Valvular Disease

Question 1

What are the four types of valvular disease?

Answer 1

mitral stenosis
mitral regurgitation
Aortic stenosis
Aortic regurgitation

Question 2

What is the main cause for mitral stenosis

Answer 2

rheumatic heart disease

Question 3

Describe the sequences of patho physiology of mitral stenosis.

Answer 3

Valve decreases in size-MV orifice

Question 4

What are the clinical signs of mitral stenosis ?

Answer 4

¥ Dyspnoea (SOB): mild exertional to pulmonary oedema
¥ Haemoptisis: rupture of thin-walled veins
¥ Systemic embolisation: Left Atria and Left Atria Appendage enlargement – which can cause a stroke
¥ IE – infected endocarditis
¥ Chest pain
Hoarseness (compression of the L recurrent laryngeal nerve

Question 5

Clinical examination for mitral stenosis.

Answer 5

¥	Mitral facies – redness of the checks and nose
¥	Pulse – normal (no volume overload) 
¥	JVP – prominent a wave
¥	Tapping apex beat and diastolic thrill
¥	RV heave
¥	Murmur on auscultation

Question 6

What four investigations should be done for mitral stenosis?

Answer 6

• ECG
• CXR
• Echocardiography - Thickening and scarring of the leaflets, Fusion of the commissures
• Cardiac magnetic resonance

Question 7

what is the treatment for mitral stenosis ?

Answer 7

Nothing should be done until the stenosis is severe.
¥ Diuretics and restriction of Na intake
¥ AF: SR restoration or ventricular rate control
¥ Anticoagulation: all those with AF, debatable in SR

Intervention treatment:
¥ Valvotomy (balloon vs surgical)
¥ MVR

Question 8

What are the causes of mitral regurgitation?

Answer 8

¥ Rheumatic Heart Disease – strephtococcal infection (sore throat) = leading cause
¥ Mitral valve prolapse (MVP) – bulges into atrium
¥ IE – infected endocarditis
¥ Degenerative – genetic
¥ Functional Mitral Regurgitation due to LV and annular (ring around valve) dilatation

Question 9

When the annular enlarged the regurgitant volume increases with MR. The enlargement is dependant on three things. What are they?

Answer 9

preload
after load
LV contractibility

Question 10

The left ventricle has to pump harder as the preload is less as blood is flowing back into the left atrium instead of out the aorta.
Compare the differences of acute and chronic mitral regurgitation.

Answer 10

ACUTE - Decreased = ESV and wall tension

CHRONIC - Increased = EDV, Normal = ESV, LVH develops

Question 11

What are the clinical signs of acute and chronic mitral regurgitation?

Answer 11

Acute MR (valve perforation(hole), chordal/pap muscle) - sudden
¥ Breathlessness: pulm oedema, cardiogenick shock
¥ Rapid, sudden volume overload, sudden snapping of pap muscle for example

Chronic MR:
¥ Fatigue, exhaustion (low CO), Right heart failure, SOB
¥ Dyspnoea or palpitations due to Afib
¥ Over years

Question 12

What should be found on clinical examination with MR?

Answer 12

¥ Pulse – normal or reduced in heart failure
¥ JVP – prominent if RH failure present
¥ Brisk and hyperdynamic apex beat
¥ RV heave
¥ Murmur - Holosystolic, blowing, loud at apex, radiating to the axilla

Question 13

What are the three investigations that should be done for mitral regurgitation?

Answer 13

¥	ECG:
o	LA enlargement (P>0.12 sec, tall), 
o	RVH (prominent R wave in R precordial leads)
¥	CXR: 
o	cardiomegaly, 
o	LA enlargement, 
o	calcification of mitral annulus		
¥	Cardiac catheterisation: 
o	LV angiography – obsolete
¥	Echocardiography 
o	LV dimensions

Question 14

Treatment for mitral regurgitation?

Answer 14

¥ Acute MR: preload and afterload reduction may be life-saving (sodium nitroprusside, dobutamine, IABP- vasodilators)
¥ Chronic MR: lack of evidence that any therapy is beneficial for haemodynamic improvement, LV function preservation – wait till severe

Interventional treatment – only if regurgitation is severe
¥ Mitral valve apparatus repair
¥ Mitral valve replacement

Question 15

LA compliance may be increased or decreased with MR.

