Valvular Disease

Question 1

What are the 4 valve areas for auscultation?

Answer 1

Aortic: 2nd I.C.S right sternal boarder
Pulmonary: 2nd I.C.S left sternal boarder
Tricuspid: 5th I.C.S left sternal boarder
Mitral: 5th I.C.S mid clavicular line (apex area)

Question 2

The first heart sound (S1) is caused by

Answer 2

closure of mitral and tricuspid valves
soft if long PR or mitral regurgitation
loud in mitral stenosis

Question 3

The second heart sound (S2) is caused by

Answer 3

closure of aortic and pulmonary valves
soft in aortic stenosis
splitting during inspiration is normal

Question 4

S3 (third heart sound) is caused by

Answer 4

caused by diastolic filling of the ventricle

considered normal if < 30 years old (may persist in women up to 50 years old)

heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

Question 5

What causes S4 fourth heart sound?

Answer 5

caused by atrial contraction against a stiff ventricle
(therefore coincides with the P wave on ECG)

may be heard in aortic stenosis, hypertension & HOCM (in HOCM a double apical impulse may be felt as a result of a palpable S4)

Question 6

Aortic stenosis Clinical features of symptomatic disease?

Answer 6

chest pain
dyspnoea
syncope

Question 7

What type of murmur do you get in aortic stenosis?

Answer 7

an ejection systolic murmur (ESM) is classically seen in aortic stenosis
classically radiates to the carotids
this is decreased following the Valsalva manoeuvre

Question 8

Features of severe aortic stenosis

Answer 8

Pulse: narrow pulse pressure & slow rising pulse
Heart Sounds: delayed Ejection Systolic Murmur, soft/absent S2, S4

thrill
left ventricular hypertrophy or failure

Question 9

Causes of aortic stenosis

Answer 9

degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM

Question 10

Management of aortic stenosis

Answer 10

if asymptomatic then observe the patient is general rule (unless valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery)

if symptomatic then valve replacement

Cardiovascular disease may coexist. For this reason an angiogram is often done prior to surgery so that the procedures can be combined
balloon valvuloplasty (limited to patients with critical aortic stenosis who are not fit for valve replacement)

Question 11

What murmur do you get in Aortic regurgitation

Answer 11

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre

Question 12

Features of aortic regurgitation

Answer 12

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

Question 13

Causes of aortic regurgitation (due to valve disease)

Answer 13

rheumatic fever
infective endocarditis
connective tissue diseases e.g. RA/SLE
bicuspid aortic valve

Question 14

Causes of aortic regurgitation (due to valve disease)

Answer 14

aortic dissection
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan's, Ehler-Danlos syndrome

Question 15

Ejection systolic murmur

louder on expiration suggests?

Answer 15

aortic stenosis

hypertrophic obstructive cardiomyopathy

Question 16

Ejection systolic murmur

louder on inspiration suggests?

Answer 16

pulmonary stenosis
atrial septal defect
also: tetralogy of Fallot

Question 17

Holosystolic (pansystolic) murmur could be?

Answer 17

mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)

tricuspid regurgitation becomes louder during inspiration, unlike mitral stenosis
during inspiration, the venous blood flow into the right atrium and ventricle are increased → increases the stroke volume of the right ventricle during systole

ventricular septal defect (‘harsh’ in character)

Question 18

Late systolic murmur could be?

Answer 18

mitral valve prolapse

coarctation of aorta

Question 19

Early diastolic murmur could be?

Answer 19

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

Question 20

Mid-late diastolic murmur?

Answer 20

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

Question 21

Continuous machine-like murmur?

Answer 21

patent ductus arteriosus

Question 22

Features of mitral stenosis?

Answer 22

mid-late diastolic murmur (best heard in expiration)
loud S1, opening snap
low volume pulse
malar flush
atrial fibrillation

Question 23

causes of mitral stenosis?

Answer 23

rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis

Question 24

Features of severe MS?

Answer 24

length of murmur increases

opening snap becomes closer to S2

Question 25

CXR & MS?

Answer 25

left atrial enlargement may be seen

Question 26

Echo & MS?

Answer 26

the 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

Question 27

hARD ASS MRS. MSD

Answer 27

hARD: Aortic Regurg = Diastolic
ASS: Aortic Stenosis = Systolic
MRS: Mitral Regurg = Systolic
MSD: Mitral Stenosis = Diastolic

Question 28

What is Mitral regurgitation

Answer 28

mitral regurgitation (MR) occurs when blood leaks back through the mitral valve on systole
mitral valve is located between the left atrium and ventricle, and regurgitation leads to a less efficient heart as less blood is pumped through the body with each contraction.

Question 29

Mitral regurgitation is the commonest valve disease

Answer 29

false

It is the second most common valve disease after aortic stenosis.

Question 30

MR is common in otherwise healthy patients to a trivial degree and does not need treatment.

Answer 30

true

Question 31

What is the sequelae of MR?

Answer 31

As the degree of regurgitation becomes more severe, the body’s oxygen demands may exceed what the heart can supply and as a result, the myocardium can thicken over time. While this may be benign initially, patients may find themselves increasingly fatigued as a thicker myometrium becomes less efficient, and eventually go into irreversible heart failure.

Question 32

Risk factors for MR?

Answer 32

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

Question 33

Causes of MR?

Answer 33

Following coronary artery disease or post-MI: if the papillary muscles or chordae tendinae are affected by a cardiac insult, mitral valve disease may ensue as a result of damage to its supporting structures.
Mitral valve prolapse: Occurs when the leaflets of the mitral valve is deformed so the valve does not close properly and allows for backflow. Most patients with this have a trivial degree of mitral regurgitation.
Infective endocarditis: When vegetations from the organisms colonising the heart grow on the mitral valve, it is prevented from closing properly. Patients with abnormal valves are more likely to develop endocarditis as opposed to their peers.
Rheumatic fever: While this is uncommon in developed countries, rheumatic fever can cause inflammation of the valves and therefore result in mitral regurgitation.
Congenital

Question 34

Symptoms MR?

Answer 34

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.

This may present as fatigue, shortness of breath and oedema.

Question 35

Characteristic of MR murmur?

Answer 35

“blowing” pansystolic murmur described as .
It is heard best at the apex and radiating into the axilla.
S1 may be quiet as a result of incomplete closure of the valve. Severe MR may cause a widely split S2

Question 36

Investigations of MR?

Answer 36

ECG may show a broad P wave, indicative of atrial enlargement
Cardiomegaly may be seen on chest x-ray, with an enlarged left atrium and ventricle
Echocardiography is crucial to diagnosis and to assess severity

Question 37

Treatment for MR?

Answer 37

Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output

If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone

In acute, severe regurgitation, surgery is indicated

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

Question 38

ascending aortic dissection may cause aortic stenosis

Answer 38

false

aortic regurgitation

Question 39

A systolic murmur heard best in the 5th intercostal space is most consistent with ?

Answer 39

mitral regurgitation