Valve Disease Flashcards
What is aortic stenosis?
- Obstruction of blood flow across the aortic valve due to pathological narrowing.
- It is a progressive disease.
- Can be congenital or acquired.
How does aortic stenosis present?
- Presents after a long subclinical period with the following symptoms:
- Decreased exercise capacity
- Exertional chest pain (angina)
- Syncope
- Heart failure
What are the causes of congenital aortic stenosis?
- Bicuspid aortic valve
- Subaortic (e.g. fibromuscular) ring
- Supravalvular (e.g. Williams syndrome)
What are the causes of acquired aortic stenosis?
- Senile calcification is the most common cause of aortic stenosis.
- Rheumatic heart disease.
What are the risk factors for developing aortic stenosis?
- Age >60
- Congenitally bicuspid aortic valve
- Rheumatic heart disease
- Chronic kidney disease
Which investigations would be carried out to diagnose aortic stenosis?
- Transthoracic echocardiogram
- ECG
- Cardiac MRI
- Cardiac cathaterisation
- ECG exercise stress testing
What are the signs of aortic stenosis?
- Slow rising pulse with narrow pulse pressure
- Heaving, non-displaced apex beat
- Left ventricular heave
- Aortic thrill
- Ejection systolic murmur
Describe the pathophysiology of aortic stenosis.
- Causes increased afterload.
- Results in failure to increase cardiac output during exertion.
- Due to increased myocardial oxygen requirement, it causes progressive left ventricular hypertrophy.
- Due to decreased myocardial oxygen delivery, it causes decreased systemic coronary flow.
What is aortic regurgitation?
- Diastolic leakage of blood from the aorta into the left ventricle.
- Can be acute or chronic.
- Occurs due to inadequate coaptation of valve leaflets resulting from either intrinsic valve disease or dilation of the aortic root.
- Can remain asymptomatic for decades before patients present with irreversible myocardial damage.
What are the presenting symptoms of aortic regurgitation?
- Exertional dyspnoea
- Orthopnoea
- PND
- Palpitation
- Angina
- Syncope
What are the risk factors for developing aortic regurgitation?
- Bicuspid aortic valve
- Rheumatic fever
- Endocarditis
- Connective tissue disease
Which investigations would be used to diagnose aortic regurgitation?
- ECG
- CXR
- Echo
What are the causes of acute aortic regurgitation?
- Infective endocarditis
- Ascending aortic dissection
- Chest trauma
What are the causes of chronic aortic regurgitation?
- Congenital
- Connective tissue disorders (Marfan’s; Ehlers-Danlos)
- Rheumatic fever
- Rheumatoid arthritis
- Hypertension
- Osteogenesis imperfecta
- Syphylitic aortitis
Describe the pathophysiology of aortic regurgutation.
- Due to the diastolic reflux of blood back into the left ventricle, there is a volume overload.
- Can cause left ventricular dilation.
What is mitral stenosis?
- Narrowing of the mitral valve orifice.
- Normal mitral valve orifice is ~5-6cm. Symptoms usually begin when orifice becomes <2cm.
What are the signs of mitral stenosis?
- Malar flush on cheeks (due to decreased cardiac output).
- Low volume pulse.
- Right ventricular heave.
Which investigations would be used to diagnose mitral stenosis?
- ECG
- CXR
- Trans-thoracic echo
What are the risk factors for developing mitral stenosis?
- Streptococcal infection
- Femle sex
- Serotogenic medications and ergot medications
- Ergot alkaloids used to treat throbbing headaches or migraines
Describe the pathophysiology of mitral stenosis.
- Obstruction of normal transmitral flow.
- In order to maintain flow, there is an increased pressure in the left atrium, which leads to dilation of the left atrium.
- Due to increased pulmonary venous pressure, there is pulmonary congestion.
- Secondary to mitral stenosis:
- Right heart failure
- Tricuspid regurgitation
What is mitral regurgitation?
- Backflow through the mitral valve during systole.
