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Cardiology > Valvular Disease > Flashcards

Valvular Disease Flashcards

1
Q

What causes a heart murmur?

A

Turbulent distorted blood flow due to valves

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2
Q

What are the different classifications of systolic murmur based on when they occur in systole? Which types of murmur correlate with these?

A

End-systolic murmur (ESM)= Aortic stenosis or pulmonary stenosis

Pan-systolic murmur (PSM)= Mitral regurg or ventricular septal defect or tricuspid regurg

Late systolic= mitral valve prolapse

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3
Q

What causes aortic stenosis and how is this associated with the pathology of aortic stenosis?

A

Senile calcification i.e. calcification which comes with age
Congenital
Rheumatic
Bicuspid aortic valve eg. Turners syndrome

Pathology:
-stops carotid outflow due to stiffening of valves
I.e. limited CO and can lead to LV hypertrophy + volume overload back into the LV

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4
Q

What are the signs and symptoms associated with aortic stenosis?

A

Exertional dyspnoea
Syncope i.e. due to affected CO leading to compromised MABP
Angina due to impairment of coronary perfusion
I.e. ABCD:
-angina
-breathlessness/heart failure
-collapse/syncope
-death= can be 1st presentation in asymptomatic patient

Slow rising pulse 
Narrow pulse pressure 
Heaving apex beat 
Soft or absent S2 
Possible LVF i.e. S3 or pulmonary oedema
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5
Q

Where is an aortic stenosis murmur best heard and where can it radiate to?

A

2nd intercostal space right sternal angle= ask patient to sit forward to bring heart closer to chest wall to be heard

Carotids and apex

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6
Q

What causes mitral regurgitation and how is this associated with the pathology of mitral regurgitation?

A

Papillary muscle damage post-MI
Dilated cardiomyopathy= stretching of valve annulus
Rheumatic
Infective endocarditis- vegetation’s on valves associated with IV drugs
Congenital= mitral valve prolapse from birth
Connective tissue disorders i.e. Marfans syndrome= leads to inappropriate stretching of valve apparatus

Blood regurgitates into LA leading to left atrial dilation
LA dilation leads to LV dilation and failure
NOTE: mitral regurg can acutely lead to increased pressure in LA which can lead to pulmonary oedema

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7
Q

Why can pulmonary oedema sometimes by associated with mitral regurgitation?

A

When MR occurs acutely, it leads to increased pressure in LA which can result in increase back pressure across the pulmonary vasculature which then leads to pulmonary oedema

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8
Q

What are the signs and symptoms of mitral regurgitation?

A

Dyspnoea
Fatigue
Palpitations
RHF= pulmonary hypertension

AF
Displaced thrusting apex due to volume overload
LVF i.e. presents as S3 and pulmonary oedema
Pulmonary hypertension i.e. RV heave and loud P2 (seconds pulmonic heart sound)

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9
Q

Where is the mitral valve best heard and where can it radiate to?

A

Apex- ask patient to roll onto left in order to make sounds louder

Left axilla

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10
Q

What are the different classifications of diastolic murmur based on when they occur? What are the types which correlate to these?

A

Early diastolic (EDM)= Aortic regurg or pulmonary regurg

Mid diastolic (MDM)= Mitral stenosis

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11
Q

What causes aortic regurgitation and how is this associated with the pathology of aortic regurgitation?

A

Dilation of aortic root

  • hypertension
  • Marfan’s
  • syphilis infection

Abnormalities of aortic leaflets

  • prolapse
  • fenestrations

Damage to aortic leaflets

  • rheumatic fever (tends to affect the mitral valve more commonly)
  • endocarditis

NOTE: acute causes= Aortic dissection or infective endocarditis

Cause system back flow which leads to regurg through aortic valve

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12
Q

What are the signs and symptoms associated with aortic regurgitation? Which signs are specifically associated with the systemic back flow seen in aortic regurg?

