Valves Flashcards
When do you get symptoms with mitral stenosis?
Normal valve orifice is 4-6cm2 - symptoms when it decreases to
What are the symptoms of mitral stenosis?
Dyspnoea Palpitations Fatigue Chest pain Haemoptysis and cough
Signs of mitral stenosis x6
Malar flash Low-volume pulse Tapping apex - non-displaced Opening snap Loud s1 Rumbling mid-diastolic murmur (best heard in expiration with patient on their left side)
What are s1 and s2?
S1 is closure of mitral and tricuspid valves
S2 is closure of aortic and pulmonary valves
When do you get a loud s1
When there is still a lot of pressure on the valves when they come to close
Usually blood has flown into the ventricles and so pressure has decreased
In mitral stenosis - not as much blood can get through therefore no gradual decrease in flow towards end of diastole and valves therefore still at maximum excursion
Also if shortened PR interval and tachycardia - diastolic filling time is shortened
When do you get a soft s1?
When diastolic filling time is prolonged (long PR interval)
Or when mitral valve is incompetent - doesn’t close properly - mitral regurge
When do you get a soft s2
Aortic stenosis because calcification of the valve
When do you get loud a2?
Tachycardia, hypertension
When do you get loud and soft p2?
Pulmonary hypertension - loud
Pulmonary stenosis - soft
When do you get splitting of s2?
Wide splitting occurs inRBBB, pulmonary stenosis, mitral regurge and ventricular septal defect
Fixed wide splitting - atrial septal defect
Reversed splitting - a2 following p2 - occurs in LBBB, aortic stenosis, right ventricular pacing
What is s3 and when heard?
May occur just after s2
From the impact of inflowing blood against a distended or incompliant ventricle in mid-diastole
Best heard with bell over Apex
When do you get high pitched s3?
Constrictive pericarditis or restrictive cardiomyopathy
Occurs early
When do you get s4?
Occurs just before s1 - represents atrial contraction against a ventricle made stiff by any cause - therefore atria are ejecting blood into a ventricle which cannot expand any further
Eg aortic stenosis or HTN
When do you get an ejection systolic click?
Early in systole with bicuspid aortic valves and if hypertension
When do you get mid-systolic click
Mitral prolapse
When do you get opening snap?
Precedes mid-diastolic murmur of mitral or tricuspid stenosis
Indicates a pliable valve - that can only open partially during rapid filling of mid-diastole
Signs of more severe mitral stenosis
Longer murmur
Closer opening snap is to s2
ECG in mitral stenosis
P mitrale (broad and bifid wave) Can get RVH and progressive RAD
CXR in mitral stenosis
Left atrial enlargement
Pulmonary oedema
Management of mitral stenosis
If in AF - warfarin
Diuretics to decrease preload and pulmonary congestion
If sill needed - valve surgery
Complications of mitral stenosis
Pulmonary hypertension
Emboli
Pressure from large LA on nearby structures (recurrent laryngeal, bronchus, oesophagus)
Causes of mitral stenosis
Mostly rheumatic fever
Rarely congenital or mucopolysaccharidoses
Causes of mitral regurge
Functional - LV dilatation
Chordae, annulus or papillary muscle problem
RF, IE
Cardiomyopathy, congenital
Symptoms of mitral regurge
Dyspnoea
Fatigue
Palpitations
Signs of mitral regurge x7
AF Displaced apex RV heave Soft s1 Split s2 Loud p2 Pansystolic murmur - radiate to Scilla
ECG in mitral regurge
AF
P mitrale if in sinus rhythm
LVH
CXR in mitral regurge
Big LA and LV
Pulmonary oedema
Management of mitral regurge
Control rate if fast AF
Anticoagulation if AF
Diuretics
Surgery if needs be
Causes of mitral valve prolapse and incidence
Most common valve abnormality - 5% prevalence
Causes - alone or with other heart defects
Symptoms of mitral prolapse
Asymptomatic
Or
Chest pain and palpitations (can also get autonomic symptoms - anxiety, panic attack)
Signs of mitral prolapse
Mid systolic click and/Or a late systolic murmur
Complications of mitral prolapse
Mitral regurge
Emboli
Arrhythmias
Sudden death
Management of mitral prolapse
Beta-blockers can help with pain and palpitations
Surgery if bad
Causes of aortic stenosis
Young - bicuspid valve
Old - senile calcification
Presentation of aortic stenosis
Triad: syncope, angina and heart failure - usually after 60
Also dizziness
Signs of aortic stenosis x8
Slow rising pulse with narrow pulse pressure Heaving non-displaced apex beat LV heave Aortic thrill Ejection systolic murmur (radiates to carotid) Splitting of s2 - severe then reversed Quiet a2 Ejection click or s4
ECG in aortic stenosis
P mitrale
LVH
LAD - left ant hemiblock, LBBB or complete heart block
CXR in aortic stenosis
LVH
Post-stenotic dilatation of aorta
Management in aortic stenosis
Surgery - without it origin sous is poor
What is aortic sclerosis and signs?
