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CVS > Valvular Defects > Flashcards

Valvular Defects Flashcards

1
Q

What causes aortic stenosis

A

Degeneration - high BP / atherosclerosis = most common >65
Congenital bicuspid (most common in <65)
Rheumatic
- Do ASO titre if suspect
William’s
- Supra-valvular AS

SLE / Paget / infection

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2
Q

What are the DDX of AS

A

HCM
- Usually younger
Aortic sclerosis
Angina

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3
Q

What is the murmur in aortic stenosis

A

Ejection systolic
Radiates to carotid and back
Heard over aortic

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4
Q

What is aortic sclerosis

A

Calcification
Ejection systolic murmur
No radiation
Normal pulse

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5
Q

What are the symptoms of aortic stenosis

A 
Long asymptomatic
Symptoms on increased O2 demand / exertion 
Chest pain
Angina
Syncope
SOB
Dizzy
Leads to HF
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6
Q

What are signs of aortic stenosis

A 
Small volume pulse
Slow rising as blood can't get through in carotid (pulsus tarsus) 
Narrow pulse pressure
Vigourous apex beat 
Soft and split S2
S4 gallop - heard just before S1
- Due to stiff ventricle 
(If S3 think HF) 
Thrill
RH failure - JVP / RV heave 
LV heave
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7
Q

How do you investigate aortic stenosis

A 
Refer for ECHO + doppler ECHO
ECG
- Abnormal in 90% 
- LVH due to overload
- May get P-mitrale, LBBB, AV block 
CXR 
- Valve calcifcation
- Enlarged LV
- Pulmonary congestion

2nd line if inconclusive
Angiogram
Cardiac MI

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8
Q

What does ECHO look at

A 
Cusp mobility
Lv function and hypertrophy
Pressure gradient 
Vegetations 
Calcification
Assess EF
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9
Q

How does ECHO assess EF

A

Haemodynamic assessment
Pressure gradient / flow through valve
Should not have difference
If low EF = very serious

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10
Q

Why do you do angiogram

A

Check carotids before surgery as. might have CAD

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11
Q

How do you treat aortic stenosis and when should you consider Rx even if not symptomatic

What do you avoid

A

Monitor
Can give furosemide
AVOID nitrates / CI as will drop BP and reduce perfusion
Treat as soon as symptomatic or if detonating ECG / >40mmHg pressure gradient / EF <50%

Open Valve replacement or repair = 1st line in the young

TAVI - via femoral (better tolerated in elderly / frail)

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12
Q

What do you do if can’t repair

A

Balloon valvuloplasty

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13
Q

What happens after op

A

Chest drain

Pacing and sensor wires

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14
Q

What are risks of aortic stenosis

A

IE + Embolus if IE
LV hypertrophy - all patients will have
Heart failure

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15
Q

How does LVH and what are the consequences

A

Increased pressure due to stenosis
Backs into pulmonary circulation
Increased O2 demand as more muscle once hypertrophy
Can lead to ischaemia and LV failure

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16
Q

What is CI in aortic stenosis

A

ETT
Nitrates / GTN - if patient has exertional dyspnoea and suspect AS never give
BB as will reduce HR and output

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17
Q

What are the risks of surgery

A 
Infection 
Arrhythmia
MI 
Stroke
Reduced kidney
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18
Q

What causes acute aortic regurgitation

A

IE
Aortic dissection
Chest trauma

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19
Q

What causes chronic aortic regurgitation

A 
Connective tissue = most common (Marfan's or Ehler danlos) 
Congenital bicuspid 
Hypertension
Rheumatic fever
Endocarditis 
RA / SLE
Syphilis
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20
Q

What murmur is in AR and what happens

A

Early diastolic murmur

Diastolic leakage of blood from aorta back into LV
Dilates the heart rather than hypertrophy so get displaced beat

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21
Q

How does AR present

A

If acute = medical emergency

  • Sudden pulmonary oedema
  • Hypotension / shock
  • Can present as MI or dissection
Present like HF / angina
Dyspnoea
Orthopnoea
PND
Palpitations 
Syncope
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22
Q

What are the signs of AR

A 
Large volume collapsing pulse as blood flows back 
- Forceful then disappears 
Wide pulse pressure
Displaced apex
Head nodding with pulse = De Musset
Visible pulsation in nail bed
Femoral pistol shot on auscultation
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23
Q

How do you investigate AR

A 
ECHO = diagnostic 
ECG 
- LVH strain 
CXR - cardiomegaly / hypertrophy / dilated aorta
Angiogram
Ghent criteria for marfan
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24
Q

