Valvular disease

Question 1

Types of valvular disease

Answer 1

1. Mitral regurgitation
2. Mitral stenosis
3. Mitral valve prolapse
4. Aortic stenosis
5. Aortic regurgitation
6. Aortic sclerosis

Question 2

Mitral regurgitation

Answer 2

Backflow of blood into the atrium during systole

Question 3

Causes of mitral regurgitation

Answer 3

1. LV dilatation
2. Calcification (elderly)
3. Infective endocarditis
4. Rheumatic fever
5. Mitral valve prolapse
6. Ruptured chordae tendinae
7. Papillary muscle dysfunction
8. Cardiomyopathy

Question 4

Symptoms of mitral regurgitation

Answer 4

1. Dyspnoea
2. Pulmonary oedema
3. Palpitations
4. Fatigue

Question 5

Signs of mitral regurgitation

Answer 5

1. AF
2. Pansystolic murmur at apex radiating to axilla
3. Soft S1, split S2, loud P2

Question 6

Investigations for mitral regurgitation

Answer 6

1. ECG - AF, LA LV enlargement/hypertrophy
2. CXR
3. Echocardiogram (+ cardiac catheterisation to confirm)

Question 7

Management of mitral regurgitation

Answer 7

1. B-blockers if AF
2. Anticoagulate if AF, history of embolism, mitral stenosis
3. Diuretics
4. Vasodilators - hydralazine (CCB)
5. Surgery for deteriorating symptoms - prosthetic valve

Question 8

Mitral valve prolapse

Answer 8

Valve flaps bulge upwards into the left atrium. Most common valvular abnormality

Question 9

Symptoms of mitral valve prolapse

Answer 9

Usually asymptomatic. May develop palpitations, atypical chest pain

Question 10

Signs of mitral valve prolapse

Answer 10

Mid-systolic click/late systolic murmur

Question 11

Investigations or mitral valve prolapse

Answer 11

1. Echo is diagnostic

2. ECG may show T wave inversion

Question 12

Management of mitral valve prolapse

Answer 12

1. B-blockers for symptom relief

2. Surgery if severe

Question 13

Pathophysiology of mitral stenosis

Answer 13

1. Progressive dyspnoea (worse with exercise) - pulmonary HTN and fluid overload
2. Increased trans-mitral pressure - LA enlargement and AF
3. Right HF symptoms
4. Haemoptysis due to bronchial vessel rupture

Question 14

Causes of mitral stenosis

Answer 14

1. Infective endocarditis
2. Rheumatic fever - most common
3. Calcification
4. Congenital
5. Malignant carcinoid

Question 15

Mitral stenosis orifice area

Answer 15

Normal orifice area = 4-6cm2, symptoms begin when <2cm2

Question 16

Symptoms of mitral stenosis

Answer 16

1. Dyspnoea
2. Hoarse voice (recurrent laryngeal nerve compression due to enlarged LA)
3. Haemoptysis
4. Bronchial obstruction
5. Fatigue
6. Palpitations
7. Chest pain

Question 17

Signs of mitral stenosis

Answer 17

1. Malar flush
2. Signs of RVF
3. Low volume pulse
4. AF common (LA enlargement)
5. RV heave
6. Rumbling mid-diastolic murmur

Question 18

Investigations for mitral stenosis

Answer 18

1. ECG - AF common
2. CXR - LA enlargement
3. Echo (diagnostic) - assess mobility

Question 19

Management of mitral stenosis

Answer 19

1. AF control
2. Drugs - b-blockers, CCB, digoxin, diuretics
3. Serial echocardiography
4. Balloon valvuloplasty
5. Mitral valve replacement

Question 20

Typical presentation of aortic stenosis

Answer 20

Elderly person with chest pain, exertional dyspnoea or syncope.

Question 21

Causes of aortic stenosis

Answer 21

1. Senile calcification (most common)
2. Congenital
3. Rheumatic heart disease

Question 22

Define aortic stenosis

Answer 22

Narrowing of aortic valve opening, restricting blood flow. Usual opening 3-4cm2. Symptoms occur at 1/4th the size of normal.

Question 23

Pathophysiology of aortic stenosis

Answer 23

1. Pressure gradient develops between left ventricle and aorta (increased afterload)
2. LV pressure initially maintained by LV hypertrophy
3. Compensatory pressure exhausted, LV function decline

Question 24

Symptoms of aortic stenosis

Answer 24

1. Classic triad - angina, syncope, HF
2. Exertional dyspnoea
3. Dizziness
4. Systemic emboli (if infective endocarditis)

Question 25

Signs of aortic stenosis

Answer 25

1. Slow rising pulse with narrow pulse pressure 2. Aortic thrill 3. Ejection systolic murmur (heard at base left sternal edge radiating to carotids) crescendo-decrescendo 4. Heaving, non-displaced apex beat

Question 26

Investigation for aortic stenosis

Answer 26

1. ECG 2. CXR 3. Echo - diagnostic - shows valve area, LV size and function

Question 27

Management of aortic stenosis

Answer 27

1. Valve replacement | 2. TAVI - transcatheter aortic valve implantation

Question 28

Define aortic sclerosis

Answer 28

Senile degeneration of the valve

Question 29

Signs of aortic sclerosis

Answer 29

Ejection systolic murmur with no radiation to carotids. Normal pulse and S2.

Question 30

Define aortic regurgitation

Answer 30

Leakage of blood into the LV during diastole due to ineffective coaptation of the aortic cusps

Question 31

Causes of acute aortic regurgitation

Answer 31

1. Infective endocarditis 2. Chest trauma 3. Ascending aortic coarctation

Question 32

Causes of chronic aortic regurgitation

Answer 32

1. Congenital 2. Rheumatic fever 3. Connective tissue disorder (e.g Marfan's) 4. Rheumatoid arthritis

Question 33

Pathophysiology of aortic regurgitation

Answer 33

Pressure and volume overload. Compensatory mechanisms -> LV dilation -> heart failure

Question 34

Clinical features of aortic regurgitation

Answer 34

1. Breathlessness 2. Orthopnoea 3. Palpitation 4. Diastolic blowing murmurs

Question 35

Investigations for aortic regurgitation

Answer 35

1. CXR - enlarged cardiac silhouette and aortic root enlargement 2. Echo 3. Cardiac catheterisation - assess severity

Question 36

Management for aortic regurgitation

Answer 36

1. Vasodilators 2. Serial echocardiograms 3. Surgery