Valvular disease Flashcards
Which valves cause S1?
Closure of atrioventricular = mitral and tricuspid valves
What valves cause S2?
Closure of aortic and pulmonary valves
Why is it normal for S2 to split a little? When is it best heard?
Aortic valve shuts before pulmonary valve, especially on deep inspriation as venous return to heart is delayed
When does abnormal splitting of S2 occur?
RV volume overload eg atrial septal defect
RV outflow obstruction
Delayed RV depolarisation eg complete R bundle branch block
When does narrow splitting of S2 occur?
Pulmonary hypertension - pulm valve closes earlier as higher pulm resistance
When does pulm valve close before aortic? (paradoxical splitting) - S2
Severe aortic stenosis
Left bundle branch block
How does syphilis cause aortic regurgitation?
It causes arteritis due to the inflammatory response when treponema palidium invades the aortic wall and causes necrosis of elastic fibres and CT in aortic media.
Would you get L or R HF first with aortic regurgitation?
Left - Right sided HF is DUE to pulm congestion but L sided CAUSES it
What is the most common valve disease?
Aortic stenosis
Why does aortic stenosis cause symptoms?
Reduced cardiac output to body
Increased afterload - atrum and ventricle unable to empty properly
Symptoms of aortic stenosis
Exertional dyspnoea, angina, syncope
Which valve diseases have a narrow vs wide pulse pressure?
Wide = aortic regurgitation
Narrow = aortic stenosis
Causes of mitral regurgitation
Rheumatic disease
Papillary muscle rupture or chordae tendinae
Infective endocarditis
Mitral valve prolapse - young women
Post MI - paillary muscle rupture
Dilated/hypertrophic cardiomyopathy
Connective tissue disorders eg Ehlers Danlos
Congenital
Symptoms mitral regurgitiation
Asymptomatic
HF
Anginal chest pain
Dyspnoea
Palpitations if af present
Signs of mitral regurgitation
Irrefuarly irregular pulse if AF present
Pansystolic murmur harsh radiating to axilla
LVH - displaced apex
Soft S1, split S2
What are complications of mitral regurgitiation and stenosis? What is the difference?
AF
HF
Infective endocarditis
ONly mitral regurg - pulmonary hypertension
Which valve disease radiates to the carotids?
Aortic stenosis
Which valvular disease has high pitched, high velocity ejection systolic murmur?
Aortic stenosis
What valuvlar diseases cause a displaced apex beat and why?
Any that cause LVH, aortic stenosis and mitral regurg
Complications of aortic stenosis
LVH + dilation
Sudden death
LHF -> pulmonary congestion -> RHF
MI
What is the main cause of mitral stenosis?
Rheumatic disease
Symptoms of mitral stenosis
SOB
Pink frothy sputum or haemoptysis
Anginal chest pain
Which valve disease causes a loud opeining snap and loud S1
Mitral stensosis
Which valve disease is a mid diastolic murmmur with a low volume pulse?
Mitral stenosis
Which mitral disease can present with malar flush?
Mitral stenosis
What can cause aortic regurgitiation?
Aortic valve weakness
Distortion or dilatation of aortic root and ascending aorta
Aortic dissection
Spondyloarthropathies
Syphilis
Marphans syndrome
What valvular disease can aortic dissection and trauma cause?
Aortic regurgitiation
Chronic causes of aortic regurgitation
Infective endocarditis
RHD ‘HPTN
Aortitis - takaysau, syphilis
Connective tissue disorders
Bicuspid aortic valve
What valve disease often has mild or asymptomatic as heart is compensating?
Aortic regurgitation
What are the symptoms of aortic regurgitation?
Palpitations
SOB - pulm congestion
Anginal chest pain
What valve disease causes a collapsing pulse?
Aortic regurgitation
3 signs of arotic regurgitation
De Mussets sign - head bob
Corrigans sign
Quinckes sign
Quinckes sign
Pulse in nail bed
Corrigans sign
Abrupt distension and collapse carotid arteries
De Mussets sign
Head bob
Complciations of aortic regurgitation
LVH and dialtion
LSHF - pulm congestion
RSHF
Why can aortic regurgitation cause both sides heart failure + whcih one first?