A

Fatigue
SOB
Palpations

Collapsing pulse
Wide pulse pressure
Displaced apex= due to blood regurging towards apex

Backflow signs:

  • visible carotid pulsation (Corrigans)
  • head nodding pulse (de Mussets)
  • Quinkes (red colour pulsation in nails)
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13
Q

Where is an aortic regurgitation murmur heard best? What needs to be done for the murmur to be heard?

A

Upper right sternal edge or lower left sternal edge when sitting forwards I.e. sitting forward required to accentuate the murmur

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14
Q

What causes mitral stenosis and how is this associated with the pathology of mitral stenosis?

A

Rheumatic fever
Rare congenital or connective tissue disorders
LA myxoma

Stenosis leads to high left atrial pressure which causes backflow of pressure to cause pulmonary hypertension
Pulmonary hypertension means increased afterload for RV which can lead to RV hypertrophy and potential tricuspid regurg
I.e. can lead to RHF in late stages

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15
Q

What are the signs and symptoms of mitral stenosis?

A

Dyspnoea
Fatigue
Haemoptysis= due to pulmonary hypertension causing rupture of pulmonary capillaries
Chest pain

Malar flush (plum red appearance on high cheeks) due to CO2 retention causing vasodilation and low CO
AF + thready pulse 
Tapping apex i.e. palpable S1 
Loud S1 
Pulmonary hypertension
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16
Q

Where can a mitral stenosis be heard best and what needs to be done help it been heard?

A

Apex

Ask patient to lie in lateral position

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17
Q

What are criteria for the 6 grades of heart murmur?

A

1= very faint, only heard by experts in optimum conditions
2= heard by non-expert in optimum conditions
3= easily audible, no thrill
4= loud murmur w/ thrill
5=very loud and heard over large area with thrill
6= extremely loud so can be heard w/o stethoscope

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18
Q

What is the classic AS triad?

A

Syncope
Angina
Dysnpoea

(Commonly brought on with exacerbation i.e. patient presenting with triad after exercise)

19
Q

If patient has new murmur and fever, what needs to be ruled out? How can this be done?

A

Infective endocarditis

Blood culture= test for bacteraemia
Echo= presence of vegetation’s

20
Q

What is mitral valve prolapse? How is it different to mitral regurgitation? What murmur is associated with MVP?

A

Valve leaflets balloon back into the atria during systole due to being weakened. There is no leakage of blood back into the atria, which is the difference between MVP and MR.

Can be associated with late systolic murmur

21
Q

A patient presents with a continuous murmur. What is likely to be the cause?

A

Patent ductus arteriosus

Blood able to pass freely between left and right side of heart throughout systole and diastole

22
Q

Apart from AS and PS, what else can cause an end systolic murmur?

A

Hypertrophic obstructive cardiomyopathy (HOCM)
- thickening of septal wall leads to narrowing of passage for blood to pass from ventricles to aorta= creates turbulent blood flow which generates the murmur

23
Q

What are the 3 possible causes of a pansystolic murmur? What sign is present in 2 of the murmurs?

A

Post-MI
Tricuspid regurg
Mitral regurg

Raised JVP in MR + TR

24
Q

How can you distinguish between a prosthetic and mechanical valve on auscultation?

A

Mechanical/metalic valve is associated with ejection systolic murmur due to metalic valves causing increased resistance and the turbulent flow produces the murmur

Metalic can also have audible ticking sound

25
Q

Why does AS lead to LV hypertrophy?

A

Narrowing and stiffening of aortic valve means that blood needs to be ejected at higher velocity in order to pass through the valves. This requires increased force of contraction from ventricles leading to ventricular hypertrophy i.e. AS increases the afterload for the heart to contract against

26
Q

What are the complications association with AS?

A

Diastolic or systolic dysfunction which can result in heart failure

27
Q

What are the different treatment options for someone with AS?

A

Mild= medical review with echocardiogram

Valvuloplasty= balloon guided and inflated via catheter

Valve replacement

  • surgical= tissue or mechanical (younger patients)
  • percutaneous= TAVR/TAVI (older patients)
28
Q

Where can stenosis associated with AS be located?

