Valve disease Flashcards
What are the inflow valves?
mitral and tricuspid
What are the outflow valves?
aortic and pulmonary
What is valve stenosis?
valve does not open fully
not enough blood gets through
What is valve regurgitation?
valve does not close fully
blood leaks backwards
What are the 2 most common valves to be affected by valve disease?
aortic and mitral
2 general causes of valve disease (related to structure)
disease of the valve leaflets
stretching of the structure the valve is attached to
Congenital and acquired causes of disease of the valve leaflets
congenital = born with abnormal valve that wears out faster than normal (eg. bicuspid aortic valve)
acquired = degenerative, rheumatic, endocarditis
What does stretching of the structure the valve is connected to cause?
leakage
called secondary/functional regurgitation
What can cause a dilated left ventricle and what does it cause?
causes mitral regurgitation
ischaemic heart disease
dilated cardiomyopathy
hypertension
What can cause a dilated aortic root and what does it cause?
causes aortic regurgitation
cystic medial necrosis (due to ageing, hypertension, Marfan’s)
bicuspid aortic valve
aortic dissection
Describe rheumatic fever
inflammatory condition involving heart, skin and connective tissues
usually affects children/young adults
50% have cardiac involvement
heart disease development usually due to recurrent episodes
How can rheumatic heart disease be prevented?
penicillin after sore throat or rheumatic fever
What causes valve damage in rheumatic fever?
due to abnormal tissue response to group A strep
How does valve disease present?
incidental finding (hearing a murmur, finding valve disease on an echo)
heart failure symptoms (fatigue, breathlessness, swollen legs)
What is mitral valve disease often associated with?
atrial fibrillation
What can aortic valve disease be associated with?
angina
dizziness
sudden death
Status of aortic and mitral valves in systole
mitral valve closed
aortic valve open
Status of aortic and mitral valves in diastole
mitral valve open
aortic valve closed
Anatomical cause of mitral stenosis
commisural fusion and leaflet thickening
Most common cause of mitral stenosis
rheumatic heart disease
What position accentuates the mitral stenosis murmur?
left lateral
place bell lightly at apex
heard as low frequency rumbling heard in mid diastole
Mitral stenosis treatment
anticoagulation (if AF present)
balloon valvotomy
Mitral regurgitation treatment
surgery if severe and symptomatic or asymptomatic with left ventricular impairment
mitral valve repair is treatment of choice
What is the commonest congenital heart defect?
bicuspid aortic valve
Describe the pathophysiology of aortic stenosis
thickening of aortic valve causes obstruction to outflow
pressure gradient develops across the valve and turbulent flow causes a loud murmur in systole
left ventricle is pressure loaded because of obstruction to flow and hypertrophies
Aortic stenosis symptoms
heart murmur
angina pectoris
syncope
air hunger (difficult breathing)
Signs of aortic regurgitation
collapsing pulse
wide pulse pressure
prominent carotid pulsation
laterally displaced apex beat
Symptoms of aortic regurgitation
asymptomatic for many years
develop left ventricular failure (dyspnoea, orthopnoea, fatigue)
chest pain
What signs can be seen in aortic regurgitation?
Corrigan’s sign
De Musset’s sign
Quincke’s sign
Traube’s sign
Austin Flint murmur
Duroziez’s sign
What is Corrigan’s sign?
carotid pulsation
What is De Musset’s sign?
head nodding with each heartbeat
What is Quincke’s sign?
capillary pulsations in nail bed
What is Traube’s sign?
‘pistol shot’ sound over the femoral arteries
What is Austin Flint murmur?
mid diastolic murmur over cardiac apex
What is Duroziez’s sign?
systolic and diastolic bruit over femoral arteries on gentle compression by stethoscope
What position can accentuate the sound of aortic regurgitation?
sit up
lean forward
exhale completely
hold breath in full expiration
press diaphragm firmly at left sternal edge
Describe tricuspid valve disease
mild tricuspid regurgitation = so common it’s a normal variant
significant TR usually functional and due to right ventricle enlargement
What causes tricuspid stenosis?
rare
rheumatic heart disease
Describe pulmonary valve diseases
pulmonary stenosis = rare and usually congenital
pulmonary regurgitation = usually functional due to dilated pulmonary artery caused by pulmonary hypertension
What is the key investigation for valve disease and what can it tell you?
echocardiography
- severity of stenosis
- degree of regurgitation
- ventricular size and function
- atrial size
- estimated pulmonary artery pressure
Medical therapy for valve disease
treat heart failure
AF:
- prevent embolism = anticoagulate (warfarin)
- rate control = beta blockers and digoxin
Surgical/interventional options for valve disease
valvotomy (open valve up) - mainly for mitral stenosis, can be for aortic temporarily/palliative
tricuspid valve repair (surgical/percutaneous with balloon)
repair valve surgically - almost always mitral valve
valve replacement:
- mechanical valve
- tissue valve (animal/human)
- TAVI (transcatheter aortic valve implantation)
Compare mechanical vs tissue vs repair vs catheter implanted for valve disease treatment
mechanical = durable but must anticoagulate
tissue = lasts less time, no anticoags unless AF
repair = best if can be done but only mitral, long-lasting, no anticoags, better function
percutaneous implant = only aortic
TAVI = good alternative to standard surgical aortic valve replacement
Factors that increase the risk of valve surgery
age
general physical state and comorbidities
damage already done to the heart - particularly to LV in chronic cases
renal function
cerebral and carotid arteries - these determine risk of stroke
