Valve disease Flashcards by B M

Describe the epidemiology of aortic regurgitation

3rd commonest valve disease
Increases w age
M > F

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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

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Describe the pathophysiology of aortic regurgitation

Blood flows back over aortic valve during diastole

> LV pressure increases, LVH to compensate
> eventually systolic dysfunction + CCF

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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

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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

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Describe the investigations for aortic regurgitation

ECG: LAD, LVH
CXR: cardiomegaly
Echo
Extra special tests: exercise, catheterisation

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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

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Describe the epidemiology of aortic stenosis

Most common valve disease

Increases with age

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Describe the aetiology of aortic stenosis

Calcification of normal valves (age)
Congenital biscuspid valve
Rheumatic heart disease
Connective tissue disease

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Describe the pathophysiology of aortic stenosis

Impaired flow through the aortic valve during systole

> LVH for compensation
> systolic dysfunction (reduced CO) and CCF

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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

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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

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Describe the investigations for aortic stenosis

ECG: LVH, LAD
CXR
Echo
Extra tests: stress etc

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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)

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Describe the epidemiology of mitral regurgitation

2nd commonest valve disease
F > M
Younger/middle aged

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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

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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

1. As a consequence of L heart disease (usually mitral regurgitation) 2. RHD 3. 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