Valvular Diseases

Question 1

What are the normal heart sounds?

Answer 1

S1 - LUB - closing of AV valve, start of systolic contraction of vessels - prevent back flow in atria

S2 - DUB - closing semilunar valves, once systolic is complete - prevent back flow in ventricles

Question 2

What is the third heart sound?

Answer 2

S3 - LUB DE DUB
Rapid ventricular filling - chordae tendinae pulled all the way down then fling back (think elastic band)

Question 3

What is the fourth heart sound?

Answer 3

S4 - LE LUB DUB
Heard before S1
Indicates stiff/hypertrophic ventricles

Caused by turbulent flow from atria that is contracting against a ventricle that is non-compliant and does not want to fill with blood - ventricles stiff and atria trying to fill with blood

Question 4

Where do you auscultate for the pulmonary area?

Answer 4

2nd intercostal space - left sternal border

Question 5

Where do you auscultate for the aortic area?

Answer 5

2nd intercostal space - right sternal border

Question 6

Where do you auscultate for the tricuspid area?

Answer 6

5th intercostal space - left sternal border

Question 7

Where do you auscultate for the mitral area?

Answer 7

5th intercostal space - midclavicular line - apex area

Question 8

What are the features of a murmur?

Answer 8

SCRIPT
Site
Character
Radiation
Intenstity
Pitch
Timing

Question 9

What is the grading to murmurs?

Answer 9

1 - difficult to hear
2 - quiet
3 - easy to hear
4 - easy to hear with palpable thrill
5 - hear with stethoscope barely touching
6 - hear without stethoscope touching chest

Question 10

What is valvular disease?

Answer 10

Valves not functioning

Stenosis - restriction
Regurgitation - backflow of blood
Hypertrophy - ventricular walls thicker
Dilatation - ventricular walls thinner and the ventricle expands

Question 11

What is aortic stenosis?

Answer 11

Narrow aortic valve
Left ventricle pushes on left aortic valve and ends up with left ventricular hypertrophy
As blood flows through valve in systolic contraction you’ll get turbulence of blood flow

Question 12

What murmurs are heard with aortic stenosis?

Answer 12

Ejection systolic mumur - when blood ejected form left ventricle
High pitched - high velocity, in systole
Cresendo-decresendo - loud to quiet due to different speeds
Systolic murmur in between S1 and S2 - sounds like BURRR DUB
Radiates to carotid

Question 13

What are the symptoms of aortic stenosis?

Answer 13

Dyspnoea - increased LV end diastolic pressure - not enough blood is being squeezed out, LV has to pumo harder

Angina - hypertrophy due to increased volume, high O2 consuptiom but not supples

Syncope

Question 14

What are the causes of aortic stenosis?

Answer 14

Degenerative AV disease
Calcification (including idiopathic age calcification)
Bicuspid AV - might have 2 cusps instead of 3
Rheumatic valve disease

Question 15

What are the treatments for aortic stenosis?

Answer 15

Replacement
Trans catheter AV replacement

Question 16

What is aortic regurgitation?

Answer 16

Aortic valve incompetence
Blood back to LV from aorta in diastole (okay in systole)

Question 17

What does aortic regurgitation often result in?

Answer 17

Heart failure - due to pressure caused by build up of blood in LV that needs pumping out

Question 18

What is the murmur for aortic regurgitation?

Answer 18

Early diastolic murmur and soft - LUB TARRR

Austin flint murmur - caused by blood flowing back through aortic valve and over mitral valve causing mitral leaflet to vibrate

Question 19

What are the symptoms of aortic regurgitation?

Answer 19

SOB – blood does not leave the ventricles causing pressure increase in LA
What signs do you get?
Early diastolic murmur
Difficult to accentuate the murmur – go to the left eternal edge and get patient to sit forward in and expiration
Displayed apex beat towards axilla (LV dilatation)
Collapsing pulse
Wide pulse pressure
Corrigan’s sign in necklaces – a bouncing rapid carotid pulse appears and disappears as blood is pumped out into ventricles and immediately starts flowing back through aortic valve - characterised by rapid systolic rise and rapid diastolic collapse

Question 20

What are the signs of aortic regurgitation?

Answer 20

Corrigans - Neck pulsation
De Mussets - Head bobbing in time with cardiac cycle
Duroziezs sign - Diastolic murmur head over femoral pulses when partly occluded below stethehscope
Muellers sign - Uvula pulsation
Quinckes sign - Capillary pulsation in nail bed
Traubes sign - Pistol shot systolic sound in femoral arteries – sound when ausculated

Question 21

What are the causes of aortic regurgitation?

Answer 21

Valve
Aorta – usually dilatation – think about the aorta, what are the problems with the aorta that will link to valve
Congenital (bicuspid, unicuspid, quadricuspid AV)
Connective tissue disorder – difficulty in creating dense connective tissue leading to weakness of valve leaflets
Marfans / Ehlers Danlos syndrome
Degeneration
Hypertension
Endocarditis
Ehlers Danlos
Rheumatic fever
Osteogenesis imperfecta
Trauma
Annulo-aortic dysplasia
Radiation
Following radiotherapy
Drugs
Cabergoline, fluoroquinones, chemotherapy
Idioathic age related weakness

Question 22

What are the treatments for aortic regurgitation?

Answer 22

Watchful waiting – serial of echos / seen in clinic
If symptoms or LV dysfunction (severe) - surgical aortic valve repair or replacement

Question 23

What is mitral stenosis?

Answer 23

Mitral valve narrowed

Question 24

What is the murmur for mitral stenosis?

Answer 24

Causes mid diastolic low pitched rumbling murmur – due to low velocity of blood flow – blood flowing through narrow area it flows slowly
Loud S1 – thick valves and need large systolic force to shut valve so valves shut suddenly when force is high
LUB! DUB DURRRR
Palpate tapping apex beat

Question 25

What are the symptoms for mitral stenosis?

Answer 25

SOB

Left atrial hypertrophy - LA pushing against mitral valve

Question 25

What is mitral stenosis associated with?

Answer 25

Assoicated with malar flush – flushing of cheeks – due to back pressure of blood into pulmonary system causing a rise in CO2 and vasodilation
Associated with AF – due to keft atrium struggling to push through to left ventricle and causing disruption to electrical signals

Question 26

What is the treatment for mitral stenosis?

Answer 26

Replacement
Balloon mitral comisurotomy - percutaneous

Question 27

What is mitral regurgitation?

Answer 27

Incompetent mitral vlave
Leaky valve – blood flowing back through mitral valve into left atrium during systolic contraction of left ventricle – left atrium dilatiation

Question 28

What is mitral regurgitation associated with?

Answer 28

Associated with congestive cardiac failure – elaking valve causing reduced ejection fraction – backlog of blood waiitng to be pumped from right side
May hear a this heart sound if heart failure present

Question 29

What is the murmur for mitral regurgitation?

Answer 29

Pan systolic murmur – during systole blood flowingbackwards through valve, so is present rhoguhout systolic period
High pitch – high velocity of blood flow
Sounds like BURRRR (enitre way through systole)
Listen at axilla – tends to radiate to left axilla

Question 30

What are the causes for mitral regurgitation?

Answer 30

Idiopathic weakening with age
Icheaemic heart disease
Infectivity endocardiditis
Rhematuic heart disase
Connective tissue disease: Marfan’s, elhers-danles syndrome

Question 31

What is the treatment for mitral regurgitation?

Answer 31

Repair / replacement
Transcatheter therapies