How do you treat AR

A

If EF >50% = reassure otherwise treat
Reduce systolic
- ACEI + ARB useful esp if Marfan
Vasodilator = very important
- Nifedipine + hydrazine
ECHO 6-12 months
Treat underlying cause
Surgery if symptomatic and severe asymptomatic
- Transcatherer aortic valve implantation
If Marfan may get prophylactic aortic root

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25
Q

When is surgery indicated

A

Severe AR (whole LV filled after one diastole)
Increasing symptoms
Enlarging LV

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26
Q

What are the complications of AR

A

LV has to accommodate SV + regurg volume
If acute poorly tolerate as no time for wall to adapt
Increased EDV and pressure = hypertrophy
HEART FAILURE

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27
Q

What suggests poor outcome

A

EF <50%
CCF >12 months
NHYA Class III or IV

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28
Q

What causes mitral regurgitation (blood back through mitral in systolic contraction)

A

Degeneration
Post MI
IE as vegetation prevent closure (if MR + fever)
Rheumatic but more classically cause stenosis
Connective tissue - Marfan / Ehlor
Mitral valve prolapse
LV dilatation as pulls leaflet apart = functional regurgitation
- Cardiomyopathy
- MS treatment

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29
Q

What are the symptoms of MR

A 
Asymptomatic until LV begins to fail when SV and CO can't be maintained 
Then leads to CCF 
Fatigue
SOB
Palpitations
Oedema
Hypotension
Pulmonary oedema and hypertension
Arrhythmia
Cariogenic shock
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30
Q

What type of murmur in MR

A

Pansystolic murmur
High pitched whistle due to high velocity
Radiates to apex

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31
Q

What are signs of MR

A 
Displaced apex due to dilatation of LV 
Split S2 and reduced S1 (MS has loud S1) 
Pulse is normal or reduced 
AF develops as LA dilates 
RHF develops = JVP + heave
HF signs if develop
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32
Q

How do you investigate MR

A

ECHO - MR severity, flow into pulmonary vein
ECG
CXR - cardiomegaly / calcification
Aniogram

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33
Q

What is shown on ECG and on ECHO

A

LA dilatation so PR >0.12

ECHO

  • MR severity
  • Larger LV and dilated LA
  • EF is often under-estimated as some blood going into LA in systole (so if 55% and 5 goes into LA really 50%)
34
Q

How do you treat acute MR

A 
Reduce preload and after load 
Nitrate
Diuretic 
Inotrope
Na nitroprusside ??
ACEI / BB / spironolactone - if in HF
Treat AF and anti-coagulate 
Surgery if severe
35
Q

What is better for repair

A

Repair better than replacement

36
Q

What are the affects of acute MR

A

Ventricle doesn’t have time to compensate

ESP and EDV decrease to decrease wall tension

37
Q

What happens in chronic MR

A 
EDV and ESV return to normal 
LV hypertrophy to accommodate extra blood
Heart becomes less efficient 
More severe = moer hypertrophy
HEART FAILURE

Surgery if EF falls or significant LV dilatation on ECHO or symptoms
Otherwise treat AF
- Can’t do rhythm as LA dilated

38
Q

What is the most common valve abnormality overall

A

Mitral valve prolapse

  • Very common in young girls
  • As get older AS more common
39
Q

What causes MVP

A 
ASD
PDA
Cardiomyopathy
Turner
Marfan
Osteogenesis imperfecta
WPW
40
Q

What are the symptoms of MVP

A 
Asymptomatic
Aytypical chest pain
Palpitations
Autonomic Sx
Late systolic due to sudden stretch of chordae or prolapsed leaflet
Low volume pulse
41
Q

How do you Dx

A

ECHO

ECG

42
Q

How do you treat MVP

A

BB for palpitation / chest pain

Surgery if severe

43
Q

What are complications of MVP

A

Can progress to MR
Emboli
Arrythmia
Sudden death

44
Q

What causes mitral stenosis

A 
Congenital 
Rheumatic HD !!!!!
Other rheumatic - SLE / RA
Infective endocarditis 
Carcinoid 
- more effects R side of heart but can affect L if mets in lung
45
Q

What is the murmur like in MS

A 
Mid-diastolic
Rumbling
Difficult to hear
- Should be no sound before Lub dub 
- RRRR lub dub
46
Q

What are the symptoms of mitral stenosis

A 
Pulmonary hypertension 
Pulmnary oedema
Heart failure 
SOB
Haemoptysis
Chronic bronchtiis
Fatigue
Palpitations 
Tachycardia - worse on exercise / illness
47
Q

