Valvular Defects Flashcards
What causes aortic stenosis
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
What are the DDX of AS
HCM
- Usually younger
Aortic sclerosis
Angina
What is the murmur in aortic stenosis
Ejection systolic
Radiates to carotid and back
Heard over aortic
What is aortic sclerosis
Calcification
Ejection systolic murmur
No radiation
Normal pulse
What are the symptoms of aortic stenosis
Long asymptomatic Symptoms on increased O2 demand / exertion Chest pain Angina Syncope SOB Dizzy Leads to HF
What are signs of aortic stenosis
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
How do you investigate aortic stenosis
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
What does ECHO look at
Cusp mobility Lv function and hypertrophy Pressure gradient Vegetations Calcification Assess EF
How does ECHO assess EF
Haemodynamic assessment
Pressure gradient / flow through valve
Should not have difference
If low EF = very serious
Why do you do angiogram
Check carotids before surgery as. might have CAD
How do you treat aortic stenosis and when should you consider Rx even if not symptomatic
What do you avoid
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)
What do you do if can’t repair
Balloon valvuloplasty
What happens after op
Chest drain
Pacing and sensor wires
What are risks of aortic stenosis
IE + Embolus if IE
LV hypertrophy - all patients will have
Heart failure
How does LVH and what are the consequences
Increased pressure due to stenosis
Backs into pulmonary circulation
Increased O2 demand as more muscle once hypertrophy
Can lead to ischaemia and LV failure
What is CI in aortic stenosis
ETT
Nitrates / GTN - if patient has exertional dyspnoea and suspect AS never give
BB as will reduce HR and output
What are the risks of surgery
Infection Arrhythmia MI Stroke Reduced kidney
What causes acute aortic regurgitation
IE
Aortic dissection
Chest trauma
What causes chronic aortic regurgitation
Connective tissue = most common (Marfan's or Ehler danlos) Congenital bicuspid Hypertension Rheumatic fever Endocarditis RA / SLE Syphilis
What murmur is in AR and what happens
Early diastolic murmur
Diastolic leakage of blood from aorta back into LV
Dilates the heart rather than hypertrophy so get displaced beat
How does AR present
If acute = medical emergency
- Sudden pulmonary oedema
- Hypotension / shock
- Can present as MI or dissection
Present like HF / angina Dyspnoea Orthopnoea PND Palpitations Syncope
What are the signs of AR
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
How do you investigate AR
ECHO = diagnostic ECG - LVH strain CXR - cardiomegaly / hypertrophy / dilated aorta Angiogram Ghent criteria for marfan
How do you treat AR
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
When is surgery indicated
Severe AR (whole LV filled after one diastole)
Increasing symptoms
Enlarging LV
What are the complications of AR
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
What suggests poor outcome
EF <50%
CCF >12 months
NHYA Class III or IV
What causes mitral regurgitation (blood back through mitral in systolic contraction)
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
What are the symptoms of MR
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
What type of murmur in MR
Pansystolic murmur
High pitched whistle due to high velocity
Radiates to apex
What are signs of MR
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
How do you investigate MR
ECHO - MR severity, flow into pulmonary vein
ECG
CXR - cardiomegaly / calcification
Aniogram
What is shown on ECG and on ECHO
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%)
How do you treat acute MR
Reduce preload and after load Nitrate Diuretic Inotrope Na nitroprusside ?? ACEI / BB / spironolactone - if in HF Treat AF and anti-coagulate Surgery if severe
What is better for repair
Repair better than replacement
What are the affects of acute MR
Ventricle doesn’t have time to compensate
ESP and EDV decrease to decrease wall tension
What happens in chronic MR
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
What is the most common valve abnormality overall
Mitral valve prolapse
- Very common in young girls
- As get older AS more common
What causes MVP
ASD PDA Cardiomyopathy Turner Marfan Osteogenesis imperfecta WPW
What are the symptoms of MVP
Asymptomatic Aytypical chest pain Palpitations Autonomic Sx Late systolic due to sudden stretch of chordae or prolapsed leaflet Low volume pulse
How do you Dx
ECHO
ECG
How do you treat MVP
BB for palpitation / chest pain
Surgery if severe
What are complications of MVP
Can progress to MR
Emboli
Arrythmia
Sudden death
What causes mitral stenosis
Congenital Rheumatic HD !!!!! Other rheumatic - SLE / RA Infective endocarditis Carcinoid - more effects R side of heart but can affect L if mets in lung
What is the murmur like in MS
Mid-diastolic Rumbling Difficult to hear - Should be no sound before Lub dub - RRRR lub dub
What are the symptoms of mitral stenosis
Pulmonary hypertension Pulmnary oedema Heart failure SOB Haemoptysis Chronic bronchtiis Fatigue Palpitations Tachycardia - worse on exercise / illness
What are the signs of MS
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
What arrhythmia is common
AF due to LA dilatation
How do you Dx MS
ECG - RVH / P mitrale (bifid P wave) if sinus and AF if not
CXR - RVH / oedema / LA enlargement
ECHO = diagnostic
Angiogram
How do you treat MS
Manage AF
Diuretic to reduce preload and afterload and for pulmonary oedema
Valve repalcement = gold standard
- Can be difficult if pulmonary HTN developed
What are the complications of MS
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
What does severity of valve depend
Trans valvular Flow rate
Pressure
What causes an ejection systolic murmur
Aortic stenosis Pulmonary stenosis HCM ASD Tetrology of fall out
What causes pansystolic murmur
Mitral regurgitation
Tricuspid regurgitation
VSD
What causes late systolic
MVP
Coarctation
What causes early diastolic
Aortic regurgitation
Pulmonary regurgitation
What causes Late diastolic
Mitral stenosis
Severe aortic regurgitation
Anything obstructing mitral orifice - thrombus / myxoma
What causes continuous murmur
PDA
R sided murmur
Do if have time
Tricuspid regurgitation
Cor pulmonale - pan-systolic
How do you describe murmur
SCRIPT Site Character Radiation Intensity Pitch Timing Grade 1-6 (1 hard to hear, 6 can hear without stethoscope)V
What does regurgitation cause
Dilatation
What does stenosis cause
Hypertrophy
What type of surgery for heart valve
Usually sternotomy scar (also CABG)
Open heart surgery = remains 1st line if young nd fit
TAVI
What type of valve
Bio
Mechanical
Bio valves
10 years
No anti-coagulation
Better in elderly
Mechanical valve
20 years
Life long anti-coagulation with warfarin
Target INR = 2.5-3.5
What are complications of valve
Thrombus
Embolism
IE
Haemolysis
Where do you hear click in cardiac cycle
S1 if mitral
S2 if aortic
What causes a 3rd HS
Rapid ventricular emptying Physiological if <30 Typically LVF Dilated cardiomyopathy Constrictive pericarditis MR
What causes a 4th HS
Due to atrial contraction against stiff ventricle (suggest L ventricle hypertrophy)
Aortic stenosis
HOCM
Hypertension
What makes a murmur quieter
L ventricle systolic dysfunction as reduced flow rate
What can you not grade murmur on
Loudness
Need ECHO to assess valve function
how does valsalva affect murmur
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
Most common valve defect
AS and MR
What causes a double impulse apex
HOCM due to massive left atrium
What can cause valves in R side of heart to stenose
Carcinoid syndrome
- If Hx flushing / wheeze / diarrhoea
How does it rarely present in L
If tumour has mets in lung so go into pulmonary vascular and to L side of heart
R side murmur
Louder inspiration
L side murmur
Louder expiration
What can cause clubbing
All congenital heart
- Tetrology, ASD, VSD, PDA
IE
