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Year 3: Medicine Block CARDIORESPIRATORY > Valvular Disease > Flashcards

Valvular Disease Flashcards

1
Q

What is the scale used to determine murmurs?

A

Levine Scale

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2
Q

Describe the Levine Scale?

A

Grade 1 - Very faint murmur, frequently overlooked

Grade 2 - Slight murmur

Grade 3 - Moderate murmur without palpable thrill

Grade 4 - Loud murmur with palpable thrill

Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge

Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall

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3
Q

What is the pathophysiology of Mitral Stenosis?

A
  • Normal valve orifice area is reduced to <1cm2, severe mitral stenosis is present.
  • In order to maintain sufficient cardiac output, left atrial pressure increase and left atrial hypertrophy and dilatation occur
  • Pulmonary venous, pulmonary arterial and right heart pressure increases as a result.
  • Increase in capillary pressure leads to pulmonary oedema particularly if rhythm deteriorates to atrial fibrillation with tachycardia and loss of atrial contraction.
  • Pulmonary hypertension leads to right ventricular hypertrophy, dilatation and failure with tricuspid regurgitation occurring as a result
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4
Q

What can cause Mitral Stenosis?

A
  • Rheumatic Heart Disease
  • Congenital
  • Mucopolysaccharidoses
  • Endocardial fibroelastosis
  • Malignant Carcinoid Tumour
  • Metastases
  • Prosthetic valve
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5
Q

What are symptoms of mitral stenosis?

A
  • Severe dyspnoea
  • Cough productive of blood tinged, frothy sputum or frank haemoptysis
  • Weakness, fatigue and abdominal or lower limb swelling
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6
Q

What are examination findings of Mitral Stenosis?

A
  • Malar Flush
  • Low volume pulse. May lead to AF as disease develops
  • Tapping, non-displaced, apex beat that is palpable on S1
  • Loud S1 sound
  • Rumbling mid-diastolic murmur that is heard best in expiration on patient’s left side.
  • Graham Steell murmur may be heard: high pitched early diastolic murmur
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7
Q

What are the test done for Mitral Stenosis?

A
  • Echocardiogram is diagnostic
  • ECG: atrial fibrillation, p-mitrale if in sinus rhythm, right axis deviation
  • Chest X-ray: left atrial enlarge, pulmonary oedema, mitral valve calcification
  • Cardiac MRI: Rarely used
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8
Q

How is Mitral Stenosis medically managed?

A
  • In AF, rate control is important - Bisoprolol
  • Anticoagulate with Warfarin
  • Diuretics to decrease preload and pulmonary venous congestion
  • Oral Penicillin prophylaxis can be used for recurrent rheumatic fever
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9
Q

What should be done in Mitral Stenosis if patient isn’t medically managed sufficiently?

A
  • Balloon valvuloplasty (if pliable, non-calcified valve)
  • Open Mitral Valvotomy or Valve replacement
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10
Q

What are complications of Mitral Stenosis?

A
  • Pulmonary hypertension
  • Emboli
  • Pressure from a large Left Atrium on local structures (hoarseness due to RLN
  • Dysphagia (oesophagus)
  • Bronchial obstruction
  • Infective endocarditis
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11
Q

What is the pathophysiology of Mitral Regurgitation?

A
  • Regurgitation into left atrium produces left atrial dilation.
  • Little increase in left atrial pressure if regurgitation is chronic as regurgitant flow accommodated by large left atrium
  • Left atrial u-wave is greatly increased and pulmonary venous pressure rise leading to pulmonary oedema
  • Since proportion of stroke volume is regurgitated, stroke volume increases to maintain forward cardiac out and left ventricle therefore enlarges
  • Classified by Carpentier classification
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12
Q

What are causes of Mitral Regurgitation?

A

Occur due to abnormalities of valve leaflets, the annulus, the chordae tendineae or papillary muscles or left ventricle such as:

  • LV dilatation
  • Annular calcification
  • Rheumatic Fever
  • Infective Endocarditis
  • Mitral Valve Prolapse
  • Ruptured Chordae tendineae
  • Papillary muscle dysfunction/rupture
  • Connective Tissue Disorder (Ehlers-Danlos, Marfan’s)
  • Cardiomyopathy
  • Congenital
  • Appetite Suppressants
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13
Q

What are symptoms of Mitral Regurgitation?

