Valvular Disease & Endocarditis Flashcards
What produces the first heart sound?
- closure of the mitral valve before ventricular contraction
What produces the second heart sound?
- closure of the aortic valve before ventricular relaxation
What is the third heart sound?
- sloshing in
- blood coming into contact with a compliant/dilated ventricle
When to dilated ventricles occur?
- mitral regurg
- HF with dilated cardiomyopathy
What is the 4th heart sound?
- a stiff wall
- blood pushing against non-compliant ventricle during atrial contraction (ventricular diastole)
- LVH
- Post MI fibrosis
- failure of relaxation = diastolic HF
Define stenosis
- pathological narrowing of a valve diameter
What causes stenosis?
- increased pressure = hypertrophy = dilation = failure
Define regurgiatation
pathological reverse flow of blood when valves should be closed
What causes regurgitation?
increased volumes = dilation = failure
Diastolic valvular pathologies
LHS - mitral stenosis - aortic regurg RHS - tricuspid stenosis - pulmonary regurg
Systolic valvular pathologies
LHS - aortic stenosis - mitral regurg RHS - pulmonary stenosis - tricuspid regurg
Causes of valve disease
- degeneration = calcification/old age
- infection = rheumatic fever, infective endocarditis
- abnormal valve
- abnormal surrounding myocardium = ischaemia, hypertrophy, dilatation
Mitral Regurg Causes
- myocardium dilatation
- ischaemic (post MI, ruptured chorea-tendonae)
- rheumatic fever
- infective endocarditis
- mitral valve prolapse
- calcification (elderly)
Effects of mitral regurg
- LA enlargement
- LVH = SV and ejection fraction reduction
- LV failure
- AF
Symptoms of mitral regurg
Exertional dyspnoea
palpitation
ankle swelling (CHF)
Signs of mitral regurg
Pulse = irregularly irregular
Apex = thrusting, displaced
Soft S1 HS
Pan systolic systolic murmur
Mitral regurg Ix
AF ECG
CXR Pulmonary Congestion
Causes of aortic stenosis
- senile calcification
- bicuspid aortic valve congenital
- rheumatic (rare)
Pathophys of aortic stenosis
- increased afterload
- concentric hypertrophy of LV to maintain SV
- decreased myocardial compliance in diastole = diastolic dysfunction
- reduced coronary blood flow, increased myocardial workload
- reduction in size of LV
- pulmonary venous hypertension
Symptoms of aortic stenosis
- chest pain = myocardial ischaemia
- breathlessness
- syncope
Signs of aortic stenosis
- pulse slow rising
- displaced apex
- quiet S1 if severe
- ejection systolic murmur
Aortic stenosis Ix
ECG LVH
CXR cardiac enlargement, calcification of aortic ring
Acute causes of aortic regurg
- infective endocarditis
- dissection of aortic root (ascending aorta)
Chronic causes of aortic regurg
- degeneration
- rheumatic fever
- infective endocarditis
- degeneration of bicuspid valve
- spondyloarthropathy (ANK SPON)
- aortitis (vasculitis)
Aortic regurg Pathophys
- volume overload of LV
ACUTE - rapid increase in LV pressure
- pulmonary oedema and decreased CO
CHRONIC - LV dilatation until decompensated = LV impairment, HF
- increased SV and low diastolic pressures
Symptoms of Aortic regurg
- breathlessness
- palpitations
- RHF signs
- cardiovasc collapse as loss of CO if acute
Signs of aortic regurg
- de musset sign
- corrigans sign
- muellers sign
- quincke sign
- water hammer/collapsing pulse
- traube’s sign
- bilateral inspiratory crackles
- early diastolic murmur = blowing high pitched
- Austin flint murmur = late diastolic
Aortic regurg Ix
ECG LVH
CXR = aortic root prominence
Causes of mitral stenosis
- Rhemutaic heart disease!!
- congenital (rare)
What does mitral stenosis mimic?
- atria myxoma
- atrial thrombus
Mitral Stenosis Pathophys
- high pressure in LA
- increased LA size
- pulmonary hypertension and R. HF
- AF
- associated regurg
Symptoms of mitral stenosis
- breathlessness
- palpitations
- ankle swelling
Signs of mitral stenosis
- mitral facies
- irreg pulse
- CHF signs
- Loud S1
- low pitched diastolic murmur crescendo
Mitral stenosis Ix
- ECG P mitrale
- CXR enlarged LA = double margin
Echo of mitral valve disease - what to look at?
- valve appearance
- LA size
- LV size and function
- Doppler to asses stenosis and regurg
- estimate pulmonary pressures
- R. heart size and function
Echo of aortic valve disease - what to look at?
- valve appearance
- valve gradient
- valve area
- severity of AR based on colour flow and CW doppler
- LV size and function
When to treat aortic stenosis?
- when symptomatic
- OR when certain severity parameters met on Echo
When to treat mitral regurg?
- before patient becomes symptomatic
- to prevent irreversible changes in cardiac function
Intervention for valvular disease
- repair
- replace = tissue or metallic
- balloon valvuloplasty
- transcatheter aortic valve implantation
How to repair a valve?
- annuloplasty ring
- through the groin
RF for valve disease
- pathological valve
- replacement
- structural heart disease
Dukes criteria major?
- typical organism on blood culture or positive serology + positive echo
Dukes criteria minor?
- predisposing factors
- fever
- vascular phenomena clubbing, splinter haemorrhage
- splenomegaly
- immunological phenomena
- suggestive echo
- suggestive microbiology
Peripheral signs of endocarditis
Look at slide 50 Qreview
- nodes
- clubbing
