid syndrome, SLE, drugs
Describe the pathophysiology of mitral stenosis
Reduced flow over mitral valve during diastole
-> increased LA pressure
-> pulmonary HTN, reduced CO -> CCF
+ RVH, TR, etc
Describe the presentation of mitral stenosis
Dyspnoea and fatigue commonly
AF: palpitations, syncope etc
-CCF symptoms
-Emboli -> ischaemia
Describe the signs of mitral stenosis
Hands: AF
Face: malar flush
Chest: tapping apex, opening snap + rumbling diastolic murmur at apex, radiating to axilla
With complications: parasternal heave, crackles, oedema
Describe the investigations for mitral stenosis
ECG: AF, RVH
CXR
Echo
Describe the management of mitral stenosis
Conservative:
-If mild disease. Monitor
Medical:
- AF
- Symptomatic as needed
- Prevention of RHD relapse
Surgical:
- For severe symptomatic cases
- Valve replacement/repair/balloon valvotomy
Describe the epidemiology of tricuspid regurgitation
Very common to have mild disease (50-60% of young adults)
Describe the aetiology of tricuspid regurgitation
- As a consequence of L heart disease (usually mitral regurgitation)
- RHD
- IE
Describe the pathophysiology of tricuspid regurgitation
Back flow of blood over TV during systole
-> increased RA pressures
Describe the presentation of tricuspid regurgitation
May be detected on investigation of severe MR/left heart disease
-RHF: Peripheral oedema
Describe the signs of tricuspid regurgitation
- AF
- Raised JVP (absent a waves in AF)
- Pansystolic murmur in tricuspid area, heard best on end-inspiration
- Pulsatile liver
Describe the investigations for tricuspid regurgitation
ECG: AF, RVH
CXR
Echo
Bloods: LFTs, etc
Describe the management of tricuspid regurgitation
Conservative:
-Mild/mod disease
Medical:
- Managing assoc symptoms
- AF
Surgical/interventional:
- Tricuspid valve replacement/repair
- (deal with the cause eg. mitral valve replacement)
Describe the aetiology of pulmonary hypertension
1: pulmonary arterial HTN: idiopathic, familial, drugs
2: PH from left heart disease (cor pulmonale)
3: PH from chronic hypoxic lung disease
4: chronic thromboembolic PH
5: unknown aetiology
Describe the pathophysiology of pulmonary hypertension
Depends on the cause
- Left heart disease: increased L sided pressures -> increased pressure in pulmonary circulation
- Hypoxic lung disease: V/Q mismatch -> vascular remodelling -> increased pressures
What are normal pulmonary pressures?
PAP: <25mmHg
PAWP (measure for L sided heart disease): <15 mmHg
Describe the presentation of pulmonary hypertension
PAH: chronic progressive dyspnoea, exercise intolerance, fatigue
May also have symptoms of L heart failure: chest pain, syncope
Chronic: RHF (oedema, early satiety)
Describe the signs of pulmonary hypertension
Initially normal exam
- > JVP V wave, parasternal heave, loud P2
- > raised JVP, oedema, pulsatile hepatomegaly
Describe the investigations for pulmonary hypertension
History and exam -ECG: RVH -Bloods: general screen, BNP, D-dimer -CXR -Echo -Cardiac catheterisation for pressures \+ HRCT etc
Describe the management of pulmonary hypertension
Depends on class
Conservative:
-If mild symptoms
Medical:
- Treat cause eg. bronchodilator/steroids for lung disease
- Treat symptoms: CCBs, prostanoids, sildenafil, nitrates
Surgical/interventional:
eg. valve replacement
- Lung transplant
