Valvular Disease Flashcards
1
Q
What is the scale used to determine murmurs?
A
Levine Scale
2
Q
Describe the Levine Scale?
A
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
3
Q
What is the pathophysiology of Mitral Stenosis?
A
- Normal valve orifice area is reduced to <1cm2, severe mitral stenosis is present.
- In order to maintain sufficient cardiac output, left atrial pressure increase and left atrial hypertrophy and dilatation occur
- Pulmonary venous, pulmonary arterial and right heart pressure increases as a result.
- Increase in capillary pressure leads to pulmonary oedema particularly if rhythm deteriorates to atrial fibrillation with tachycardia and loss of atrial contraction.
- Pulmonary hypertension leads to right ventricular hypertrophy, dilatation and failure with tricuspid regurgitation occurring as a result
4
Q
What can cause Mitral Stenosis?
A
- Rheumatic Heart Disease
- Congenital
- Mucopolysaccharidoses
- Endocardial fibroelastosis
- Malignant Carcinoid Tumour
- Metastases
- Prosthetic valve
5
Q
What are symptoms of mitral stenosis?
A
- Severe dyspnoea
- Cough productive of blood tinged, frothy sputum or frank haemoptysis
- Weakness, fatigue and abdominal or lower limb swelling
6
Q
What are examination findings of Mitral Stenosis?
A
- Malar Flush
- Low volume pulse. May lead to AF as disease develops
- Tapping, non-displaced, apex beat that is palpable on S1
- Loud S1 sound
- Rumbling mid-diastolic murmur that is heard best in expiration on patient’s left side.
- Graham Steell murmur may be heard: high pitched early diastolic murmur
7
Q
What are the test done for Mitral Stenosis?
A
- Echocardiogram is diagnostic
- ECG: atrial fibrillation, p-mitrale if in sinus rhythm, right axis deviation
- Chest X-ray: left atrial enlarge, pulmonary oedema, mitral valve calcification
- Cardiac MRI: Rarely used
8
Q
How is Mitral Stenosis medically managed?
A
- In AF, rate control is important - Bisoprolol
- Anticoagulate with Warfarin
- Diuretics to decrease preload and pulmonary venous congestion
- Oral Penicillin prophylaxis can be used for recurrent rheumatic fever
9
Q
What should be done in Mitral Stenosis if patient isn’t medically managed sufficiently?
A
- Balloon valvuloplasty (if pliable, non-calcified valve)
- Open Mitral Valvotomy or Valve replacement
10
Q
What are complications of Mitral Stenosis?
A
- Pulmonary hypertension
- Emboli
- Pressure from a large Left Atrium on local structures (hoarseness due to RLN
- Dysphagia (oesophagus)
- Bronchial obstruction
- Infective endocarditis
11
Q
What is the pathophysiology of Mitral Regurgitation?
A
- Regurgitation into left atrium produces left atrial dilation.
- Little increase in left atrial pressure if regurgitation is chronic as regurgitant flow accommodated by large left atrium
- Left atrial u-wave is greatly increased and pulmonary venous pressure rise leading to pulmonary oedema
- Since proportion of stroke volume is regurgitated, stroke volume increases to maintain forward cardiac out and left ventricle therefore enlarges
- Classified by Carpentier classification
12
Q
What are causes of Mitral Regurgitation?
A
Occur due to abnormalities of valve leaflets, the annulus, the chordae tendineae or papillary muscles or left ventricle such as:
- LV dilatation
- Annular calcification
- Rheumatic Fever
- Infective Endocarditis
- Mitral Valve Prolapse
- Ruptured Chordae tendineae
- Papillary muscle dysfunction/rupture
- Connective Tissue Disorder (Ehlers-Danlos, Marfan’s)
- Cardiomyopathy
- Congenital
- Appetite Suppressants
13
Q
What are symptoms of Mitral Regurgitation?
A
- Palpitations due to increase stroke volume
- Dyspnoea and orthopnoea due to pulmonary venous hypertension
- Fatigue and lethargy due to reduced cardiac output
- Cardiac cachexia may develop.
