Valve disease 2 Flashcards
What is aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps
Aortic regurgitation epidemiology
- ends to present between the fourth and sixth decades of life. The prevalence of aortic regurgitation increases with advancing age.
- M>F
- Severe disease is seen in < 1% of the population.
What are the causes/ RFs of chronic aortic regurgitation (CAR)?
- Bicuspid aortic valve
- Rheumatic fever
- Infective endocarditis
- Connective tissue disorders
- Aortic dissection + aneursym
What is the pathophysiology of AR?
- Blood leaks from aorta into LV > ventricular BV increases > Increases SV
- More blood pumped out of heart per squeeze requires more pressure so Sytolic BP increases but diastolic BP decreases
- High systolic + low diastolic known as hyperdynamic circulation
- Overtime increase in BV in LV causes it to undergo ventricular hypertrophy
What do patients with hyperdynamic circulation have?
Bounding pulses / water hammer puleses
What do you find on the physical exams for AR?
- Wide pulse pressure: most sensitive
- Hyperdynamic and displaced apical impulse
- Early decrescendo murmur: due to blood flowing back into LV
- Soft S1 and S2
- Apex beat is displaced laterally
What is the natural history of AR?
Asymptomatic until 4th or 5th decade
Rate of Progression: 4-6% per year
Progressive Symptoms include:
Dyspnoea: exertional, orthopnea, and paroxsymal nocturnal dyspnea
Palpitations: due to increased force of contraction and ectopics
Symptoms of AR
- Dyspnoea
- Chest pain
- Palpitations
- Syncope
How can we evaluate AR?
- CXR: enlarged cardiac silhouette and aortic root enlargement
- ECHO: Allows evaluation of the AV and aortic root with measurements of LV dimensions and function (cornerstone for decision making and follow up evaluation)
How do we manage AR?
- General: consider IE prophylaxis
- Medical: Vasodilators (ACEI’s potentially improve stroke volume and reduce regurgitation but indicated only in CCF or HTN
- Root replacement or replacement of valve
- Serial Echocardiograms: to monitor progression.
- Surgical Treatment: Definitive Tx
What are the indications of surgery in AR?
ANY Symptoms at rest or exercise
Asymptomatic treatment if:
EF drops below 50% or LV becomes dilated > 50mm at end systole
Complications of AR
- Heart failure
- Pulmonary oedema
- Cardiogenic shock
What is mitral stenosis (MS)?
Mitral stenosis is a narrowing of the mitral valve orifice, making it difficult for blood to flow from the left atria to the left ventricle.
What is the normal mitral valve area?
4-6 cm2
When do transmitral gradients and symptoms begin?
areas less than 2 cm2
What is the predominant cause of mitral stenosis?
Rheumatic carditis
decreasing due to a reduction of rheumatic heart disease.
What are the causes of mitral stenosis?
- Rheumatic heart disease: 77-99% of all cases
- Infective endocarditis: 3.3%
- Mitral annular calcification: 2.7%
- Congenital MS
- Fabrys disease
After this flashcard look at slide 59 onwards of the valvular heart disease powerpoint
MS pathophysiology
MV dont open - LV dont fill
LA BV increases - higher pressures in LA - causes a snap when valve opens followed by disatolic rumble through smaller opening
What does a constant elevation in BV and pressure in the left atrium do?
Causes LA to dilate > allow blood back up into pulmonary circulation
Leads to Pulmonary congestion and oedema
Leads to PHT + Right sided HF
Effects of MS
- Progressive Dyspnoea (70%): LA dilation > pulmonary congestion (reduced emptying)
-worse with exercise, fever, tachycardia, and pregnancy - Increased Transmitral Pressures: Leads to left atrial - enlargement and atrial fibrillation.
- Right heart failure symptoms: due to Pulmonary venous HTN
- Hemoptysis: due to rupture of bronchial vessels due to elevated pulmonary pressure
Signs of MS
- Loud S1 snap
- Mid diastolic murmur
- A fib
- Signs of right sided HF
- Pulmonary HT
What is the natural history of MS?
Mild MS: 10 years after initial RHD insult
Moderate: 10 years later
Severe: 10 years later
What is the mortality of MS due to?
Due to progressive pulmonary congestion, infection, and thromboembolism.
What are the physical signs of mitral stenosis?
- prominent “a” wave in jugular venous pulsations: Due to pulmonary hypertension and right ventricular hypertrophy
- Signs of right-sided heart failure: in advanced disease
- Mitral facies: When MS is severe and the cardiac output is diminished, there is vasoconstriction, resulting in pinkish-purple patches on the cheeks
What are the heart sounds of ms?
Diastolic murmur:
Low-pitched diastolic rumble most prominent at the apex.
Heard best with the patient lying on the left side in held expiration
Intensity of the diastolic murmur does not correlate with the severity of the stenosis
How do we evaluate MS?
ECG: may show atrial fibrillation and LA enlargement
CXR: LA enlargement and pulmonary congestion. Occasionally calcified MV
ECHO: The GOLD STANDARD for diagnosis. Asses mitral valve mobility, gradient and mitral valve area
What is the medical management of MS?
- Medications: MS like AS is a mechanical problem and medical therapy does not prevent progression
- B-blockers, CCBs, Digoxin which control heart rate and hence prolong diastole for improved diastolic filling
- Duiretics for fluid overload
How else can you manage MS?
Serial echocardiography:
Mild: 3-5 years
Moderate:1-2 years
Severe: yearly
What are the indications for mitral valve replacement?
ANY SYMPTOMATIC Patient with NYHA Class III or IV Symptoms
Asymptomatic moderate or Severe MS with a pliable valve suitable for PMBV
Complications of MS
- Pulmonary hypertension and right sided heart failure: as blood backs up in the pulmonary system
- Atrial fibrillation
- Thrombus formation: due to AF causing blood to stagnate. These thrombi can make it into the systemic circulation
- Stroke: due to thrombus embolising to brain