A
  • Palpitations due to increase stroke volume
  • Dyspnoea and orthopnoea due to pulmonary venous hypertension
  • Fatigue and lethargy due to reduced cardiac output
  • Cardiac cachexia may develop.
  • In the late stages symptoms of right sided heart failure may occur and lead to congestive cardiac failure
  • Thromboembolism is less common but subacute infective endocarditis much more common in mitral regurgitation than mitral stenosis
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14
Q

What are examination findings of Mitral regurgitation?

A
  • Laterally displaced hyperdynamic apex and systolic thrill
  • Right ventricular heave
  • Soft S1; Split S2; Loud P2 (pulmonary hypertension)
  • Pansystolic murmur at apex radiating to axilla
  • Mid-systolic click
  • Prominent third heart sound due to sudden rush of blood into dilated ventricle
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15
Q

What are investigations done for Mitral Regurgitation?

A
  • ECG: AF (+-) P-mitrale if in sinus rhythm, LVH represented by tall R waves in left lateral leads and Deep S in the right sided precordial leads, Left atrial delay represented by bifid P waves
  • Chest X-Ray: big left atrium and left ventricle; mitral valve calcification; pulmonary oedema, increase in cardiothoracic ratio
  • Echocardiogram can be used to assess left ventricular function and aetiology. Doppler echo can be used to asses size and site of regurgitant jet.
  • Cardiac Catheterization - demonstrate prominent left atrial systolic pressure
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16
Q

What does echocardiogram show for mitral regurgitation?

A

Shows

  • Dilated left atrium and left ventricle
  • There may be chordal or papillary muscle rupture.
  • Severity can be assessed with use of colour Doppler looking at narrowest jet width and area and calculation regurgitant fraction, volume or orifice area
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17
Q

What is the management of Mitral Regurgitation?

A
  • Control rate for Fast Atrial Fibrillation
  • Anticoagulated in event of atrial fibrillation, history of embolism, prosthetic valve, additional mitral stenosis
  • Diuretics improve symptoms
  • Surgery for deteriorating symptoms; aim to repair or replace the valve before left ventricle irreversibly impaired
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18
Q

What are causes of Aortic Stenosis?

A
  • Senile calcification is the commonest
  • Bicuspid Aortic Valve (commonest in <65)
  • Rheumatic Heart Disease
  • Chronic Kidney Disease
  • Paget’s disease of bone
  • Previous Radiation Exposure
  • SLE
  • Williams Syndrome
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19
Q

What some differentials for Aortic Stenosis?

A
  • Hypertrophic cardiomyopathy
  • Supravalvular obstruction
  • Subvalvular Aortic stenosis
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20
Q

What is the pathophysiology of Aortic Stenosis?

A
  • Obstructed left ventricular emptying lead to increased left ventricular pressure and compensatory left ventricular hypertrophy
  • Results in relative ischaemia of left ventricular myocardium and consequent angina, arrhythmias and left ventricular failure.
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21
Q

What happens to patients with Aortic Stenosis during exercise?

A
  • Obstruction to left ventricular emptying is relatively more severe on exercise
  • When there is severe narrowing of aortic valve orifice, cardiac output can hardly increase during exercise.
  • So blood pressure falls, coronary ischaemia worsens, myocardium fails and cardiac arrhythmias develop.
  • Left ventricular systolic function preserved in patient with AS
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22
Q

What symptoms of Aortic Stenosis?

A
  • Exercise-Induced syncope
  • Angina
  • Dyspnoea occurs when moderately severe
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23
Q

What are examination findings in Aortic Stenosis?

A
  • Ejection Systolic Murmur
  • Slow rising pulse with narrow pulse pressure
  • Non-displaced apex beat
  • LV heave
  • Aortic Thrill
24
Q

What are tests for Aortic Stenosis?

A
  • ECG: P-mitrale, LVH with strain pattern; LAD; poor R wave progression; LBBB or complete AV block (calcified ring)
  • Chest-XRay: Left Ventricular Hypertrophy; Calcified aortic valve; Post Stenotic Dilatation of ascending aorta
  • Echocardography
  • Cardiac Catheter can assess valve gradient; LV function; Coronary Artery Disease but risks emboli
25
Q

What does Echocardiogram of Aortic Stenosis show?

A
  • Doppler echo can estimate gradient across valves: severe stenosis if peak gradient is >50mmHg and valve area <1cm2. If aortic jet velocity is >4m/s then risk of complications increases.
  • Echo can demonstrate thickened, calcified and immobile aortic valve cusps and ventricular hypertrophy
26
Q

What is the management of Aortic Stenosis who is asymptomatic?

