Valvular disease

Question 1

Main causes of mitral Regurgitation

Answer 1

1. Annular dilatation (functional regurgitation)
2. Mitral valve prolapse
3. Myxomatous degeneration
4. Ischaemic (papillary muscle dysfunction)
5. Chronic rheumatic disease
6. HCM (functional regurgitation)
7. Endocarditis
8. COllagen disorders: Marfan;s syndrome, Ehler’s danlos
9. Autoimmune: SLE
10. Iatrogenic: centrally acting appetite supresants (fenfluramine), dopamine agonists (cabergoline)

Question 2

Presentation of mitral regurgitation

Answer 2

Can be asymptomatic for years and cardiac dimensions increase greatly

• *Dyspnoea + orthopnea due to pulmonary HTN**
• Fatigue + lethargy due to ↓CO*

In late stages, R heart failure and eventually congestive heart failure

Cardiac cachexia may develop

Subacute IE very common

Question 3

SIGNS of MR

Answer 3

• Laterally displaced thrusting apex
• Soft S1 due to incomplete closure of the valve
• Pansystolic murmur radiating to axial, heard throughout precordium
• Prominent S3 (early diastole) due to the sudden rush of blood into dilated LV
• The more severe, the larger the left ventricle.

Question 4

pathology in MR

Answer 4

Regurgitation into LA causes dilatation but little increase in pressure as the flow is accommodated.
In acute MR→↑↑pulmonary pressure → pulm oedema
To maintain sufficient CO → LV enlarges (hypertrophy+dilatation)

Question 5

Mitral stenosis presentation

Answer 5

Sx: mainly palpitations, breathlessnes + marked exertional Sxs.

+haemoptysis (due to pulmonary HTN)

dysphagia (due to atriomegaly)

• Malar flush(due to ↓ CO)
• Left parasternal heave if pulmonary HTN
• Pulmonary HTN → haemoptysis
• AF due to dilated LA → emboli
• Sx of Right Hear failure: ↑JVP, ascites, hepatomegaly, peripheral oedema, dyspnea, weakness, fatigue

Question 6

causes of MS

Answer 6

1. Rheumatic fever 2o A Beta-hemolytic strep
2. Lutembacher’s syndrome
3. Congenital
4. In elderly: calcification + fibrosis
5. Carcinoid tumour
6. SLE

Question 7

pathology in MS

Answer 7

Normal orifice 4-6cm2
To maintain sufficient CO →↑LA pressure → LA hypertrophy + dilatation → ∴↑pulmonary pressure (pulmonary HTN) →↑R heart pressure → RV hypertrophy + dilatation →→pulm. oedema, esp when AF develops

Question 8

SIGNS of MS

Answer 8

• Malar flush(due to ↓ CO)
• Left parasternal heave if pulmonary HTN
• Pulmonary HTN → haemoptysis
• **Localised tapping apex (palpable S1)
• Mid-diastolic murmu**r (bell, best in expiration, with pt on left side)
• Loud S1 initially. Softens when valve is immobile
• Loud S2 if Pulmonary HTN
• AF due to dilated LA → emboli
• Sx of Right Hear failure: ↑JVP, ascites, hepatomegaly, peripheral oedema, dyspnea, weakness, fatigue
• Length of diastolic murmur is proportional to severity
• The more severhe closer the opening snap is to S2
• Graham Steell murmur – pulmonary regurg due to pulm artery dilatation caused by ↑pulm pressure

Question 9

complications of MS

Answer 9

Complications:

1. Pulmonary HTN;
2. emboli,
3. pressure from large LA on local structures, eg hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus), bronchial obstruction;
4. IE.

Question 10

Aortic stenosis presentation

Answer 10

TRIAD: angina, dyspnea, syncope

sometimes sudden death

Question 11

Causes of Aortic Stenosis

Answer 11

SUBVALVULAR:

HCM

VALVULAR

1. Degeneration and calcification
2. Congenital abnormality and faster degeneration (bicuspid)
3. Rheumatic fever
4. Chronic kidney disease
5. Paget’s disease of bone
6. Previous radiation exposure
7. Homozygous familial hypercholesterolemia

SUPRAVALVULAR

obstructive

Question 12

Pathology in AS

Answer 12

Obstructed LV emptying →∴↑LV pressure → compensatory LV hypertrophy → relative ischemia of LV myocardium

Question 13

Sx of AS

Answer 13

• Pulse: small volume, slow-rising
• Apex not displaced
• May be ejection click unless valve immobile and calcified
• Soft A2/inaudible when valve immobile
• Reversed splitting of S2 (on expiration splits) rare
• S4 caused by atrial contraction unless concurrent MS prevents this
• Systolic ejection murmur,+/- radiates to carotids

Aortic sclerosis
is senile degeneration of the valve. There is an ejection systolic murmur, no carotid radiation, and normal pulse (character and volume) and S2.

Question 14

Causes of Aortic REGURGITATION

Answer 14

ACUTE: IE, ascending aorta dissection, chest trauma

CHRONIC

1. Collagen disease: Marfans, Ehlers-Danlos
2. RF
3. akayasu arteritis, rheumatoid arthritis,SLE; pseudoxanthoma elasticum,
4. appetite suppressants (eg fenfluramine, phentermine), seronegative arthritides (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthropathy),
5. hypertension,
6. osteogenesis imperfecta,
7. syphilitic aortitis.

Question 15

AR presentation

Answer 15

predominantly breathlessness

• Sx occur late not until LV failure develops.

Question 16

SIGNS OF AR

Answer 16

• Pounding of the heart due to hypertrophy
• Angina pectoris, dyspnea
• Pulse: bounding or collapsing
• Quincke’s sign – capillary pulsation in nail beds
• De musset’s sign – head nodding with each heart beat
• Duroziez’s sign – to-and-fro murmur when femoral a. is auscultated in severe AR
• Apex displaced laterally and downwards, forceful
• High-pitched early diastolic murmur best heard at LSE with pt leaning forward in expiration
• Volume overload frequently cuases ejection systolic flow murmur
• Austin Flint rumble – impinged anterior mitral valve cusp by regurgitant jet

Question 17

HCM\definition and presentation

Answer 17

≈lv outflow tract (LVOT) obstruction from asymmetric septal hypertrophy. leading cause of sudden cardiac death in the young.
0.2% Autosomal dominant, 50% sporadic. 70% have mutations in genes encoding β-myosin, α-tropomyosin, and troponin t. ? FHx of sudden death.
Sudden death may be the first manifestation, , angina, dyspnoea, palpitation, syncope, ccf.

Question 18

SIGNS OF HCM

Answer 18

• Jerky pulse;
• a wave in JVP;
• double-apex beat;
• systolic thrill at lower left sternal edge;
• harsh ejection systolic murmur.