Senile degeneration of valve
Ejection systole murmur but no radiation and normal pulse and normal s2
Causes of aortic regurge
Acute - IE and more
Chronic - many different systemic things
Symptoms of aortic regurge
Dyspnoea Orthopnoea PND Palpitations Syncope Angina
Signs of aortic regurge
Collapsing pulse
Wide pulse pressure
Displaced hyper dynamic apex beat
Early diastolic murmur (expiration with patient sitting forward)
Eponymous signs in aortic regurge DM do muscular Co cow Qu queens D dance T to A abba
De Mussets - head nodding with heart beat
Corrigans sign - carotid pulsation
Quinckes sign - capillary pulsation in nail bed
Duroziezs sign - groin pressing on femoral artery - 2cm distal to stethoscope - diastolic murmur
Traubes sign - pistol shot over femoral arteries
Austin Flint - severe AR
ECG in aortic regurge
LVH
CXR in aortic regurge
Cardiomegaly
Dilated ascending aorta
Pulmonary oedema
Management of aortic regurge
Reduce systolic HTN - ace-I
Surgery if bad
Causes of tricuspid regurge
Functional - RV dilatation due to pulmonary hypertension caused by LVF
Rheumatic fever
IE (IVDU)
Conventional
Symptoms of tricuspid regurge
Fatigue Hepatic pain Ascites Oedema Dyspnoea + orthopnoea if due to LVF
Signs in tricuspid regurge
Giant v waves and prominent y descent in JVP
RV Heave
Pan systolic murmur
Jaundice, hepatomegaly (pulsatilla) and ascites
Management of tricuspid regurge
Treat underlying cause
Diuretics
Replace valve
Causes of tricuspid stenosis
Main cause is rheumatic fever
Also get mitral or aortic valve disease
Symptoms of tricuspid stenosis
Fatigue, ascites, oedema
Signs of aortic stenosis
Giant a wave and slow y descent in JVP
Opening snap
Early diastolic murmur
Causes of pulmonary stenosis
Usually congenital
Can also be RF
Symptoms of pulmonary stenosis
Fatigue, ascites, oedema and dyspnoea
Signs of pulmonary stenosis
Ejection click
Ejection systolic murmur
Widely split s2
ECG in pulmonary stenosis
P pulmonale - wide p wave
RVH
Rbbb
Causes of pulmonary regurge
Causes of pulmonary HTN
Early diastolic murmur
Aortic regurge
Displaced apex beat
Aortic or mitral regurgitation
Ejection systolic murmur
Aortic stenosis
Mid-diastolic murmur
Mitral stenosis
Pan systolic murmur
Mitral regurge
Collapsing pulse
Aortic regurge
Slow rising pulse
Aortic stenosis
What valvuloplasty and when used?
In mitral or pulmonary stenosis
Balloon catheter inserted across the valve and inflated
What is valvotomy
Cutting of stenosed valve
Difference between mechanical valves and xenografts
Mechanical more durable but need lifelong anticoagulation
Complications of prosthetic valves
Emboli IE Haemoptysis Structural valve failure Arrhythmias
When do you consider cardiac transplant
When severely curtailing quality of life
And life expectancy not beyond 6-12 months
Fever + new murmur
IE until proven otherwise
Chief cause of IE on normal valve
Staph aureus
Acute infection with acute heart failure
Risk factors for IE if normal valves
Dermatitis IVDU Renal failure Organ transplantation DM Post op wounds
Cause of IE in abnormal valves and presentation
Strep viridans
Sub acute course!!
Two types of Endocarditis on prosthetic valves
Early - during surgery + poor prognosis
Late - haematogenous
Septic signs of IE
Septic - fever, rigours night sweats, malaise, weight loss, anaemia, splenomegaly
Cardiac signs of IE
New murmur or changing pre-existing murmur
Abscess can cause prolonged PR
Immune complex deposition signs in IE
Vasculitis
Microscopic haematuria
Roth spots - boat shaped retinal haemorrhages
Splinter haemorrhages
Oslers nodes (painful pulp infarcts in fingers or toes)
Embolic signs of IE
Abscesses (brain, heart, spleen, kidney, gut - lung if right sided)
Or skin - janeways lesions
Major criteria for diagnosis IE - duke criteria
Positive blood culture (2 separate cultures of persistently +ve)
Endocardium involved - positive echo (vegetation, abscess, dehiscence of prosthetic valve) or new valve regurgitation
Minor criteria needed for IE diagnosis - duke criteria
Predisposition Fever >38 Vascular/immunological signs Positive blood culture - doesn't meet major criteria Echo that doesn't meet major criteria
Criteria needed for diagnosis
2 major
1 major 3 minor
All 5 minor
Anaemia in IE
Normochromic, normocytic
Neutrophillia
High ESR and CRP
Treatment of IE
Antibiotics
When surgery in IE
If heart failure
Valvular obstruction
Repeated emboli
Abscess
Prevention of IE
No antibiotic prophylaxis recommended for IE
