Valvular disease

Question 1

Cause of Aortic Stenosis?

Answer 1

old: calcification of the valve
younger: bicuspid valve, williams synd
Rheumatic fever

Question 2

Symptoms of Aortic Stenosis?

Answer 2

classic triad is dyspnoea, angina, syncope (w/ exercise)
LXF: PND, orthopnoea, frothy sputum
arrhytmias
death

Question 3

Signs of Aortic Stenosis?

Answer 3

Slow rising pulse
aortic thrill
apex is forceful

Question 4

Murmur in Aortic Stenosis?

Answer 4

ESM
right 2nd ICS
sitting forward in end expiration
radiates to carotid

Question 5

Indicators of severe Aortic Stenosis?

Answer 5

Quiet / absent A2
 S4
 Narrow pulse pressure
 Decompensation: LVF

Question 6

DD of Aortic Stenosis?

Answer 6

 Coronary artery disease
 MR
 Aortic sclerosis
 Valve thickening: no pressure gradient
 Turbulence → murmur
 ESM c¯ no radiation and normal pulse
 HOCM
 ESM murmur which ↑ in intensity c¯ valsalva (AS↓)

Question 7

Ix for all murmurs

Answer 7

bloods
ecg
chest xray
echo
cardiac catheterisation

Question 8

Management of AS?

Answer 8

Medical
 Optimise RFs: statins, anti-hypertensives, DM
 Monitor: regular f/up c¯ echo
 Angina: β-B
 Heart failure: ACEi and diuretics
 Avoid nitrates
Surgical
 Poor prog. if symptomatic
 Angina/syncope: 2-3yrs
 LVF: 1-2yrs
 Indications for valve replacement
 Severe symptomatic AS
 Severe asymptomatic AS c¯ ↓ EF (<50%)
 Severe AS undergoing CABG or other valve op
 Valve types
 Mechanical valves last longer but need
anticoagulation: young pts.
 Bioprosthetic don’t require anticoagulation but
fail sooner (10-15yrs)

Question 9

Options for unfit pts in AS?

Answer 9

 Balloon Valvuloplasty
 Limited use in adults as complication rate is
high (>10%) and restenosis occurs in 6-12mo
 Transcatheter Aortic Valve Implantation (TAVI)
 Folded valve deployed in aortic root.
 ↑ perioperative stroke risk cf. replacement
 ↓ major bleeding
 Similar survival @ 1yr
 Little Long-term data

Question 10

Causes of AR?

Answer 10

Acute
 Infective endocarditis
 Type A aortic dissection
Chronic
 Congenital: bicuspid aortic valve
 Rheumatic heart disease
 Connective tissue: Marfan’s, Ehler’s Danlos
 Autoimmune: Ank spond, RA

Question 11

Symptoms of AR?

Answer 11

 LVF: Exertional dyspnoea, PND, orthopnoea
 Arrhythmias (esp. AF) → palpitations
 Forceful heart beats
 Angina

Question 12

Signs of AR? eponyms?

Answer 12

Collapsing pulse (Corrigan’s pulse)
 Wide PP
 Apex: displaced (volume overload)

 Corrigan’s sign: carotid pulsation
 De Musset’s: head nodding
 Quincke’s: capillary pulsation in nail beds
 Traube’s: pistol-shot sound over femorals
 Austin-Flint murmur
 Rumbling MDM @ apex due to regurgitant jet
fluttering the ant. mitral valve cusp.
 = severe AR
 Duroziez’s
 Systolic murmur over the femoral artery c¯ proximal
compression.
 Diastolic murmur c¯ distal compression

Question 13

Murmur in AR?

Answer 13

EDM
 URSE + 3rd left IC parasternal
 Sitting forward in end-expiration
 ± ejection systolic flow murmur
 ± Austin-Flint murmur

Question 14

indicators of severe AR?

Answer 14

 Wide PP and collapsing pulse
 S3
 Long murmur
 Austin Flint murmur
 Decompensation: LVF

Question 15

surgical treatment of AR?

Answer 15

aortic valve replacement
 Definitive therapy
 Indicated in severe AR if:
 Symptoms of heart failure
 Asympto c¯ LV dysfunction: ↓EF/↑ES dimension

Question 16

Causes of MS?

Answer 16

aortic valve replacement
 Definitive therapy
 Indicated in severe AR if:
 Symptoms of heart failure
 Asympto c¯ LV dysfunction: ↓EF/↑ES dimension

Question 17

Pathophysiology of MS?

Answer 17

Valve narrowing → ↑ left atrial pressure → loud S1
and atrial hypertrophy → AF
 → pulmonary oedema and PHT → loud P2, PR
 → RVH → left parasternal heave

 → RHF → ↑JVP, oedema, ascites

Question 18

Symptoms of MS?

Answer 18

Dyspnoea
 Fatigue
 Chest pain
 AF → palpitations + emboli
 Haemoptysis: rupture of bronchial veins

Question 19

Signs of MS?

Answer 19

Symptoms manifest when orifice <2cm2
 (norm 4-6)
 AF, low volume pulse
 Malar flush (↓CO → backpressure + vasoconstriction)
 JVP may be raised late on
 Prominent a waves: PTH
 Large v waves: TR
 Absent a waves: AF
 Left parasternal heave (RVH 2O to PHT)

Question 20

Murmur in MS?

Answer 20

Rumbling MDM
 Apex
 Left lateral position in end expiration
 Radiates to the axilla
 ± Graham Steell murmur (EDM 2O to PR)

Question 21

indicators of severe MS?

Answer 21

Longer murmur
 Opening snap closer to 2nd heart sound
 High LA pressure forcing valve open early
 Decompensation: RVF

Question 22

Complications of MS

Answer 22

 Pulmonary HTN
 Emboli: TIA, CVA, PVD, ischaemic colitis
 Hoarseness: rec laryngeal N. palsy = Ortner’s Syn
 Dysphagia (oesophageal compression)
 Bronchial obstruction

Question 23

Management of MS?

Answer 23

AF: rate control and anticoagulate
 Diuretics provide symptom relief

Surgical
 Indicated in mod–severe MS (asympto and symptomatic)
 Percutaneous balloon valvuloplasty
 Rx of choice
 Suitability depends on valve characteristics
 Pliable, minimally calcified
 CI if left atrial mural thrombus
 Surgical valvotomy / commissurotomy: valve repair
 Valve replacement if repair not possible

Question 24

Causes of MR?

Answer 24

Mitral valve prolapse
 LV dilatation: AR, AS, HTN
 Annular calcification → contraction (elderly)
 Post-MI: papillary muscle dysfunction/rupture
 Rheumatic fever
 Connective tissue: Marfan’s, Ehlers-Danlos

Question 25

Symptoms of MR?

Answer 25

Dyspnoea, fatigue
 AF → palpitations + emboli
 Pulmonary congestion → HTN + oedema

Question 26

Signs of MR

Answer 26

AF

 Left parasternal heave (RVH)

Question 27

Murmur in MR?

Answer 27

 Blowing PSM
 Apex
 Left lateral position in end expiration
 Radiates to the axilla

Question 28

Severe MR?

Answer 28

Larger LV
 Decompensation: LVF
 AF

Question 29

Management of MR?

Answer 29

AF: rate control and anticoagulate
 Also anticoagulate if: Hx of embolism, prosthetic
valve, additional MS
 Drugs to ↓ afterload can help ↓ symptoms
 ACEi or β-B (esp. carvedilol)
 Diuretics

Surgical
 Valve replacement or repair
 Indications
 Severe symptomatic MR
 Severe asympto MR c¯ diastolic dysfunction: ↓EF