Valvular disease Flashcards
Discuss clinical features of IE
Fever
Malaise
(Weakness, myalgias, back pain, dyspnea, chest pain, cough, headache, anorexia)
Murmur
Vsaculitic lesions (petechia, splinter haemorrahge, janeway lesions)
Immunological (Osloers)
Roth spots
Discuss risk factors for the development of IE
Age > 60 Male IVDU poor dentition or dental infection Structural heart disease Valvular disease Congenital heart disease Prosthetic heart valves Trancatheter aortic valve replacement History of IE Intravascualr device Cardiac implantable electonic device Chronic HD HIV
Discuss microbiology of IE
1) IVUDA
- staph aureas - MRSA
- Strep vridans
- pseudomonas
- often polymicrobial
2) IVDU with HIV
- unusual organisms such as salmonella, listeria, bartonella
3) T2DM
- Staph
4) Prosthetic valves <2months
- staph, epidermidis, aureas
- enterococcus
5) prostehetic valve >2 months
- Staph aureas
- strep viridans
HACEK (Haemophilus, aggregatibacter, cardiobacterium hominus, eikenella corrodens, kingella kingae)
Other
Polymicrobial
Discuss ix of IE
FBC - leukocytosis non specific ESR CRP Mild anaemia Urine for microscopic haematuria as a result of embolic lesions of the kidney Culture ideally x3
CXR (failure, embolic disease)
ECHO, high specificty but sensitivity can be poor due to obsesity, COPD and chest wall deformities
TOE eliminates these and is superior in diagnosis
DIscuss DUKEs criteria
Pathological criteria
- pathologic lesions - vegetation or intracardiac abscess demonstrating active endocarditis on histology
- Micro-organism - demenstrated by culture or histology of a vegetation or intracardiac abscess
CLinical
Definite endocarditis: considered definite if any one of the following is present
- Two major clinical
- one major and 3 minor
- fiver minor
Possible:
- One major and one or two minor clinical criteria
- three minor clinical criteria
Major criteria
#Positve blood cultures
-Typical micro-organisms consistent with IE from 2 seperate blood cultures (staph, viridans strep, strep gallolyticus, HACEK)
-Persistently positive blood culture
-single positive blood culture for coxiella burnetii or phase 1 IgG antibody titre
#evidecne of endocardial involvement by ECHO such as
—-endocardial vegetation
—- paravalvular abscess
—- new partial dehiscence of prosthetic valve
—-New valvular regurg
Minor #Predisposption (heart condition or IVDU) #Fever #Vascular phenomena (arterial emboli, septic pulmonary infarct, mycotic aneurysm, conjunctival haemorrahge, or janeway) #Immunological phenomena (osler's node, Roth's spot and rheumatoid factor) #Micro evidence - single blood culture (except for coagulase -ve staph -does not cause IE)
Discuss management of IE
Native valve
- Benpen 1.8g q4 hourly
- Fluclox 2g q4 hourly
- Gentamicin 5-7mg/kg
Native vlave MRSA
- ad above but replace ben pen with Vanc 25-30mg/kg
Non native valve or implantable device
- Vanc 25-30mg/kg
- fluclox 2 g Q4 hourly
- Gentamycin
Anaphylaxis to penicillin replace fluclox with cephazolin 2 g
Discuss mitral stenosis
The most common cause of mitral stenosis is RHD
Symptoms of valvular dysfunction typically develop after a latency period of 1-3 decards.
The normal cross sectional area of the mitralv valve is 4-6cm2, stenosis becomes signifiacnt below 2cm2
Impeded flow from the left atrium to the left ventricle results in left atrial hypertension restricted CO and ultimately pulmonary congestion.
The most common complication of mitral stenosis is AF wchihc in the absence of rate control si not well toelrated. Patients with mitral stenosis will decompensate under other condition associated with increased cardiac demand and reduced ventricular filling such as pregnancy anaemia infection and hyperthyroidism .
Discuss clinical features and management of mitral stenosis
Early symptoms include reduced exercise toleracne and dyspnea on exertion.
Patient with more advanced disease may have orthopnea and if RV failure is present peripheral oedema
Haemoptysis caused by rupture fo the bronchial vein and hoarsens caused by compression of the recurrent layrngeal nerve are classic but uncommon finding
Typical signs of heart failure present in later disease
HS are charachterised by a loud S1 an opening snap and in early diastole accompanoied by a low pitched rumbling diastolic apical murmur
Management
-diuresis for vascular congestion and anticoagulation for af
Breifly discuss mitral regurg
ACute MR is a mediacl emergency seen most commonly in the setting of MI and pap muscle rupture – presents with fulminant pulmonary oedema
Chronci MR is seen in dilated CMX
Causea
- IE
- Pap muscle disorder (ischaemia or infarct, trauma, infiltrative disease)
- Rupture of the chordae (RF, iE, Trauma)
- mitral leaflet disorder (IE, myxomatous degenr)
Discuss aortic stenosis
The most common cause of AS is calcific degneration - occurs mainly in older patient but is seen in a younger age group with biscup valves
The normal aortic valve area is larger than 3cm2 - significant obstruction occurs when the valve area is reduced by more than 50%/ Critcal aoritc stenosis is defined as a valve area of less than 0.8cm2
Compensatory LVH can maintain CO until the AS becomes severe. Indiviuals with severe or critical AS are preload dependant and have very little CVS reserve
Discuss clinical features of AS
Classic symptoms of AS progress from angina to exertional syncope to heart failure.
Crescendo decrescendo systolic murmur best heard at the base(right second intercostal space) that radiates into the carotids and is assocaited with the presence of an S4 gallop and a soft aoritc componenet o.
Counterintuitively as the severity of the disase increases the murmur peaks later and becomes less pronounced
ECG:- LVH
Discuss aortic insufficiency
Causes include RHD, IE or the presence of bicuspid valve. Aortic abnormalities such as ectasia, aneurysm or dissection can lead to aortic insufficiency
Can rpeent with severe respiraotyr distress or frank cardiogenic shock.
Clinical finding incoude rapidly rising and falling carotid pulse (water hamer) spontaneous nail bed pulsations or a to and fro murmur over the femoral artery,
A high pitched blowing diastolic murmur at the left sternal border is characteristic of chronic aortic insufficiency