- In the late stages symptoms of right sided heart failure may occur and lead to congestive cardiac failure
- Thromboembolism is less common but subacute infective endocarditis much more common in mitral regurgitation than mitral stenosis
14
Q
What are examination findings of Mitral regurgitation?
A
- Laterally displaced hyperdynamic apex and systolic thrill
- Right ventricular heave
- Soft S1; Split S2; Loud P2 (pulmonary hypertension)
- Pansystolic murmur at apex radiating to axilla
- Mid-systolic click
- Prominent third heart sound due to sudden rush of blood into dilated ventricle
15
Q
What are investigations done for Mitral Regurgitation?
A
- ECG: AF (+-) P-mitrale if in sinus rhythm, LVH represented by tall R waves in left lateral leads and Deep S in the right sided precordial leads, Left atrial delay represented by bifid P waves
- Chest X-Ray: big left atrium and left ventricle; mitral valve calcification; pulmonary oedema, increase in cardiothoracic ratio
- Echocardiogram can be used to assess left ventricular function and aetiology. Doppler echo can be used to asses size and site of regurgitant jet.
- Cardiac Catheterization - demonstrate prominent left atrial systolic pressure
16
Q
What does echocardiogram show for mitral regurgitation?
A
Shows
- Dilated left atrium and left ventricle
- There may be chordal or papillary muscle rupture.
- Severity can be assessed with use of colour Doppler looking at narrowest jet width and area and calculation regurgitant fraction, volume or orifice area
17
Q
What is the management of Mitral Regurgitation?
A
- Control rate for Fast Atrial Fibrillation
- Anticoagulated in event of atrial fibrillation, history of embolism, prosthetic valve, additional mitral stenosis
- Diuretics improve symptoms
- Surgery for deteriorating symptoms; aim to repair or replace the valve before left ventricle irreversibly impaired
18
Q
What are causes of Aortic Stenosis?
A
- Senile calcification is the commonest
- Bicuspid Aortic Valve (commonest in <65)
- Rheumatic Heart Disease
- Chronic Kidney Disease
- Paget’s disease of bone
- Previous Radiation Exposure
- SLE
- Williams Syndrome
19
Q
What some differentials for Aortic Stenosis?
A
- Hypertrophic cardiomyopathy
- Supravalvular obstruction
- Subvalvular Aortic stenosis
20
Q
What is the pathophysiology of Aortic Stenosis?
A
- Obstructed left ventricular emptying lead to increased left ventricular pressure and compensatory left ventricular hypertrophy
- Results in relative ischaemia of left ventricular myocardium and consequent angina, arrhythmias and left ventricular failure.
21
Q
What happens to patients with Aortic Stenosis during exercise?
A
- Obstruction to left ventricular emptying is relatively more severe on exercise
- When there is severe narrowing of aortic valve orifice, cardiac output can hardly increase during exercise.
- So blood pressure falls, coronary ischaemia worsens, myocardium fails and cardiac arrhythmias develop.
- Left ventricular systolic function preserved in patient with AS
22
Q
What symptoms of Aortic Stenosis?
A
- Exercise-Induced syncope
- Angina
- Dyspnoea occurs when moderately severe
23
Q
What are examination findings in Aortic Stenosis?
A
- Ejection Systolic Murmur
- Slow rising pulse with narrow pulse pressure
- Non-displaced apex beat
- LV heave
- Aortic Thrill
24
Q
What are tests for Aortic Stenosis?
A
- ECG: P-mitrale, LVH with strain pattern; LAD; poor R wave progression; LBBB or complete AV block (calcified ring)
- Chest-XRay: Left Ventricular Hypertrophy; Calcified aortic valve; Post Stenotic Dilatation of ascending aorta
- Echocardography
- Cardiac Catheter can assess valve gradient; LV function; Coronary Artery Disease but risks emboli
25
What does Echocardiogram of Aortic Stenosis show?
* Doppler echo can estimate gradient across valves: severe stenosis if peak gradient is \>50mmHg and valve area \<1cm2. If aortic jet velocity is \>4m/s then risk of complications increases.
* Echo can demonstrate thickened, calcified and immobile aortic valve cusps and ventricular hypertrophy
26
What is the management of Aortic Stenosis who is asymptomatic?
