Valvular Disease Flashcards by Tan Kitipornchai | Brainscape

Q

What are the differentials for an ejection systolic murmur louder with expiration?

A

Aortic stenosis

HOCM

Supravalvular aortic stenosis (Williams syndrome)

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Q

Aortic Stenosis - general indication for AVR

ie. Echo characteristics of severe AS

A

Severe AS = AVA < 1.0cm2

Mean gradient > 40mmHg

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Q

Aortic stenosis - indications for replacement

Symptomatic vs asymptomatic AS

A

Symptomatic AS

Severe = mean gradient > 40mmHg, AVA < 1.0cm

Asymptomatic AS:

Mod/severe AS undergoing other cardiac surgery

Severe AS AND:

LV systolic dysfunction
abnormal BP response to exercise
recurrent VT
Valve area < 0.6cm2

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Q

What are the causes of aortic stenosis?

A

Bicuspid aortic valve (young)

Degenerative calcification (elderly)

Rheumatic valve disease

Congenital

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Q

Aortic Stenosis CXR

A

LVH

Valve Calcification

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Q

Aortic Stenosis ECG

A

LVH

LV strain - ST depression + TWI in left sided leads

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Q

Aortic Stenosis - signs of severity

Pulse and palpation (2 + 2)

A

Low volume and/or slow rising pulse

Narrow pulse pressure

Aortic thrill

Heaving apex beat

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Q

Signs of aortic stenosis - characteristics on auscultation (4) + others (2)

A

Long, harsh, late-peaking murmur

S4 (gallop)

Paradoxical split S2

Soft or absent aortic component of S2

Pulmonary HTN

LV failure

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Q

Discuss SAVR vs TAVI for symptomatic AS

(4 steps)

A

Refer multidisciplinary heart valve team
Assess Life expectancy > 1 year?
Assess surgical risk and co-morbid conditions
Decision: Intermediate risk and above = TAVI; Low risk = SAVR

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Q

Aortic regurgitation - signs of severity

Pulse / Periphery (3)

Palpation / Praecordium (2)

A

Large volume, collapsing pulse

Wide pulse pressure

Signs of pulmonary hypertension

Displaced apex beat

Thrusting - hyperdynamic circulation

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Q

Aortic regurgitation - signs of severity

Auscultation (3)

Increased with isometric handgrip

(increased afterload)

A

Long duration of decrescendo diastolic murmur

Third heart sound

Soft A2

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Q

What does an Austin Flint murmur signify?

And is the mechanism behind an Austin Flint murmur?

What does an Austin Flint murmur sound like?

A

Marker of severe AR

Aortic regurgitation jet impinging on the anterior mitral valve leaflet

Low pitched, mid-diastolic murmur

Clinically, sounds same as mitral stenosis

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Q

Causes of AR

Chronic:

[valvular (2) and root (3)]

Acute (3)

A

Rheumatic fever

Congenital - bicuspid aortic valve

Age - degenerative

Aortitis - Ank Spondylitis, psoriasis etc

Marfan’s syndrome

Infective endocarditis

Dissection

Hypertension

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Q

Aortic regurgitation - indications for surgery (asymptomatic)

A

“RULE OF 55”

Ejection fraction < 55

Left ventricular end-systolic dimension (LVESD) > 55mm

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Q

Precordial pansystolic murmur - differential diagnosis (4)

A

Mitral regurgitation

Triscuspid regurgitation

Ventricular septal defect

Patent ductus arteriosis

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Q

Mitral Regurgitation - signs of severity

Peripheral signs - pulse (1)

Palpation (2)

A

Pulse - normal or jerky (if severe)

Displaced apex beat - enlarged LV

Apical systolic thrill

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Q

Mitral regurgitation - signs of severity

Auscultation (5)

A

Soft S1

Widely split S2

Third heart sound S3

Fourth heart sound S4 (if in sinus rhythm)

Mid-diastolic flow murmur

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Q

Causes of mitral regurgitation

Chronic (3)

Acute (3)

A

Degenerative

Functional MVP

Rheumatic heart disease

Infective endocarditis

AMI - papillary muscle rupture

Surgery (failing valve)

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Q

Investigations for Mitral regurgitation

ECG (3)

CXR (2)

A

p-mitrale

Atrial fibrillation

LVH/RVH

LA enlargement

Cardiomegaly

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Q

Mitral regurgitation - indications for surgery if asymptomatic

EF and LVEDD

A

“Rule of 60”

Ejection fraction < 60%

Left ventricular end-diastolic dimension > 60mm

Surgery indicated if symptomatic!

