Valvular disease Flashcards
Causes of Aortic Stenosis
Age related Calcification Bicuspid valve Rheumatic heart disease ESRF Paget's SLE Fabry's disease Alkaptonuria
Clinical manifestation of Aortic Stenosis
Ejection systolic murmur at right upper sternal edge - Mid-late indicates severity - Loud murmur indicates severity - Gallavardin phenomenon is the radiation to apex beat and mimicking MR Soft S2 - Absent S2 in severe cases Delayed rising carotid pulse S1 ejection click in bicuspid valve Heaving Apex beat
Indications for valve replacement
Aortic stenosis - Aortic valve area <1.0cm2, pressure >40mmHg or vmax >4m/s
- With symptoms of cardiac failure, syncope or angina OR
- LVEF <50% OR
- Undergoing other cardiac surgery OR
- Abnormal stress test OR
- Low surgical risk Vmax >5m/s or change 0.3m/s/yr
Below severe cases and the following
- LVEF <50%, Valve <1cm2 and Vmax >4m/s after Dobamine stress test with symptoms
- Other cardiac surgery at the same time
Causes of Mitral regurgitation
1) Valve related Myxomatous degeneration of heart valve Rheumatic heart disease Infective endocarditis Annular calcification Ergotamine medications 2) Functional Post-infarction MR Papillary muscle rupture Dilated cardiomyopathy Hypertrophic cardiomyopathy Right heart pacing
Clinical manifestation of mitral regurgitation
Pansystolic murmur at apex radiating to axilla
- mid to late reflects severity
- Loudness reflects severity in primary MR
Murmur reduced in intensity with valsalva, increased with leg raising (increasing venous return)
Soft S1 in chronic states
Split S2 in chronic states
Loud P2 in chronic states, reflecting pulmonary regurgitation
Bounding pulse in acute MR only
Clinical indications for valve replacement in MR
Severe MR- Regurgitant volume >60mL, regurgitant fraction is > 50%, effective regurgitant orifice >0.4cm2
- Symptomatic and LVEF >30%
- Asymptomatic and LVEF <60% and LV end systolic diameter >4cm
- Asymptomatic, likelihood of successful outcome, end systolic diameter <4cm, LVEF >60% and/or new AF or PASP >50mmHg
For functional MR, if NYHA III-IV symptoms with severe MR, indication for treatment
Causes of mitral stenosis
Rheumatic heart disease Age related calcification SLE Ergotamine or anorectic based drugs Carcinoid syndrome
Complications of Mitral Stenosis
Atrial fibrillation Atrial thrombosis Pulmonary Hypertension Right Heart failure Infective endocarditis Hoarseness (laryngeal compression from atrial hypertrophy)
Clinical manifestations of Mitral Stenosis
Ruddy face
JVP - enlarged v wave (if associated TR), a wave (if associated pulmonary stenosis and no AF)
AF
Soft S1
Opening snap (OS) after S2
- S2-OS interval increases (and makes audible) with expiration
Late diastolic murmur at apex
- The length of time murmur present indicates severity
- Increasing venous return increases duration of murmur (but shortens S2-OS interval)
Loud P2, parasternal heave
Indications for intervention for mitral stenosis
Mitral valve area of <1.5cm2 Absence of atrial thrombus Absence of MR NYHA III-IV heart failure symptoms Favourable valve morphology
Balloon valvotomy first, if fails then surgery
Asymptomatic patients Mitral valve area <1.0cm2 required plus above
Indications for valve replacement in Infective Endocarditis
Aortic/mitral valves
- New Heart failure
- Para-aortic abscess or valvular destruction
- New regurgitation
- Vegetation >10mm
- Persistent positive BCs >5/7
Modified Duke criteria for IE
Major
- Two positive BCs growing typical IE bacteria S aureus, S. viridians, S. gallolyticus/bovis, E. faecalis w/o localisation, HACEK
- Persistently positive BCs >4 skin contaminant bacteria
- Single positive Coxiella culture or IgG titre >800
- Vegetation, new regurgitation, abscesss, partial dishescence
Minor
- Prosthetic heart valve or lesion
- Fever
- Positive cultures that do not meet criteria
- Vascular phenomenon - emboli, septic pulmonary infarcts, mycotic aneurysm, conjunctival haemorrhages, janeway lesions, cerebral haemorrhages
- Autoimmune phenomenon - GN, osler’s nodes, roth spots, positive RF
Jones criteria for Rheumatic fever
5 Major Criteria
- Cariditis or valvulitis (mitral and aortic valve involvement most commonly, pancarditis in severe cases)
- Arthritis (asymmetric large joint migratory polyarthritis 2-3 wks post GAS infection, self limiting 4wks)
- Sydenham’s Chorea
- Subcutaneous nodules (symmetric small nodules over tendons and bony regions, most commonly olecranon, present with severe carditis, self limiting 4wks)
- Erythema marginatum (pink non-purpuric rash on trunk and limbs)
4 Minor criteria
- Arthralgia
- Fever
- Elevated ESR and CRP
- prolonged PR on ECG
Diagnosis of Rheumatic fever
Documented GAS infection (positive ASOT, positive throat culture, rapid antigen test) and 2 major manifestations or 1 major and 2 minor manifestations
PHx ARF w/ 2 major, 1 major and 2 minor and 3 minor criteria suffice for dx
Chorea alone suffices for suspicion and requires TTE
Carditis following GAS infection
Lower cut offs for endemic areas: monoarthritis/arthralgia,ESR >30
Treatment of ARF and prophylaxis
NSAIDs for arthritis
Penicillin G from diagnosis and treatment for impetigo
Throat cultures for household contacts
Treatment for carditis heart failure - frusemide, ACEI
Prophylaxis
- ARF with carditis and residual RHD - Penicillin G 10 yrs or until 40yo
- ARF with carditis w/o resitdual RHD - 10yrs or until 21yrs
- ARF w/o carditis - 5yrs
