Valvular Disease Flashcards
What is the scale used to determine murmurs?
Levine Scale
Describe the Levine Scale?
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
What is the pathophysiology of Mitral Stenosis?
- 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
What can cause Mitral Stenosis?
- Rheumatic Heart Disease
- Congenital
- Mucopolysaccharidoses
- Endocardial fibroelastosis
- Malignant Carcinoid Tumour
- Metastases
- Prosthetic valve
What are symptoms of mitral stenosis?
- Severe dyspnoea
- Cough productive of blood tinged, frothy sputum or frank haemoptysis
- Weakness, fatigue and abdominal or lower limb swelling
What are examination findings of Mitral Stenosis?
- 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
What are the test done for Mitral Stenosis?
- 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
How is Mitral Stenosis medically managed?
- 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
What should be done in Mitral Stenosis if patient isn’t medically managed sufficiently?
- Balloon valvuloplasty (if pliable, non-calcified valve)
- Open Mitral Valvotomy or Valve replacement
What are complications of Mitral Stenosis?
- Pulmonary hypertension
- Emboli
- Pressure from a large Left Atrium on local structures (hoarseness due to RLN
- Dysphagia (oesophagus)
- Bronchial obstruction
- Infective endocarditis
What is the pathophysiology of Mitral Regurgitation?
- 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
What are causes of Mitral Regurgitation?
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
What are symptoms of Mitral Regurgitation?
- 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
What are examination findings of Mitral regurgitation?
- 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
What are investigations done for Mitral Regurgitation?
- 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
What does echocardiogram show for mitral regurgitation?
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
What is the management of Mitral Regurgitation?
- 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
What are causes of Aortic Stenosis?
- 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
What some differentials for Aortic Stenosis?
- Hypertrophic cardiomyopathy
- Supravalvular obstruction
- Subvalvular Aortic stenosis
What is the pathophysiology of Aortic Stenosis?
- 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.
What happens to patients with Aortic Stenosis during exercise?
- 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
What symptoms of Aortic Stenosis?
- Exercise-Induced syncope
- Angina
- Dyspnoea occurs when moderately severe
What are examination findings in Aortic Stenosis?
- Ejection Systolic Murmur
- Slow rising pulse with narrow pulse pressure
- Non-displaced apex beat
- LV heave
- Aortic Thrill
What are tests for Aortic Stenosis?
- 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
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
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
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)
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.
What is aortic sclerosis?
- Senile degeneration of the valve
- Ejection systolic murmur, no carotid radiation, and normal pulse and S2
What are acute causes of Aortic Regurgitation?
- Infective endocarditis
- Ascending aortic dissection
- Acute Rheumatic fever
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
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
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
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
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.
What is the medical management of Aortic Regurgitation?
- ACE-inhibitor is used to help
- Echocardiography every 6 months to monitor
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
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
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
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
What are tests for Tricuspid Regurgitation?
Echocardiogram shows dilatation of right ventricle with thickening of the valve
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
What are causes of Triscuspid Stenosis?
- Main cause is Rheumatic Fever
- Congenital
- Infective endocarditis
- Carcinoid syndrome
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
What are symptoms of Tricuspid Stenosis?
- Abdominal pain (due to hepatomegaly)
- Swelling (due to ascites)
- Peripheral oedema severe when compared with degree of dyspnoea
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
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
What is the management of Tricuspid Stenosis?
- Diuretics
- Salt restriction
- Surgical: tricuspid valvotomy and tricuspid replacement often necessary
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
What are symptoms of Pulmonary Stenosis?
- Fatigue
- Syncope
- Symptoms of right heart failure
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
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
What is the management of Pulmonary Stenosis?
Pulmonary Valvuloplasty or Valvotomy (balloon valvotomy or direct surgery)
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.
What is the management of pulmonary regurgitation?
Pulmonary regurgitation usually causes no symptoms and treatment rarely necessary
When is a Prolapsing Mitral Valve seen?
More commonly seen in young women than in men or older women, and has a familial incidence.
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