Left first - LVH
causes pulmonary congestion, RHF secondary to pulmonary congestion
What can an ECG find realted to valvular disease?
LVH, Arrhthmias, AF
What can a Transthoracic Echocardiogram do?
Determine extent or severity of stenosis
Assess LV function, flow status, wall thickness
How do you investigate valvular disease?
Bloods - Brain natiuretic peptides
ECG
CXR
TTECHO
When consider Aortic valve disease for surgical treatment
Symptomatic
Asymptomatic but severe AS/AR on echo or LVEF <55%
What is a TAVR and when is it used?
Transcatheter aortic valve implantation (TAVR) for patients with higher operative risk
Intervention for aortic valve disease if critically ill + not suitable for surgery
Percutaneous balloon valvotomy
Indications for consideration of surgical treatment mitral valve disease
Symptomatic
Asymptomatic but severe MS/MR on echo or LVEF < 60%
Which mitral valve disease can be treated with transcatheter volvotomy aswell as surgical valve replacment?
Mitral stenosis
Which valve replacement needs long term anticoagulation therapy?
mechanical valve
Why are biological valves not always a good option in young people?
Structural deterioration/calcification over time
What are the congenital cause of aortic regurgitation?
Bicuspid valve
What valve disease is accentuated when patient sat forward?
Aortic stenosis
What murmur can a L atrial myxoma cause?
Mitral stenosis
Where does hypertrophy occur in mitral stenosis?
Left atrium
What causes pulmonary oedema in mitral stenoisis?
LA hypertrophy -> backflow through pulm veins
Where is the murmur best heard in mitral stenosis, what exaggerated it?
Mid diastolic murmur at the apex
Left lying down exaggerates
What are the features of a diastolic murmur?
Loud S1 + early diastolic opening snap
WHich murmurs are increased by valsalva manourvre?
Aortic stenosis
HOCM
Increased LV afterload
When is mitral regurgitation murmur loudest?
On expiration when lying on L side
Investigations for valvular disease
ECG
ECHO
CXR - LVH etc
Character of narrow pulse pressure
<30mmHg slow rising narrow
Character of wide pulse pressure
non-displaced, heaving apex beat >60mmHg
Character of aortic stenosis murmur
Crescendo-decrescendo
Where aortic stenosis murmur best heard
R sternal border 2nd ICS. Peripheral pulses weakened/delayed
What is aortic valve replacement? Large benefit?
TAVI - can use local anaesthetic
What surgical management is there for mitral valve diseas?
Transcatherter vavlotomy replace or edge to edge repair for regurgitation, replace for stenosis
Indications for ECHO
-sus HF
-murmurs suggestive disease
-endocarditis
-known valve disease + symptom progression
Arrhythmias or syncope w reasonable suspicion underlying structural HD
Cardiac origin sus stroke TIA, peripheral emboli
Chest pain + post MU complications
Pre-op assessment
Screening family disease
Pregnant known HD
Assess LV function before giving cardiotoxic chemotherapy
What valve disease should a patient with syncope have as a differential?
Aortic stenosis
When offer ECHO for valvular disease 2 week referral
Nature of murmur (ejection systolic murmur with reduced S2 but no other signs or symptoms)
Family history
Age eg over 75n
Medical history eg AF
Signs - peripheral oedema or symoptoms (angina, SOB)
Abnormal ECG
When refer to specialist after ECHO
Moderate to severe valve disease
Bicuspid aortic valve disease of any severity incl mild valve disease
Which valves are open in diastole
Mitral and tricuspid
Which valves are open in systole
Pulmonary and aortic
What is R heart valve disease normally a sign of?