A
  • If asymptomatic then observe the patient is general rule
  • If asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
  • If asymptomatic and severe aortic stenosis and a deteriorating ECG, valve replacement is recommended
27
Q

What is the management of a symptomatic patient with Aortic Stenosis?

A
  • Surgery for valve replacement
  • If patient not suitable for surgery then percutaneous valvuloplasty may be attempted (TAVI)
28
Q

What is the prognosis of a patient with aortic stenosis?

A
  • If symptomatic, prognosis is poor without surgery: 2-3 year survival if angina/syncope; 1-2yr of cardiac failure.
  • If moderate to severe and treated medically, mortality can be as high as 50 % at 2 yrs therefore prompt valve replacement is usually recommended.
29
Q

What is aortic sclerosis?

A
  • Senile degeneration of the valve
  • Ejection systolic murmur, no carotid radiation, and normal pulse and S2
30
Q

What are acute causes of Aortic Regurgitation?

A
  • Infective endocarditis
  • Ascending aortic dissection
  • Acute Rheumatic fever
31
Q

What are Chronic Causes of Aortic Regurgitation?

A
  • Congenital
  • Connective Tissue Disorders (Marfan’s Syndrome, Ehlers-Danlos)
  • Rheumatic Fever
  • Takayasu Arteritis
  • Rheumatoid Arthritis
  • SLE
  • Pseudoxanthoma Elasticum
  • Appetite Suppressants
  • Seronegative Arthritides (ankylosing spondylitis, Reiter’s syndrome, Psoriatic Arthropathy
  • Hypertension
  • Osteogenesis Imperfecta
  • Syphilitic Aortis
32
Q

What are symptoms of Aortic Regurgitation?

A
  • Pounding of the heart
  • Angina pectoris
  • Varying grades of dyspnoea occur depending of extent of left ventricular dilatation and dysfunction
  • Arrhythmias relatively uncommon
33
Q

What are examination findings of Aortic Regurgitation?

A
  • Collapsing pulse; wide pulse pressure;
  • Displaced, hyperdynamic apex beat;
  • High-pitched early diastolic murmur
  • Corrigan’s sign: carotid pulsation
  • De Musset’s sign: head nodding with each heart beat • Quincke’s sign: capillary pulsations in nail beds
  • Duroziez’s sign: in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal, it gives a diastolic murmur as blood flows backwards
  • Traube’s sign: pistol shot sound over femoral arteries
34
Q

What are the investigations of Aortic Regurgitation?

A
  • Echocardiography is diagnostic.
  • ECG: left ventricular hypertrophy which shows deeply inverted T wave and tall R waves in the left sided chest leads and deep S waves in right sided leads
  • Chest X-ray: cardiomegaly; dilated ascending aorta; pulmonary oedema, ascending aortic wall may be calcified in syphilis which can responsible for regurgitation
  • Cardiac Catheterization to assess the severity of the lesion; anatomy of aortic root; LV function: other valve disease
35
Q

What does Echocardiography show for Aortic Regurgitation?

A
  • Demonstrates vigorous cardiac contraction
  • Dilated left ventricle
  • Diastolic fluttering of mitral leaflets or septum occur in severe aortic reurgitation. Severity is assessed with colour doppler and CW dopper.
36
Q

What is the medical management of Aortic Regurgitation?

A
  • ACE-inhibitor is used to help
  • Echocardiography every 6 months to monitor
37
Q

What is the surgical management of Aortic Regurgitation?

A
  • Surgery is considered in patient who have: increasing symptoms; an enlarged heart on CXR/echo; ECG deterioration; Infective endocarditis refractory to medical therapy.
  • Aim to replace the valve before significant LV dysfunction occurs
  • Predictors of poor post-operative survival are ejection fraction <50%, duration of congestive cardiac failure of more than 12 months
38
Q

What are the causes of Tricuspid regurgitation?

A
  • Functional regurgitation may occur whenever right ventricle dilates (Cor pulmonale, MI or pulmonary hypertension)
  • Rheumatic fever
  • Infective endocarditis
  • Carcinoid Syndrome
  • Congenital (Ebstein’s anomaly)
  • Drugs
39
Q

What are symptoms of Triscuspid Regurgitation?

A
  • Awakening at night with shortness of breath
  • Shortness of breath during exercise or when lying flat.
  • Coughing
  • Wheezing
  • Difficulty concentrating
  • Dizziness
  • Fatigue
  • Fluid retention
40
Q

What are examination findings of Tricuspid Regurgitation?