* If asymptomatic then observe the patient is general rule
* If asymptomatic but valvular gradient \> 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
* If asymptomatic and severe aortic stenosis and a deteriorating ECG, valve replacement is recommended
27
What is the management of a symptomatic patient with Aortic Stenosis?
* Surgery for valve replacement
* If patient not suitable for surgery then percutaneous valvuloplasty may be attempted (TAVI)
28
What is the prognosis of a patient with aortic stenosis?
* If symptomatic, prognosis is poor without surgery: 2-3 year survival if angina/syncope; 1-2yr of cardiac failure.
* If moderate to severe and treated medically, mortality can be as high as 50 % at 2 yrs therefore prompt valve replacement is usually recommended.
29
What is aortic sclerosis?
* Senile degeneration of the valve
* Ejection systolic murmur, no carotid radiation, and normal pulse and S2
30
What are acute causes of Aortic Regurgitation?
* Infective endocarditis
* Ascending aortic dissection
* Acute Rheumatic fever
31
What are Chronic Causes of Aortic Regurgitation?
* Congenital
* Connective Tissue Disorders (Marfan’s Syndrome, Ehlers-Danlos)
* Rheumatic Fever
* Takayasu Arteritis
* Rheumatoid Arthritis
* SLE
* Pseudoxanthoma Elasticum
* Appetite Suppressants
* Seronegative Arthritides (ankylosing spondylitis, Reiter’s syndrome, Psoriatic Arthropathy
* Hypertension
* Osteogenesis Imperfecta
* Syphilitic Aortis
32
What are symptoms of Aortic Regurgitation?
* Pounding of the heart
* Angina pectoris
* Varying grades of dyspnoea occur depending of extent of left ventricular dilatation and dysfunction
* Arrhythmias relatively uncommon
33
What are examination findings of Aortic Regurgitation?
* Collapsing pulse; wide pulse pressure;
* Displaced, hyperdynamic apex beat;
* High-pitched early diastolic murmur
* Corrigan’s sign: carotid pulsation
* De Musset’s sign: head nodding with each heart beat • Quincke’s sign: capillary pulsations in nail beds
* Duroziez’s sign: in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal, it gives a diastolic murmur as blood flows backwards
* Traube’s sign: pistol shot sound over femoral arteries
34
What are the investigations of Aortic Regurgitation?
* **Echocardiography is diagnostic.**
* **ECG:** left ventricular hypertrophy which shows deeply inverted T wave and tall R waves in the left sided chest leads and deep S waves in right sided leads
* **Chest X-ray:** cardiomegaly; dilated ascending aorta; pulmonary oedema, ascending aortic wall may be calcified in syphilis which can responsible for regurgitation
* **Cardiac Catheterization** to assess the severity of the lesion; anatomy of aortic root; LV function: other valve disease
35
What does Echocardiography show for Aortic Regurgitation?
* Demonstrates vigorous cardiac contraction
* Dilated left ventricle
* Diastolic fluttering of mitral leaflets or septum occur in severe aortic reurgitation. Severity is assessed with colour doppler and CW dopper.
36
What is the medical management of Aortic Regurgitation?
* **ACE-inhibitor** is used to help
* **Echocardiography** every **6 months** to monitor
37
What is the surgical management of Aortic Regurgitation?
* Surgery is considered in patient who have: increasing symptoms; an enlarged heart on CXR/echo; ECG deterioration; Infective endocarditis refractory to medical therapy.
* Aim to replace the valve before significant LV dysfunction occurs
* Predictors of poor post-operative survival are ejection fraction \<50%, duration of congestive cardiac failure of more than 12 months
38
What are the causes of Tricuspid regurgitation?
* Functional regurgitation may occur whenever right ventricle dilates (Cor pulmonale, MI or pulmonary hypertension)
* Rheumatic fever
* Infective endocarditis
* Carcinoid Syndrome
* Congenital (Ebstein’s anomaly)
* Drugs
39
What are symptoms of Triscuspid Regurgitation?
* Awakening at night with shortness of breath
* Shortness of breath during exercise or when lying flat.
