Valvular Disease Flashcards
What are the 4 valve areas for auscultation?
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)
The first heart sound (S1) is caused by
closure of mitral and tricuspid valves
soft if long PR or mitral regurgitation
loud in mitral stenosis
The second heart sound (S2) is caused by
closure of aortic and pulmonary valves
soft in aortic stenosis
splitting during inspiration is normal
S3 (third heart sound) is caused by
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
What causes S4 fourth heart sound?
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)
Aortic stenosis Clinical features of symptomatic disease?
chest pain
dyspnoea
syncope
What type of murmur do you get in aortic stenosis?
an ejection systolic murmur (ESM) is classically seen in aortic stenosis
classically radiates to the carotids
this is decreased following the Valsalva manoeuvre
Features of severe aortic stenosis
Pulse: narrow pulse pressure & slow rising pulse
Heart Sounds: delayed Ejection Systolic Murmur, soft/absent S2, S4
thrill
left ventricular hypertrophy or failure
Causes of aortic stenosis
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
Management of aortic stenosis
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)
What murmur do you get in Aortic regurgitation
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
Features of aortic regurgitation
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
Causes of aortic regurgitation (due to valve disease)
rheumatic fever
infective endocarditis
connective tissue diseases e.g. RA/SLE
bicuspid aortic valve
Causes of aortic regurgitation (due to valve disease)
aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome
Ejection systolic murmur
louder on expiration suggests?
aortic stenosis
hypertrophic obstructive cardiomyopathy
Ejection systolic murmur
louder on inspiration suggests?
pulmonary stenosis
atrial septal defect
also: tetralogy of Fallot
Holosystolic (pansystolic) murmur could be?
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)
Late systolic murmur could be?
mitral valve prolapse
coarctation of aorta
Early diastolic murmur could be?
aortic regurgitation (high-pitched and 'blowing' in character) Graham-Steel murmur (pulmonary regurgitation, again high-pitched and 'blowing' in character)
Mid-late diastolic murmur?
mitral stenosis ('rumbling' in character)
Austin-Flint murmur (severe aortic regurgitation, again is 'rumbling' in character)Continuous machine-like murmur?
patent ductus arteriosus
Features of mitral stenosis?
mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillation
causes of mitral stenosis?
rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
Features of severe MS?
length of murmur increases
opening snap becomes closer to S2
CXR & MS?
left atrial enlargement may be seen
Echo & MS?
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
hARD ASS MRS. MSD
hARD: Aortic Regurg = Diastolic
ASS: Aortic Stenosis = Systolic
MRS: Mitral Regurg = Systolic
MSD: Mitral Stenosis = Diastolic
What is Mitral regurgitation
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.
Mitral regurgitation is the commonest valve disease
false
It is the second most common valve disease after aortic stenosis.
MR is common in otherwise healthy patients to a trivial degree and does not need treatment.
true
What is the sequelae of MR?
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.
Risk factors for MR?
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
Causes of MR?
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
Symptoms MR?
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.
Characteristic of MR murmur?
“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
Investigations of MR?
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
Treatment for MR?
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
ascending aortic dissection may cause aortic stenosis
false
aortic regurgitation
A systolic murmur heard best in the 5th intercostal space is most consistent with ?
mitral regurgitation