Cardioresp sstem malfunction eg pulm HPTN (tricuspid regurg)
What would a young patient w aortic stenosis tend to have>
Bicuspid aortic valve disease
Symptoms of pulmonary stensosi
SOB
Chest oain
Syncope/fainting
Sudden death
What murmur is pulmonary stenosis and where is it heard best
Systolic ejection murmur
L upper sternal boreder
Cause of pulmonary stenosis
Congential - noonans, alagille, rheumatic
Decreased outflow to lungs from RV
Management cyanotic pulmonary stenosis
Oxygen and pGE1
When do you do a percutaneous balloon valvotomy for pulmonary stenosis
In moderate/severe disease
Otherwise monitor
Risk factors tricuspid regurg
L HF
DIlated tricuspid annulator
Rheumatic HD
Pacemaker
Symptoms of tricuspid regueg
Fatigeu
SOB
Extermity oedema
Drecreased exercise tolerance
Palpitations
May cause hepatomegaly and abdo distension - venous back log
Symptoms and signs are usually absent, but severe TR can cause neck pulsations, a holosystolic murmur, and right ventricular–induced heart failure or atrial fibrillation.
Pimrary vs secondary valvular disease
Primary - abnormal valve
Seconadry = normal valve, caused by other pathology
Investigations for tricuspid regurgitiation
LFTs, urea and creatinine
ECG
ECHO
CXR
Tricuspid regurgitation where and when
Rarely heard
In L sternal border
Patient standing
Seondary tricuspid regurg due to
annular dilation (typical of right atrial dilation caused by chronic atrial fibrillation) and/or papillary muscle displacement (left heart disease -> pulmonary hypertension -> RV dilation).
INvestigation results tricuspid regurg
ECG - tall peaked P waves caused by right atrial enlargement, a tall R or QR wave in V1 characteristic of RV hypertrophy, or atrial fibrillation.
CXR - RV hypertrophy or RV dysfunction–induced HF, an enlarged superior vena cava, an enlarged right atrial or RV silhouette, or pleural effusion
What murmur does pulmonary HPTN casue
Pulmonary regurgitation
Normally asymptomatic
What is tricuspid stenosis
Tricuspid stenosis (TS) is narrowing of the tricuspid orifice that obstructs blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms include a fluttering discomfort in the neck, fatigue, cold skin, and right upper quadrant abdominal discomfort. Jugular pulsations are prominent, and a presystolic murmur is often heard at the left sternal edge in the fourth intercostal space and is increased during inspiration. Diagnosis is by echocardiography. TS is usually benign, requiring no specific treatment, but symptomatic patients may benefit from surgery.
Key points tricuspid stenosis
Tricuspid stenosis is almost always due to rheumatic fever; tricuspid regurgitation and mitral stenosis are often also present.
Heart sounds include a soft opening snap and a mid-diastolic rumble with presystolic accentuation; the murmur becomes louder and longer with maneuvers that increase venous return (eg, exercise, inspiration, leg-raising) and softer and shorter with maneuvers that decrease venous return (standing, Valsalva maneuver).
Treatment includes diuretics and aldosterone antagonists; surgical repair or replacement is rarely needed.
What is aortic stenosis
rtic stenosis (AS) is narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole
What is aortic regurgitation
incompetency of the aortic valve causing backflow from the aorta into the left ventricle during diastole.
What is mitral regurgitiation
incompetency of the mitral valve causing flow from the left ventricle (LV) into the left atrium during ventricular systole.
What is mitral stenosis
narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle. The usual cause is rheumatic fever
What is pulmonary regurgitation
Pulmonic (pulmonary) regurgitation (PR) is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole. The most common cause is pulmonary hypertension. PR is usually asymptomatic. Signs include a decrescendo diastolic murmur. Diagnosis is by echocardiography. Usually, no specific treatment is necessary except for management of pulmonary hypertension.
What is pulmonary stenosis
Pulmonic stenosis (PS) is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole. Most cases are congenital.
crescendo-decrescendo ejection murmur.
What is tricuspid regurgitation
Tricuspid regurgitation (TR) is insufficiency of the tricuspid valve causing blood flow from the right ventricle to the right atrium during systole. The most common cause is dilation of the right ventricle. Symptoms and signs are usually absent, but severe TR can cause neck pulsations, a holosystolic murmur, and right ventricular–induced heart failure or atrial fibrillation.
What valvular disease can cause liver spulsation
Tricuspid regurgitation