- The mitral valve apparatus consists of anterior and posterior leaflets, chordae tendinea, anterolateral and posteromedial papillary muscles and mitral annulus. Any abberations
What are the possible causes of mitral regurgitation?
- Leaflets - rheumatic or degenerative
- Chordae tendinea - myxomatous (floppy mitral valve syndrome)
- Papillary muscles - ischaemic or functional
- Annulus - congenital or infective (for example endocarditis)
What are the risk factors for developing mitral regurgitation?
- Mitral valve prolapse
- Hx of rheumatic heart disease
- Infective endocarditis
- Hx of cardiac trauma
What are the signs of mitral regurgitation?
- AF
- Displaced, hyperdynamic apex
- Pansystolic murmur at apex radiating to axilla
- The more severe these signs, the larger the left ventricle
How does mitral regurgitation present?
- Dyspnoea
- Fatigue
- Palpitations
- Symptoms of the causative factor
What is tricuspid stenosis?
Defined by an abnormally elevated pressure gradient across the tricuspid valve during diastolic filling of the right ventricle.
How does tricuspid stenosis present?
- Fatigue
- Ascites
- Oedema
Which investigations would be used to diagnosi tricuspid stenosis?
- ECG
- CXR
- Trans-thoracic echo
- Doppler transthoracic echo
What are the risk factors for developing tricuspid stenosis?
- Group A streptococcal pharyngitis
- Metastatic carcinoid tumours
- Artificial tricuspid valve
- IV drug use
What are the signs of tricuspid stenosis?
- Opening snap.
- Early diastolic murmur heard at the left sternal edge in inspiration.
- AF can also occur.
What is tricuspid regurgitation?
- Occurs when blood flows backwards through the tricuspid valve.
- Caused by:
- Rheumatic fever
- Secondary to right heart dilatoin
- Secondary to pulmonary hypertension
How does tricuspid regurgitation present?
- Fatigue
- Hepatic pain on exertion
- Ascites
- Oedema
- Symptoms of the causative condition
What investigations would be used to diagnose tricuspid regurgitation?
- Transthoracic echo
- ECG
- LFTs
- Serum urea and creatinine
What are the risk factors for tricuspid regurgitation?
- Left-sided heart failure
- Dilated tricuspid annulus
- Rheumatic heart disease
- Permanent pacemaker
What are the signs of tricuspid regurgitation?
- Right ventricular heave
- Pansystolic murmur
- Heard best at lower sternal edge in inspiration
- Pulsatile hepatomegaly
- Jaundice
What is pulmonary stenosis?
- Obstruction of the blood flow from the right ventricle into the pulmonary bed, resulting in a pressure gradient >10mmHg across the pulmonary valve during systole.
- It is commonly associated with other factors.
How would pulmonary stenosis present?
- Dyspnoea
- Fatigue
- Oedema
- Ascites
Which investigations would be used to diagnose pulmonary stenosis?
- ECG
- CXR
- Echo with doppler
- Hb
- Hct
What are the risk factors for developing pulmonary stenosis?
- Black ethnicity
- Noonan syndrome
- LEOPARD syndrome
- Alagille syndrome
What are the signs of pulmonary stenosis?
- In mild stenosis, there is ejection click and ejection systolic murmur (which radiates to the left shoulder).
- In severe stenosis the murmur becomes much longer and obscures A2.
What is pulmonary regurgitation?
Backflow of blood through the pulmonary valve caused by any disease of the left side of the heart which causes pulmonary hypertension.
How would pulmonary regurgitation present?
- Rarely symptomatic but patient may have dyspnoea.
- Decreased exercise tolerance
- Diastolic murmur
- Orthopnoea
Which investigations would be used to diagnose pulmonary regurgitation?
- ECG
- Trans-thoracic doppler echo
- CXR
What are the key diagnostic factors for pulmonary regurgitation?
- Presence of risk factors
- Decrescendo murmur in early diastole at the left sternal edge
