Valve disease

Question 1

What are the clinical features of Aortic Stenosis? (5)

Answer 1

1. High-pitched and loud ejection systolic murmur
2. Slow-rising pulse
3. Low volume pulse
4. Radiates to carotid
5. Loudest on expiration

Question 2

What are the clinical and history features suggestive of severe aortic stenosis? (5)

Answer 2

1. Long duration of murmur
2. Quiet second heart sound
3. Heave
4. Angina
5. Syncope

Question 3

What are the differentials for an ejection systolic murmur? (3)

Answer 3

1. Aortic stenosis
2. Aortic sclerosis
3. HOCM

Question 4

What are the management optios for aortic stenosis? (3)

Answer 4

1. Beta blockers
2. Avoid ACE-i and nitrates
3. Consideration for surgical management:
   - Tissue valve replacement
   - Metallic valve replacement
   - TAVI (if not fit for surgery)

Question 5

What are the pros and cons of a metallic heart valve?

Answer 5

Pros:
- Durable

Cons:
- Lifelong anticoagulation

Question 6

What are the indications for a Mitral Valve replacement?

Answer 6

1. Mitral stenosis - signs of pulmonary HTN
2. Mitral regurgitation
3. Infective endocarditis

Question 7

How would you manage a mitral valve prolapse or replacmenet incompetence?

Answer 7

Surgical repair considered then replacement considered

Question 8

What are the congenital causes of pulonary valve disease?

Answer 8

1. Rubella
2. Down’s syndrome
3. Turner’s syndrome
4. Noonan’s syndrome

Question 9

What are the features to comment on in congenital valve disease? (3)

Answer 9

1. Cyanotic or acyanotic
2. Previous surgeries
3. Presence of any congenital syndromes

Question 10

What are the features to comment on in congenital valve disease? (3)

Answer 10

1. Cyanotic or acyanotic
2. Previous surgeries
3. Presence of any congenital syndromes

Question 11

What are the features of severe Mitral regurgitation? (5)

Answer 11

1. Raised JVP
2. Loud P2
3. S3 gallop rhythm
4. Right ventricular heave
5. Displaced thrusting apex

Question 12

What are the symptoms of severe Mitral regurgitation? (3)

Answer 12

1. Dyspnoea
2. Reduced exercise tolerence
3. Fluid overload

Question 13

What is the JVP?

Answer 13

JVP is a visual reflection of the pressures in the right atrium
Can see externally abnormalities in right heart pressure
e.g. Pulmonary HTN caused a raised JVP

Question 14

What are the indications of Mitral Valve replacement? (6)

Answer 14

1. Symptoms
2. Pulmonary hypertension - surgery should ideally be performed before pulmonary hypertension occurs
3. Fluid overload
4. Reduced ejection fraction
5. Acute MR e.g. post MI
6. Increased LV dilatation

Question 15

What are the causes of Mitral Regurgitation? (4)

Answer 15

1. Degenerative e.g. age related
2. Mitral valve prolapse
   - Elhers-Danlos
3. MI - pipillary muscle rupture
4. Infection e.g. rheumatic fever or Infective Endocarditis

Question 16

What investigations should be performed in Mitral Regurgitation? (6)

Answer 16

1. ECG - AF
2. Urine dip of haemturia and proteinuria (IE)
3. Blood cultures - infective endocarditis
4. Routine bloods - anaemia, WCC, CRP, ESR, U&Es
5. ECHO - mitral valve, vegetations, prolapse, LV Ejection Fraction
6. Chest x-ray
7. Fundoscopy (IE)

Question 17

When should bio valve replacements be offered? (5)

Answer 17

1. Young women of child bearing age
2. AS >70
3. MR >65
4. If high risk of haemorrhage
5. If poorly compliant with medications and follow up (need to take lifelong warfarin)

Question 18

When should metallic heart valve replacements be offered? (2)

Answer 18

1. Don’t meet criteria for bio
2. Already on life-long anticoagulation e.g. in AF