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Q

Mitral valve prolapse

Auscultation characteristics (2)

A

Systolic click

High pitched, late systolic murmur

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Q

Mitral valve prolapse

Dynamic auscultation

Longer (1)

Shorter (2)

A

Longer with: VALSALLLLLLVA

Shorter with: Hand grip or squat

(Squatting makes you shorter!)

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Q

Mitral stenosis - signs of severity

Pulse / Periphery (1)

Palpation (1)

A

Narrow pulse pressure

Diastolic thrill - “tapping apex beat”

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Q

Mitral Stenosis

Signs of severity

Auscultation (3)

A

Loud S1

Early opening snap

Length of low pitched “rumbling” late-diastolic murmur

Q

Causes of mitral stenosis

(2)

A

Rheumatic fever

Rheumatic fever

Rheumatic fever

Congenital (rare)

Q

Investigations for Mitral Stenosis

ECG (2)

CXR (2)

A

p-mitrale (bifid p waves)

Atrial fibrillation

Left atrial enlargement

Congestive cardiac failure

Q

Mitral stenosis - indications for surgery (2)

Type of procedure?

A

Valves area < 1.0cm

Mean gradient > 10mmHg

Balloon valvotomy consider in first instance unless MR

Q

Tricuspid Regurgitation - murmur characteristics (3)

A

Pan-systolic murmur

Loudest at left sternal edge

Loudest in inspiration

Q

Signs of Pulmonary Hypertension (4)

(also signs of severity of TR)

A

JVP - prominent “v” waves

Palpable P2

Parasternal heave

RHF - oedema, ascites, pulsatile hepatomegaly

Q

Causes of secondary pulmonary hypertension

What other diseases to look for on examination? (6)

A

Obstructive airways disease

Chronic type 2 respiratory failure - kyphoscoliosis or obesity

Intersitial lung disease

Systemic sclerosis

Rhuematoid arthritis

SLE

Q

Causes of TR (5)

A

Functional TR from RV dilatation

Infective endocarditis

Ebstein’s anomaly - congenital right atrial dilatation a/w ASD

RV papillary rupture

Rheumatic Heart Disease (rare than other valve lesions)

Q

Pulmonary stenosis -

Murmur characterstics (3)

Signs of severity (3)

A

Ejection systolic murmur

Loudest at pulmonary area

Increased with inspiration

Giant “a” waves in JVP (in sinus rhythm)

RV heave

Pulmonary thrill

Q

Pulmonary stenosis causes (4)

A

Congenital

Rheumatic Heart Disease

Congenital rubella

Tetralogy of Fallot

Q

Pulmonary Regurgitation Signs

Auscultation (3)

A

Early diastolic murmur

Upper left sternal edge -> radiates down left sternal edge

Loudest in inspiration

Q

Causes of pulmonary regurgitation

Primary (3)

Secondary (2)

A

Infective endocarditis

Rheumatic Heart Disease

Iatrogenic - balloon valvuloplasty, swan-ganz, fallot repair complication

Primary pulmonary hypertension

Secondary pulmonary hypertension

Q

HOCM characteristics

Pulse (2)

Palpation (1)

JVP (1)

A

Jerky carotid pulse

Double carotid impulse

Double / triple apical impulse

Prominent “a” wave - due to decreased RV compliance

Q

HOCM -

Characteristics on auscultation (3)

Dynamic auscultation (2)

A

Late ejection systolic murmur

Loudest at left sternal edge

+/- pansystolic murmur from systolic anterior motion of mitral valve

Louder with: Valsalva and standing

Softer with: squatting and handgrip

Q

HOCM investigations

ECG (3)

CXR (3)

TTE (2)

A

LVH +/- strain

Left axis deviation

deep Q waves

Cardiomegaly

Left atrial dilatation

Pulmonary congestion

Asymmetrical septal hypertrophy

Systolic anterior motion of mitral valve

Q

Atrial septal defect

Auscultation characteristics (2)

A

HALLMARK = Fixed and widely split second heart sound (S2)

ESM in pulmonary area = pulmonary flow murmur

Increased flow across pulmonary valve

Q

Signs of severity for ASD

Indicating haemodynamically significant R to L shunting

Palpation (1)

Auscultation (2)

