Valve pathologies Flashcards
What investigations should be conducted into mitral stenosis and state some potential findings:
CXR
- enlarged left atrium
- Dilation of pulmonary vessels
ECG
- Bifib - p-wave (long closure of the left atrium)
- AF
- Right axis deviation
Echocardiogram
- assess degree of dilation
- also assess for tricuspid regurgitation due to back log
- TOE - assess thrombus formation
What are the symptoms of mitral stenosis:
Dyspnoea Chronic bronchiolitis Dysphagia Hoarseness - compression on laryngeal nerve Fatigue
What is the murmur that can occur on the right side of the heart due to mitral stenosis affecting the pulmonary valve?
Graham Steel Murmur
- early diastolic murmur due to pulmonary regurgitation
What is the management of mitral stenosis?
Control AF
+
VTE prophylaxis
Diuretics
Surgically:
- Trans-septal Balloon valvotomy
- Open valvotomy
- Mitral valve replacement
What are some signs of mitral regurgitation?
Laterally displaced/ Hyperdynamic apex beat
- this is a sign of severe MR
Systolic thrill
Soft S1 sound
Signs of pulmonary congestion
AF
What are some causes of mitral regurgitation?
Post M.I/ Ischemia
Annular calcification of valvular apparatus
- seen in elderly
Iatrogenic
- valvuloplasty for mitral
Autoimmune
- RA
- SLE
Infective endocarditis
Dilated cardiomyopathy
What investigations are done into mitral regurgitation?
CXR
- left ventricular hypertrophy
Echocardiogram with doppler
- assess leaflets
- chordae tendinea
- papillary muscle function
Cardiac Catherization
- uses dye to see retrograde flow
*cardiac catherization is usually diagnostic
What is the management for mitral regurgitation?
Medication:
- ACE
- Diuretics
Surgical:
valve replacement before LV function is completely lost
What are the causes of aortic stenosis?
Calcific aortic valvular disease
- immune mediated calcification
- common in males
- elderly age
- high LDLs
Rheumatic fever
Bicuspid calcification
Other causes:
- CKD
- Paget’s disease
When will some with aortic stenosis start to develop symptoms?
Once reduced to 1/3rd size
What pathology causes a displaced apex beat?
Dilation of the heart
- dilated cardiomyopathy
- Mitral valve regurgitation (usually secondary to the dilated ventricle)
- Aortic regurgitation
What signs are seen in aortic stenosis?
Slow rising pulse
Narrow pulse pressure
Left ventricular heave
Aortic thrill
What may occur with regards to S2 heart sounds in aortic stenosis? and what does this indicate?
Reverse splitting
- only splitting is heard during expiration
*this is because during expiration the A2 in aortic stenosis takes longer to shut (it should be other way round) and in inspiration the P2 catches up to match the A2 - thus the splitting disappears
**this is a sign of severe disease
What is the murmur heard in aortic stenosis?
Crescendo decrescendo Systolic ejection click
- radiating to the carotids
- low pitched
What are the main differentials for aortic stenosis?
Obstructive cardiomyopathy
Aortic sclerosis (no radiation to carotids)
What is the treatment for aortic valve stenosis?
Aortic valve replacement
Valvuloplasty
- balloon dilation
TAVI
- used for those who are not suitable for surgical replacement of aortic valve
What are the causes of aortic regurgitation?
Acute:
- infective endocarditis
- rheumatic fever
- Aortic dissection
Chronic:
- long standing hypertension
- RA
- ankylosing spondylitis
- Syphilis
What are the signs of aortic regurgitation?
Bounding pulse/ collapsing pulse
Wide pulse pressure
Capillary pulsation
Head nodding
Pistol shot femorals
- a large band heard over the femoral with each heart beat
Hyperdynamic Apex beat
- which is often laterally positioned
What is the murmur heard in aortic regurgitation?
Early diastolic
- left sternal edge
*heard better when patient sits up and exhales and holds
What is the murmur which can occur in severe aortic regurgitation and why does it occur?
Austin flint murmur
Jet of blood back in can imping on the anterior mitral cusp causing a mid-diastolic murmur
What tests are done into aortic regurgitation?
CXR
- ventricular enlargement
Echocardiography
- diagnostic
Cardiac catherization
- this is to assess severity and perfusion of coronary using dyes.
- important for surgery
What is the treatment of aortic regurgitation?
Treat underlying cause
Hypertension management
- ACE inhibitor
+
- beta blockers
Surgical replacement of valves
What valvular pathology may be seen with carcinoid syndrome?
Tricuspid stenosis
What is the murmur heard with tricuspid stenosis?
Mid-diastolic murmur
- heard best over the lower left sternal edge
List some causes for tricuspid regurgitation:
High pulmonary pressures
- cor-pulonale
Infective endocarditis
Rheumatic fever
Epstein’s anomaly
What is the imaging of choice in suspected endocarditis of a mechanical heart valve?
TOE
Which bacteria may not grow in cultures but can cause infective endocarditis?
Chlamydia species
Legionella
Bartonella
*if blood cultures are negative it is usually worth searching for these
What are the associated complications with pregnancy and prosthetic valves?
Biological valves:
- preferred as no anticoagulation needed
- wear down very fast in women of child baring age
Mechanical:
- need warfarin which is teratogenic so most switch to LMWH.
- increased mortality of 1-4% in women with mechanical heart valves
What parameters are used to assess the severity of aortic stenosis?
Area of annulus
Peak velocity
Pressure gradient
Calcification
How is aortic stenosis managed in adults?
Replacement
- either open valve replacement
or
- TAVI
Inter-arterial balloon septostomy
*repair is not done in adults. only children.
Where would you see a mitral valvotomy scar?
Laterally thoracotomy scar
Would you hear a third heart sound with mitral stenosis?
No
3rd heard sound is associated with rapid ventricular filling.
this can be a useful indicator between mitral stenosis and mitral regurgitation
if someone collapses and a whooshing noise was heard by the patient, what is the likely cause?
Aortic stenosis
What are the three parameters which are measured in order to diagnose an aortic stenosis?
Velocity
(decreased narrowing increases pressure)
Pressure gradient
(pressure between the aorta and the ventricle)
Diameter of stenosis
(<2cm) (<1cm is severe)
+/-
Calcification levels
What are the indications for surgery in Aortic stenosis?
Symptomatic
Congestive heart failure
> 40mmHg gradient pressure
What medication are people put on following CABG?
Aspirin Clopidogrel Statin ACE Beta blocker \+/- Eplerenone