A
  • Giant V waves and prominent Y descent in JVP
  • Right ventricular heave
  • Pansystolic murmur that is heard best at lower left sternal edge in inspiration
  • Pulsatile hepatomegaly; Jaundice; Ascites
  • Atrial fibrillation is common
41
Q

What are tests for Tricuspid Regurgitation?

A

Echocardiogram shows dilatation of right ventricle with thickening of the valve

42
Q

What is the management of Triscuspid Regurgitation?

A
  • Treat underlying cause
  • Drugs: Diuretics, Digoxin, ACE-inhibitors
  • Valve replacement which has around a 10% 30-day mortality

Tricuspid regurgitation resulting in myocardial dysfunction or dilatation has a mortality of up to 50% at 5 years

43
Q

What are causes of Triscuspid Stenosis?

A
  • Main cause is Rheumatic Fever
  • Congenital
  • Infective endocarditis
  • Carcinoid syndrome
44
Q

What is pathophysiology of Tricuspid Stenosis?

A
  • Reduced cardiac output which is restored towards normal when right atrial pressure increases.
  • Resulting systemic venous congestion produced hepatomegaly, ascites and dependant oedema
45
Q

What are symptoms of Tricuspid Stenosis?

A
  • Abdominal pain (due to hepatomegaly)
  • Swelling (due to ascites)
  • Peripheral oedema severe when compared with degree of dyspnoea
46
Q

What are examination findings of Tricuspid Stenosis?

A
  • Giant ‘A wave’ and slow ‘Y descent’ in JVP
  • Opening snap
  • Early diastolic murmur heard at the left sternal edge in in inspiration
  • AF can also occur
47
Q

What are investigations used in Tricuspid Stenosis?

A
  • Echocardiogram is diagnostic.
    • Shows thickened and immobile tricuspid valve
  • CXR may show prominent right atrial bulge
  • ECG: peaked, tall P waves (>3mm) in lead 2
48
Q

What is the management of Tricuspid Stenosis?

A
  • Diuretics
  • Salt restriction
  • Surgical: tricuspid valvotomy and tricuspid replacement often necessary
49
Q

What are causes of Pulmonary Stenosis?

A

Pulmonary stenosis may be valvular, sub-valvular or supra valvular anc caused by:

  • Turner’s syndrome
  • Noonan’s syndrome
  • William’s syndrome
  • Fallot’s tetralogy
  • Congenital Rubella syndrome
  • Rheumatic fever
  • Carcinoid syndrome
50
Q

What are symptoms of Pulmonary Stenosis?

A
  • Fatigue
  • Syncope
  • Symptoms of right heart failure
51
Q

What are examination findings in Pulmonary Stenosis?

A
  • Dysmorphic facies; prominent ‘A wave’ in JVP; RV heave
  • Ejection systolic murmur (which radiates to the left shoulder; widely split S2)
  • In severe stenosis, the murmur becomes longer and obscures A2
  • P2 becomes softer and may be inaudible
  • Right ventricular fourth sound
52
Q

What are test for Pulmonary Stenosis?

A
  • Cardiac catheterization is diagnostic
  • ECG:
    • RAD, P-pulmonale, right ventricular hypertrophy, right bundle branch block
  • CXR:
    • prominent main, right or left pulmonary arteries caused by post-stenotic dilatation
53
Q

What is the management of Pulmonary Stenosis?

A

Pulmonary Valvuloplasty or Valvotomy (balloon valvotomy or direct surgery)

54
Q

What is the cause of Pulmonary Regurgitation?

A
  • Results from dilatation of pulmonary valve ring which occurs with pulmonary hypertension (graham stell murmur)
  • May also occur following Tetralogy of Fallot repair.
55
Q

What is the management of pulmonary regurgitation?

A

Pulmonary regurgitation usually causes no symptoms and treatment rarely necessary

56
Q

When is a Prolapsing Mitral Valve seen?

A

More commonly seen in young women than in men or older women, and has a familial incidence.

57
Q

What is a Prolapsing Mitral Valve associated with?

A

Associated with

  • Connective tissue disorders
    • Marfan syndrome
    • Ehlers–Danlos syndrome
    • Pseudoxanthoma elasticum
  • Atrial septal defect
  • Ebstein’s anomaly

Year 3: Medicine Block CARDIORESPIRATORY (28 decks)

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