* Coughing
* Wheezing
* Difficulty concentrating
* Dizziness
* Fatigue
* Fluid retention
40
What are examination findings of Tricuspid Regurgitation?
* Giant **V waves** and prominent **Y descent** in JVP
* **Right ventricular heave**
* **Pansystolic murmur** that is heard best at lower left sternal edge in inspiration
* Pulsatile hepatomegaly; Jaundice; Ascites
* Atrial fibrillation is common
41
What are tests for Tricuspid Regurgitation?
Echocardiogram shows dilatation of right ventricle with thickening of the valve
42
What is the management of Triscuspid Regurgitation?
* **Treat** underlying **cause**
* **Drugs:** Diuretics, Digoxin, ACE-inhibitors
* **Valve replacement** which has around a 10% 30-day mortality
Tricuspid regurgitation resulting in myocardial dysfunction or dilatation has a mortality of up to 50% at 5 years
43
What are causes of Triscuspid Stenosis?
* **Main** cause is **Rheumatic Fever**
* Congenital
* Infective endocarditis
* Carcinoid syndrome
44
What is pathophysiology of Tricuspid Stenosis?
* Reduced cardiac output which is restored towards normal when right atrial pressure increases.
* Resulting systemic venous congestion produced hepatomegaly, ascites and dependant oedema
45
What are symptoms of Tricuspid Stenosis?
* Abdominal pain (due to hepatomegaly)
* Swelling (due to ascites)
* Peripheral oedema severe when compared with degree of dyspnoea
46
What are examination findings of Tricuspid Stenosis?
* Giant 'A wave' and slow 'Y descent' in JVP
* Opening snap
* Early diastolic murmur heard at the left sternal edge in in inspiration
* AF can also occur
47
What are investigations used in Tricuspid Stenosis?
* **Echocardiogram** is diagnostic.
* Shows thickened and immobile tricuspid valve
* **CXR** may show prominent right atrial bulge
* **ECG:** peaked, tall P waves (\>3mm) in lead 2
48
What is the management of Tricuspid Stenosis?
* Diuretics
* Salt restriction
* Surgical: tricuspid valvotomy and tricuspid replacement often necessary
49
What are causes of Pulmonary Stenosis?
Pulmonary stenosis may be valvular, sub-valvular or supra valvular anc caused by:
* Turner’s syndrome
* Noonan’s syndrome
* William’s syndrome
* Fallot’s tetralogy
* Congenital Rubella syndrome
* Rheumatic fever
* Carcinoid syndrome
50
What are symptoms of Pulmonary Stenosis?
* Fatigue
* Syncope
* Symptoms of right heart failure
51
What are examination findings in Pulmonary Stenosis?
* Dysmorphic facies; prominent 'A wave' in JVP; RV heave
* Ejection systolic murmur (which radiates to the left shoulder; widely split S2)
* In severe stenosis, the murmur becomes longer and obscures A2
* P2 becomes softer and may be inaudible
* Right ventricular fourth sound
52
What are test for Pulmonary Stenosis?
* **Cardiac catheterization** is diagnostic
* **ECG:**
* RAD, P-pulmonale, right ventricular hypertrophy, right bundle branch block
* **CXR:**
* prominent main, right or left pulmonary arteries caused by post-stenotic dilatation
53
What is the management of Pulmonary Stenosis?
Pulmonary Valvuloplasty or Valvotomy (balloon valvotomy or direct surgery)
54
What is the cause of Pulmonary Regurgitation?
* Results from dilatation of pulmonary valve ring which occurs with pulmonary hypertension (graham stell murmur)
* May also occur following Tetralogy of Fallot repair.
55
What is the management of pulmonary regurgitation?
Pulmonary regurgitation usually causes no symptoms and treatment rarely necessary
56
When is a Prolapsing Mitral Valve seen?
More commonly seen in young women than in men or older women, and has a familial incidence.
57
What is a Prolapsing Mitral Valve associated with?
Associated with
* Connective tissue disorders
* Marfan syndrome
* Ehlers–Danlos syndrome
* Pseudoxanthoma elasticum
* Atrial septal defect
* Ebstein's anomaly
