Valvular Disease

Question 1

What is the clinical presentation of valvular heart disease?

Answer 1

Chest pain, breathlessness, collapse/dizzy spells. Exertional symptoms.

Question 2

Describe the New York Heart Functional Classification (NYHA).

Answer 2

I - no limitation. II - slight limitation. III - marked limitation of less than ordinary activity. IV - severe limitation of minimal activity or at rest.

Question 3

What are the signs of right heart failure?

Answer 3

Raised JVP. 
Pitting oedema (put 1 finger pressure above medial malleolus). Hepatic congestion.

Question 4

What will the apex beat be like in mitral stenosis?

Answer 4

Tapping apex.

Question 5

What causes the parasternal heave?

Answer 5

Due to right ventricular overload e.g. cor pulmonale/pulmonary hypertension.

Question 6

What questions should you answer when describing murmurs?

Answer 6

Systole or diastole? What type of murmur? Where is it loudest? Where does it radiate to? What grade of murmur? Influenced by respiration?

Question 7

What are the 2 types of systolic murmur and what condition is it associated with?

Answer 7

Pansystolic (goes all the way through with same volume) e.g. mitral regurgitation. 
Ejection systolic (volume increases then decreases) e.g. aortic stenosis.

Question 8

What are the types of diastolic murmur?

Answer 8

Early diastolic (loud at start and decreases).
Mid-diastolic (rumbling).

Question 9

What is a common feature of right sided murmurs?

Answer 9

They are louder with inspiration.

Question 10

What are features of innocent murmurs?

Answer 10

Soft (less than 3/6 severity).
Position dependent.
Often early systolic (diastolic murmurs always pathological).

Question 11

What is mixed valve disease?

Answer 11

Valves which neither open properly nor close properly.

Question 12

What are the non-invasive and invasive investigations of valvular heart disease?

Answer 12

Non-invasive: echo.

Invasive: cardiac catheterisation.

Question 13

What are 3 causes of aortic stenosis?

Answer 13

1. Degenerative (age related, commonest cause).

2. Congenital e.g. bicuspid

Question 14

What are the symptoms of aortic stenosis?

Answer 14

Breathlessness, chest pain (they will not have sufficient output to coronary arteries and will get LVH leading to ischaemic chest pain), dizziness/syncope.

Question 15

What are the signs of aortic stenosis?

Answer 15

Low volume pulse, forceful displaced apex, ejection systolic murmur that can radiate to the carotids.

Question 16

What is the diagnostic investigation for valve disease?

Answer 16

Echocardiogram.

Question 17

What is the treatment for aortic stenosis?

Answer 17

Conventional valve replacement, trans catheter aortic valve replacement (TAVI), balloon aortic valvotomy (BAV).

Question 18

What are the features of mechanical and bio-prosthetic valves?

Answer 18

Mechanical: longevity (more suitable in younger patients), need warfarin for life.
Bio-prosthetic: no warfarin needed, 10 years, older patients.

Question 19

What are the benefits of aortic valve replacement (AVR, open heart surgery) over transcatheter aortic valve implantation (TAVI)?

Answer 19

It is still preferred, better long term outcomes, used when no-contraindications, can do CABG at same time.

Question 20

When would you do TAVI instead of AVR?

Answer 20

If there was co-morbitidity meaning they could not withstand surgery, or if they had a previous sternotomy (makes it difficult to do surgery again).

Question 21

What problems involving the leaflets could cause mitral regurgitation?

Answer 21

Prolapse, rheumatic, myxomatous (floppy), endocarditis.

Question 22

What problems involving chordae rupture (degenerative could cause mitral regurg)?

Answer 22

Prolapse/fail of leaflet.

Question 23

What can cause the papillary muscles to rupture (causes mitral regurg)?

Answer 23

Ischaemia.

Question 24

What are the symptoms of mitral regurgitation?

Answer 24

Breathlessness, peripheral oedema, fatigue.

Question 25

What are the clinical signs of mitral regurgitation?

Answer 25

Displaced apex, pansystolic murmur (radiates to axilla).

Question 26

What is the treatment for mitral regurgitation?

Answer 26

Medication (diuretics and heart failure [ACEIs]), surgical (repair for prolapse, replacement for degenerative), percutaneous (clips in infancy - encouraging results).

Question 27

What most often causes mitral stenosis?

Answer 27

Rheumatic cause.

Question 28

What are the symptoms of mitral stenosis?

Answer 28

Symptoms: breathlessness, fatigue, palpitations (AF, look in ECG).

Question 29

What are the signs of mitral stenosis?

Answer 29

Malar flush (caused by other things as well), tapping apex beat, mid-diastolic rumbling murmur localised to paex (patient lying on left side listening with the bell).

Question 30

What is the treatment for mitral stenosis?

Answer 30

Medications (diuretics and treat AF), surgery (valve replacement), balloon valvuloplasty.

Question 31

What are the causes of aortic regurgitation involving the leaflets?

Answer 31

Endocarditis, connective tissue diseases, rheumatic.

Question 32

What are the causes of aortic regurgitation involving the annulus (fibrous ring of the heart)?

Answer 32

Marfans, aortic dissection.

Question 33

What are the symptoms and signs of aortic regurgitation?

Answer 33

Symptoms: breathlessness.
Signs: collapsing pulse, wide pulse pressure, displaced apex, early diastolic murmur left sternal edge (decreases in volume over diastole).

Question 34

What will be seen in a CXR with aortic regurgitation?

Answer 34

Cardiomegaly.

Question 35

What treatments are there for aortic regurgication?

Answer 35

Medication (ACEIs), surgery (valve replacement).