Valve Diseases - Clinical Presentation

Question 1

Outline the cause, pathophysiology, signs & symptoms for Aortic stenosis

Answer 1

Aetiology;

• Calcification
  
  • Bicuspid valve (middle age)
  • Normal valve (senile)
• Rheumatic Heart Disease
• Impeded blood flow
  
  • Ejection systolic murmur [aortic area, radiates to carotids]
  • Ejection click [pliable valve]
  • Thrill [palp. murmur]
  • **Slow rising pulse **+ narrow pulse pressure [110/90]
  • **Syncope **[fixed cardiac output]
• ⇒ inc AFTERLOAD ⇒ LV hypertrophy
  
  • Heavy non-displaced apex beat
  • LV heave
  • **​Angina - **Inc demand, low supply [low aortic pressure]
  • S4 [stiff ventricles]
• ⇒ inc** End-diastolic LV pressure** & volume
  
  • ⇒ Back pressure ⇒ LA dilatation ⇒ AF & CCF
  • ⇒ LV dilatation ⇒ Failure

Symptoms;

1. Angina [LV hypertrophy + inc afterload]
2. **Syncope **[fixed cardiac output]
3. **CHeart failure **[dilatation]
4. ​Dyspnoea

• Paradoxical/ reverse splitting of 2nd heart sound
  
  • Normally S₂ = A₂..then..P₂… [P2 moves left on inspiration nearer to A2]
  • S₂ = P₂..then..A₂… [P2 moves left on inspiration, further from A2]
    
    • LH slowed [Aortic stenosis or LBBB]
    • RH sped [tricuspid regurg (blood can exit RV in 2 places fast)]

Question 2

Outline the cause, pathophysiology, signs & symptoms for Aortic regurgitation

Answer 2

• Acute; IE, trauma, aortic dissection
• Chronic; Congential, connective tissue disorder (marfan’s), rheumatic heart disease

Pathophysiology;

• Blood flows back during diastole
  
  • **​Early diastolic murmur **[tricuspid area, sitting forward, expiration & hold]
  • Syncope, CCF
• ⇒** Low diastolic aortic pressure** ⇒** ↑LV SV**
  
  • Angina [↓pressure]
  • **Wide pulse-pressure **[140/40]
  • Collapsing water-hammer pulse
• ⇒ LVH
  
  • ​Displaced, hyperdynamic beat

Symptoms;

• Dyspnoea, orthopnea, PND
• Angina [Coronary perfusion occurs during diastolly, low diastolic aortic pressure due to regurg = low perfusion]
• Syncope, CCF

SIGNS;

• Austin Flint murmur - aortic regurg blocks mitral valve ⇒ mitral stenosis rumbling diastolic murmur
• Corrigan’s sign - carotid pulsation
• de Musset’s sign - head nodding with HR
• Quincke’s sign - capillary pulsations in nail bed
• Duroziez’s sign - finger compressing femoral artery, listen 2cm proximal for systolic murmur, 2cm distal for diastolic murmur
• Traube’s sign - pistol shot sound

Corrigan’s carotid nodded at de Musset while Traube shot his pistol @ Quincke’s nailbed while Duroziez heard a femoral murmur

Question 3

Outline the cause, pathophysiology, symptom & signs for Mitral stenosis

Answer 3

20-yrs post Rheumatic Heart Disease

• Thickening & immobility of the valve leaflets **⇒ **obstruction of blood flow
  
  • ​Loud palpable S1
  • Opening snap
  • Rumbing mid-diastolic murmur
    
    • Apex with bell + lying on left + expiration
    • Pre-systolic accentuation
  • Low-volume pulse
• ↑LA pressure ⇒ eventual dilatation
  
  • Atrial fibrilation
  • **Thromboembolism **⇒ stroke etc
• ⇒ Pulmonary hypertension
  
  • Pulmonary oedema
  • ⇒ vasoconstriction ⇒** Haemoptysis**
• ⇒ RV hypertrophy
  
  • Parasternal heave
  • ​⇒ dilatation ⇒ RH failure

Symptoms (when orifice ²);

• Dyspnoea, orthopnea, PND
• Chest pain, palpitations

Question 4

Outline the cause, pathophysiology, symptom & signs for Mitral regurgitation

Answer 4

Causes;

• Mitral valve prolapse
• Chordae tendineae/ papillary muscle
• Acute cause: Infective endocarditis

Pathophysiology;

• **Blood flow back into LA **during systole
  
  • Apex pansystolic murmur ⇒ axilla
  • Quiet S₁ [valve doesnt properly shut]
• Acute - regurgitated blood causes
  
  • LA pressure increases ⇒ pulmonary congestion
    
    • Loud palpable P2
    • Pulmonary oedema
    • CCF
  • **LV volume overload **[↑blood: normal + re-entering regurgitated] ⇒ ↑SV [frank]
• Chronic [compensated ⇒ uncompensated & CCF]
  
  • **LV hypertrophy **[maintain output with volume overload] ⇒ dilatation & failure
    
    • ​Displaced hyperdynamic apex
  • LA dilatation [↓pulmonary pressure]
    
    • AF
• Symptoms
  
  • ​Dyspnoea, orthopnea, PND