What are the signs of MS

A 
Loud S1 as large force needed to shut 
Tapping apex beat 
Rumbling murmur after 
JVP
RV heave
Diastolic thrill
Malar flush
- Sign of low CO state due to pulmonary HTN = vasodilatation 
Normal pulse - may have low volume
AF - any problem causing LA dilatation 
Signs of pulmonary HTN
48
Q

What arrhythmia is common

A

AF due to LA dilatation

49
Q

How do you Dx MS

A

ECG - RVH / P mitrale (bifid P wave) if sinus and AF if not
CXR - RVH / oedema / LA enlargement
ECHO = diagnostic
Angiogram

50
Q

How do you treat MS

A

Manage AF
Diuretic to reduce preload and afterload and for pulmonary oedema

Valve repalcement = gold standard
- Can be difficult if pulmonary HTN developed

51
Q

What are the complications of MS

A

Tight MV = pressure increases in LA and dilates
Embolization due to LA enlargement
Hoarse voice - LA presses on recurrent laryngeal rare
Bronchial obstruciton / dysphagia
IE
Increased pressure goes into PV and PA = RV hypertrophy
Pulmonary HTN and cor-pulmonale

52
Q

What does severity of valve depend

A

Trans valvular Flow rate

Pressure

53
Q

What causes an ejection systolic murmur

A 
Aortic stenosis
Pulmonary stenosis 
HCM
ASD
Tetrology of fall out
54
Q

What causes pansystolic murmur

A

Mitral regurgitation
Tricuspid regurgitation
VSD

55
Q

What causes late systolic

A

MVP

Coarctation

56
Q

What causes early diastolic

A

Aortic regurgitation

Pulmonary regurgitation

57
Q

What causes Late diastolic

A

Mitral stenosis
Severe aortic regurgitation
Anything obstructing mitral orifice - thrombus / myxoma

58
Q

What causes continuous murmur

A

PDA

59
Q

R sided murmur

A

Do if have time

60
Q

Tricuspid regurgitation

A

Cor pulmonale - pan-systolic

61
Q

How do you describe murmur

A 
SCRIPT 
Site
Character
Radiation
Intensity 
Pitch 
Timing 
Grade 1-6 (1 hard to hear, 6 can hear without stethoscope)V
62
Q

What does regurgitation cause

A

Dilatation

63
Q

What does stenosis cause

A

Hypertrophy

64
Q

What type of surgery for heart valve

A

Usually sternotomy scar (also CABG)
Open heart surgery = remains 1st line if young nd fit
TAVI

65
Q

What type of valve

A

Bio

Mechanical

66
Q

Bio valves

A

10 years
No anti-coagulation
Better in elderly

67
Q

Mechanical valve

A

20 years
Life long anti-coagulation with warfarin
Target INR = 2.5-3.5

68
Q

What are complications of valve

A

Thrombus
Embolism
IE
Haemolysis

69
Q

Where do you hear click in cardiac cycle

A

S1 if mitral

S2 if aortic

70
Q

What causes a 3rd HS

A 
Rapid ventricular emptying 
Physiological if <30
Typically LVF
Dilated cardiomyopathy
Constrictive pericarditis
MR
71
Q

What causes a 4th HS

A

Due to atrial contraction against stiff ventricle (suggest L ventricle hypertrophy)
Aortic stenosis
HOCM
Hypertension

72
Q

What makes a murmur quieter

A

L ventricle systolic dysfunction as reduced flow rate

73
Q

What can you not grade murmur on

A

Loudness

Need ECHO to assess valve function

74
Q

how does valsalva affect murmur

A

Valsalva reduces the peripheral pressure
Heart fills with more blood and hence the chamber opens up
Means the narrowing at the level of the aortic valve is reduced so the murmur is quieter

75
Q

Most common valve defect

A

AS and MR

76
Q

What causes a double impulse apex

A

HOCM due to massive left atrium

77
Q

What can cause valves in R side of heart to stenose

A

Carcinoid syndrome

- If Hx flushing / wheeze / diarrhoea

78
Q

How does it rarely present in L

A

If tumour has mets in lung so go into pulmonary vascular and to L side of heart

79
Q

R side murmur

A

Louder inspiration

80
Q

L side murmur

A

Louder expiration

81
Q

What can cause clubbing

A

All congenital heart
- Tetrology, ASD, VSD, PDA
IE

CVS (30 decks)

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