What are the effects of increased and decreased compliance?

Answer 15

Reduced 
-	marked pressure rise, 
-	thickening of atrial myocardium, 
-	increase in PVR 
-	remodeling of the pulmonary vasculature with PHT
Increased – 	
-	marked volume enlargement, 
-	lesser changes in pulmonary vasculature
-	develop AF

Question 16

What are the three causes of aortic stenosis?

Answer 16

¥ Degenerative - linked to atherosclerosis, a slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins
¥ Rheumatic - Adhesion, fusion of the commissures and retraction and stiffening of the free cusp margins
¥ Bicuspid – born with two cusps – prone to becoming leaky/narrow

Question 17

What is the normal and stenosed diameters of the aorta?

Answer 17

normal = 3-4cm

stenosis =

Question 18

What is the patho physiology of aortic stenosis?

Answer 18

1. Increased LV systolic pressure
2. Severe concentric hypertrophy and LVM (mass)
3. Increased LVEDP (Left atrial p increases, PHT)
4. Increased O2 demand
5. Myocardial ischaemia
6. LV failure

Question 19

what are the symptoms of aortic stenosis?

Answer 19

¥ Long asymptomatic phase- can go decades without symptoms
¥ However, when the patient gets symptoms the survival curve is very dramatic and sudden death rate is very high.
¥ Cardinal Symptoms
Ð Chest pain (angina)
Ð Syncope/Dizziness (exertional pre-syncope)
Ð Breathlessness on exertion
Ð Heart failure

Question 20

What would be found on clinical examination for aortic stenosis?

Answer 20

¥ Pulse – small volume and slowly rising
¥ JVP – prominent if RH failure present, low BP
¥ Vigurous and sustained apex beat
¥ RV heave
¥ Murmur = Late peaking, loud at the base, harsh, radiating to the carotids – easiest murmur to hear

Question 21

What are the three investigations used for aortic stenosis/

Answer 21

ECG (LV strain) 
CXR 
Echocardiography 
o	Demonstrates the AV cusp mobility
o	LV function and hypertrophy
o	Doppler haemodynamic assessment of pressure gradient and AVA

Question 22

Treatment for aortic stenosis?

Answer 22

Very limited

Interventional treatment
¥ Aortic valve replacement or repair

Question 23

What are the main causes for aortic regurgitation regarding the aorta and the leaflets?

Answer 23

Aorta
Ð Dilated aorta (Marfans, hypertension)
Ð Connective tissue disorders – aorta becomes enlarged which pulls the leaflets apart and causes the valve to be more leaky.

Leaflets
Ð	Bicuspid aortic valve
Ð	Rheumatic heart disease
Ð	Endocarditis
Ð	Myxomatous degeneration

Question 24

What is the patho physiology for aortic regurgitation?

Answer 24

1. LV accommodates both SV and RegVol (volume overload)
2. Increased LV-EDV and LV systolic pressure
3. LV hypertrophy as LV having to pump harder to expel more blood and LV dilatation
4. Increased demand for O2
5. Myocardial ischaemia
6. LV failure

Question 25

Symptoms of aortic regurgitation

Answer 25

¥ Chronic AR:
Ð Long asymptomatic phase
Ð Exertional breathlesness

¥ Acute AR:
Ð Poorly tolerated as wall tension cannot acutely adapt

Question 26

What would you find on clinical examination of aortic regurgitation?

Answer 26

¥ Pulse – large volume and collapsing (Corrigan sign)
¥ Wide pulse pressure – eg. 200/30 BP
¥ Hyperdynamic, displaced apex beat
¥ Murmur = Early diastolic, descrescendo, soft murmur

Question 27

What are the three investigations that would be done for aortic regurgitation?

Answer 27

¥ ECG: ST/T changes (LV strain), LAD
¥ CXR: cardiomegaly in chronic AR
¥ Echocardiography
o Demonstrates the AV cusp anatomy (thickening, prolapsing, number of cusps, vegetations)
o LV function, dilatation and hypertrophy
o Doppler haemodynamic assessment of regurgitant flow

Question 28

What is the treatment of aortic regurgitation ?

Answer 28

¥ Vasodilator therapy shown to delay the timing for surgical intervention

Interventional treatment
¥ Aortic valve replacement or repair