Signs of Pulmonary hypertension (4)

A

Systolic thrill over pulmonary area

Tricuspid flow murmur = mid-diastolic murmur at LSE

Loud P2

Raised JVP with prominent “v” waves

Palpable P2

Parasternal heave

RHF: oedema, ascites, hepatomegaly

Q

VSD characteristics

Palpation (1)

Auscultation (2)

A

Thrill at LSE

Harsh pan-systolic murmur at LSE

Increased with expiration

Q

VSD - indications for surgery

TTE (2)

A

Decreased gradient = increasing RV pressure

Left to right shunt with Qp:Qs > 1

Q

PDA - charactersitics

Pulse (2)

Palpation (1)

Auscultation (1)

A

Large volume pulse

Collapsing pulse

Hyperkinetic (displaced, thrusting) apex beat

Continuous “machinery” murmur in left 1st intercostal space

Q

Eisenmenger syndrome

Characteristics (4)

A

Central cyanosis

Clubbing

Pulmonary hypertension

Polycythaemia

Q

Causes of Eisenmenger syndrome (3)

And how to differentiate underlying aetiology

(as murmurs disappear once R to L shunting occurs)

A

ASD - fixed split S2

VSD - single and loud S2

PDA - differential cyanosis/clubbing of toes NOT fingers

Q

Differentials for PSM (4)

A

Mitral regurgitation

Triscuspid regurgitation

Ventral septal defect

PDA (also will be diastolic)

Q

Differentials for ESM / midsystolic murmur (4)

A

Aortic stenosis

Hypertrophic obstuctive cardiomyopathy

ASD with pulmonary flow murmur

Pulmonary stenosis

Q

Differentials for late systolic murmur

A

Mitral valve prolapse

HOCM

Q

Differentials for mid-late diastolic murmur (2)

A

Mitral stenosis

Atrial mxyoma

Q

S1 = closure of mitral valve - start of systole

Causes of loud S1 (1)

Causes of soft S1 (1)c

A

Loud S1

Mitral stenosis

Hyperdynamic circulation

Soft S1

Mitral regurgitation

Q

A2 - closure of aortic valve at end of systole

Causes of loud A2 (2)

Causes of soft A2 (1)

A

Loud A2

congenital aortic stenosis

Hypertension (from increased after load)

Soft A2

Aortic regurgitation

Q

P2 = closure of pulmonary valve at end -systole

Causes of loud P2 (1)

Causes of soft P2 (1)

A

Loud P2

Pulmonary hypertension

Soft P2

Pulmonary stenosis

Q

S3 gallop

Low pitched, early diastolic sound

Due to rapid ventricular filling

Can be physiological

Pathological causes (3)

A

Mitral regurgitation

Dilated cardiomyopathy

LVF / RVF

Q

S4

Late diastolic low pitched sound

Always pathological

Associated with poorly compliant ventricle

Associated conditions (5)

A

Aortic stenosis

Hypertension

Ischaemic heart disease

HOCM

Pulmonary hypertension

Q

Dominant “a” waves (3)

Dominant “v “waves (1)

Cannon “a” waves (1)

REMEMBER a waves cannot be seen in AF!

A

Dominant “a” waves

Pulmonary hypertension

Tricuspid stenosis, pulmonary stenosis

Dominant “v” waves

Tricuspid regurgitation

Cannon “a” waves

Complete heart block

(atrium contracting against closed MV/TV)

Q

Valsava

Louder (systolic murmurs)

Softer (systolic murmurs)

Length (MVP)

A

Louder = HOCM

Softer - AS and MR

MVP longer with VALSALLLLVA

Q

Isometric handgrip

Louder

Softer

Length (MVP)

A

Louder - MR

(due to increased afterload, more regurgitation)

Softer - HOCM and AS

MVP shorter

Q

What are the components of Fallot’s Tetrology? (4)

A

RV hypertrophy

Subvalvular pulmonary stenosis (infundibular stenosis)

VSD

Over-riding aorta (“astride” the VSD)

Q

What is a Blalock-Taussig shunt?

What are the clinical findings associated with a BT shunt? (3)

What are the features on auscultation? (3)

A

A shunt between the LEFT subclavian and LEFT pulmonary artery

Left arm smaller than Right

Left arm BP lower than Right

Left arm pulses diminished compared to Right

To-and-fro systolic and diastolic murmur

Loudest in subclavivular area

Radiates posteriorly