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CARDIOVASCULAR > Valvular disease > Flashcards

Valvular disease Flashcards

1
Q

What are the 4 valves of the heart?

A

2 atrioventricular valves - mitral (L) and tricuspid (R)

2 semilunar valves - aortic (L) and pulmonary (R)

Mitral has 2 cusps, others have 3

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2
Q

Aortic stenosis: clinical features of symptomatic disease

A
  • chest pain
  • dyspnoea
  • SYNCOPE / presyncope (e.g. exertional dizziness)
  • MURMUR = an ejection systolic murmur (ESM) in AS
    = radiates to the carotids
    = decreased following the Valsalva manoeuvre
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3
Q

AS: clinical features of severe disease

A
  • narrow pulse pressure
  • slow rising pulse
  • delayed ESM
  • soft/absent S2
  • S4
  • thrill
  • duration of murmur
  • left ventricular hypertrophy or failure
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4
Q

AS: Causes

A

Most common:
>65yo: degenerative calcification
<65yo: bicuspid aortic valve

William’s syndrome (supravalvular aortic stenosis)
Post-rheumatic disease
Subvalvular: HOCM

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5
Q

AS: Management

A

asymptomatic –> observe
- asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction –> consider surgery

Symptomatic –> valve replacement

options for aortic valve replacement (AVR) include:
1. surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined

  1. transcatheter AVR (TAVR) is used for patients with a high operative risk

*balloon valvuloplasty may be used in
- children with no aortic valve calcification
- adults limited to patients with critical aortic stenosis who are not fit for valve replacement

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6
Q

What is aortic regurgitation

A

Leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.

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7
Q

What are the 2 subgroups of AR causes?

A
  1. Valve disease
  2. Aortic root disease (distortion or dilatation of aortic root or ascending aorta)
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8
Q

AR causes: valve disease

A
  • rheumatic fever: the most common cause in the developing world
  • calcific valve disease
  • infective endocarditis
  • connective tissue diseases e.g. rheumatoid arthritis/SLE
  • bicuspid aortic valve (affects both the valves and the aortic root)
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9
Q

AR causes: aortic root

A
  • bicuspid aortic valve (affects both the valves and the aortic root)
  • aortic dissection
  • spondylarthropathies (e.g. ankylosing spondylitis)
  • hypertension
  • syphilis
  • Marfan’s, Ehler-Danlos syndrome
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10
Q

AR: features

A
  • early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
    -collapsing pulse
    -wide pulse pressure
    -Quincke’s sign (nailbed pulsation)
    -De Musset’s sign (head bobbing)
    -mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
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11
Q

AR investigations

A

Echo

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12
Q

AR management

A

medical management of any associated heart failure
surgery: aortic valve indications include
- symptomatic patients with severe AR
- asymptomatic patients with severe AR who have LV systolic dysfunction

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13
Q

Mitral stenosis: what is it

A

Obstruction of blood flow across the mitral valve from the left atrium to the left ventricle. This leads to increases in pressure within the left atrium, pulmonary vasculature and right side of the heart.

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14
Q

Causes of MS

A

rheumatic fever, rheumatic fever and rheumatic fever
Rarer causes
- mucopolysaccharidoses
carcinoid and endocardial fibroelastosis

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15
Q

Features of MS

A
  • dyspnoea
    *↑ left atrial pressure → pulmonary venous hypertension
  • haemoptysis
    • due to pulmonary pressures and vascular congestion
      may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins
  • mid-late diastolic murmur (best heard in expiration)
  • loud S1, opening snap
  • low volume pulse
  • malar flush
  • atrial fibrillation
    * secondary to ↑ left atrial pressure → left atrial enlargement
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16
Q

Features of severe MS

A

length of murmur increases
opening snap becomes closer to S2

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17
Q

MS: investigations

A

CXR - left atrial enlargement may be seen
Echo - normal cross-sectional area of the mitral valve is 4-6 sq cm. A ‘tight’ mitral stenosis implies a cross-sectional area of < 1 sq cm

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18
Q

MS: management
1. Associated AF
2. Asymptomatic
3. Symptomatic

A
  1. patients with associated atrial fibrillation require anticoagulation
    - moderate/severe MS –> warfarin
    - may consider DOACs if mild MS
  2. asymptomatic patients
    - monitored with regular echocardiograms
    - percutaneous/surgical management is generally not recommended
  3. symptomatic patients
    - percutaneous mitral balloon valvotomy
    - mitral valve surgery (commissurotomy, or valve replacement)
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19
Q

Mitral regurgitation: what is it

A

Also known as mitral insufficiency, mitral regurgitation (MR) occurs when blood leaks back through the mitral valve on systole

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20
Q

What are the most common valve problems?