A

Valvular= valve leaflets stenosed

Subvalvular= problems with heart muscle

Supravalvular= problems with ascending aorta

29
Q

What is a TAVR/TAVI and when is it used?

A

Transcutaneous aortic valve replacement/implantation

  • can be used in AS or AR
  • when patients are high risk for surgery
30
Q

What 2 morphological factors are assessed in echocardiogram when determining severity of AS?

A

Aortic valve area= <1cm^2 = severe

Velocity/gradient of flow= >40mmHg= high flow

31
Q

What is the criteria for severe aortic stenosis?

A 
AS triad (ABC) symptoms w/o other explanation 
>70
LV hypertrophy 
Gradient 30-40 mmHg
AVA <0.8 cm^2
32
Q

There are different ways to hear the murmurs better. What can be done for right and left sided murmurs? What is done for diastolic murmurs?

A

Right= best heard on INSPIRATION

Left= best heard on EXPIRATION

Diastolic= can use accentuating manouvres

  • aortic regurg= lean forwards
  • mitral stenosis= turn onto left
33
Q

What are the treatment options for AR?

A

Try to repair rather than replace

Tissue valves

  • xenografts i.e. pig
  • autografts i.e. Ross type AVR which is used in children= pulmonary valve is transfered to become the aortic valve and the pulmonary valve is replaced
  • homografts

TAVR

Mechanical valves

34
Q

What are people with MS at higher risk of developing and why?

A

Increased risk of embolic events= stroke/MI/PE

Low flow area in atria behind valve leads to thrombogenic environment due to blood stasis

35
Q

How can you treat mitral stenosis?

A

Anticoagulation= to decrease the risk of clot formation with low flow in atria

Percutaneous mitral commissurotomy

  • inflated balloon which can be present for up to 10 years
  • has replaced open mitral valvotomy i.e. patient would have lateral thoracotomy scar
36
Q

Which 3 valve components can be affected in severe MR and how?

A

Annulus:

  • dilated/stretched= cardiomyopathy/IHD/Marfan’s
  • calcified

Chordae tendinae

  • rupture
  • lengthening

Papillary muscle

  • ischaemia
  • dilation
37
Q

How can MR be treated?

A

Valve replacement
Valve repair= ring placed around the repaired valve as method of preventing regurg in the future
MitraClip= used when patient not suitable for surgery

38
Q

When is mechanical valve indicated and CI?

A

Indicated:

  • Patient <60 yo
  • no CI for long term anticoagulents i.e. bleeding risk/compliance/pregnant (warfarin= teratogenic)
  • patient already on long term anticoagulant

CI:

  • pregnancy= risk for warfarin
  • high risk for re-op (bio needs replacement after 10 years)
39
Q

When are bioprosthetic valves indicated and when are they CI?

A

Indicated:

  • when good quality anti-coagulation is not likely or CI
  • reoperation for mechanical heart valve
  • low operative risk for future redo
  • young women in reproductive window
  • age >65 for aortic and >75 for mitral
40
Q

What medication do people need to take once they have had a mechanical valve replacement?

A

Lifelong warfarin

41
Q

What are the underlying reasons for chest pain in AR and AS?

A

AS= LVH and heart strain leading to decreased possible LVF and decreased CO= leads to decreased BF in CA and hypoperfusion of myocardium

AR= regurg leads to compromised diastolic filling which is when the coronary artery blood flow occurs

42
Q

How would you investigation AS?

Why is a CXR not always useful?

A

ECG

FBC

Trops

Cardiac echocardiography= important for characterisation of AS

Coronary angiogram= important to identify if there are any coronary occlusions

CXR
-LVH usually seen in severe aoritc stenosis BUT the heart might be normal size due to it being hypertrophied NOT dilated

43
Q

What is the most common cause of aortic stenosis under 60?

What is the most common cause of AS over 60?

A

Bicuspid aortic valve

Degernative valve disease

44
Q

What test is contraindicated in AS?

A

Exercise tolerance test

Cardiology (15 decks)

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