A
  1. Aortic stenosis
  2. Mitral regurgitation
21
Q

Risk factors of MR

A

Female sex
Lower body mass
Older age
Renal dysfunction
Prior myocardial infarction
Prior mitral stenosis or valve prolapse
Collagen disorders e.g. Marfan’s Syndrome and Ehlers-Danlos syndrome

22
Q

Causes of MR

A
  1. CAD or post-MI: e.g. papillary muscles or chordae tendinae are affected by a cardiac insult
  2. Mitral valve prolapse
  3. Infective endocarditis
  4. Rheumatic fever
  5. Congenital
23
Q

Symptoms of MR

A
  • Most patients with MR are asymptomatic, and patients suffering from mild to moderate MR may stay largely asymptomatic indefinitely.

Symptoms tend to be due to failure of the left ventricle, arrhythmias or pulmonary hypertension.
- fatigue, shortness of breath and oedema

24
Q

MR: investigations

A
  • ECG may show a broad P wave, indicative of atrial enlargement (p mitrale)
  • CXR - cardiomegaly may be seen, with an enlarged left atrium and ventricle
  • Echocardiography is crucial to diagnosis and to assess severity
25
Q

Management of MR

A
  1. Medical management in acute cases
    - nitrates
    - diuretics
    - positive inotropes
    - intra-aortic balloon pump to increase cardiac output
  2. If HF:
    - ACE inhibitors may be considered along with beta-blockers and spironolactone
  3. In acute, severe regurgitation, surgery is indicated
  4. The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates
    When this is not possible, valve replacement with either an artificial valve or a pig valve is considered
26
Q

Mitral valve prolapse: what is it

A

Leaflets of the mitral valve are deformed so the valve does not close properly and allows for backflow. Most patients with this have a trivial degree of mitral regurgitation.

27
Q

Associations of mitral valve prolapse

A
  • usually idiopathic, but can have association with

congenital heart disease: PDA, ASD
cardiomyopathy
Turner’s syndrome
Marfan’s syndrome, Fragile X
osteogenesis imperfecta
pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
long-QT syndrome
Ehlers-Danlos Syndrome
polycystic kidney disease

28
Q

Features of mitral valve prolapse

A
  • atypical chest pain or palpitations
  • mid-systolic click (occurs later if patient squatting)
  • late systolic murmur (longer if patient standing)
29
Q

Complications of mitral valve prolapse

A

mitral regurgitation, arrhythmias (including long QT), emboli, sudden death

30
Q

Which murmurs are ejection systolic?

A
  • louder on expiration:
    1. aortic stenosis
    1. hypertrophic obstructive cardiomyopathy (HOCM)
  • louder on inspiration
    2. pulmonary stenosis
    2. atrial septal defect
  • also: tetralogy of Fallot
31
Q

Which murmurs are pansystolic?

A
  1. mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
    • TR louder during inspiration: venous blood flow into the right atrium and ventricle are increased → increases the stroke volume of the right ventricle during systole
  2. ventricular septal defect (‘harsh’ in character)
32
Q

Which murmurs are late systolic?

A

mitral valve prolapse
coarctation of aorta

33
Q

Which murmurs are early diastolic?

A

aortic regurgitation (high-pitched and ‘blowing’ in character)

Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)

34
Q

Which murmurs are mid-late diastolic?

A

mitral stenosis (‘rumbling’ in character)
Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)

35
Q

What type of murmur is PDA

A

Continuous machine-like murmur

36
Q

Murmur: AS

A

Ejection systolic

37
Q

Murmur: HOCM

A

Ejection systolic

38
Q

Murmur: pulmonary stenosis

A

Ejection systolic

39
Q

Murmur: ASD

A

Ejection systolic

40
Q

Murmur: ToFallot

A

Ejection systolic

41
Q

Murmur: MR/TR

A

Pansystolic

42
Q

Murmur: VSD

A

Pansystolic

43
Q

Murmur: mitral valve prolapse

A

Late systolic

44
Q

Murmur: coarctation of the aorta

A

Late systolic

45
Q

Murmur: AR/PR (Graham-Steel)

A

Early diastolic

46
Q

Murmur: MS

A

Mid-late diastolic

47
Q

Murmur: Severe AR (Austin-Flint)

A

Mid-late diastolic

48
Q

Murmurs: RILE mnemonic

A

Right-sided murmur → heard best on Inspiration
Left-sided murmur → heard best on Expiration

CARDIOVASCULAR (20 decks)

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