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CR3 > Valvular diseases and heart sounds > Flashcards

Valvular diseases and heart sounds Flashcards

1
Q

What are the causes of aortic stenosis?

A

Calcification of tri-leaflet aortic valve
Bicuspid aortic valve stenosis
Congenital abnormalities (supravalvular aortic stenosis, Unicuspid valve)
Degeneration (why its most common in old age)
Rheumatic aortic stenosis

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2
Q

Which other conditions is a Bicuspid aortic valve (BAV) also associated with?

A

aortic coarctation, Aortic root dilatation and, potentially, aortic dissection

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3
Q

What are the risk factors for calcified aortic stenosis?

A

hypercholesterolaemia
hypertension
Smoking
diabetes

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4
Q

What happens to the heart over time in those with aortic stenosis?

A

The heart can not pump out a normal amount of end diastolic blood

So it heart undergoes hypertrophy to compensate

The hypertrophy may eventually lead to diastolic dysfunction through impaired relaxation and reduced compliance

Causes diastolic heart failure with features of systolic heart failure

Heart failure can follow with signs of left sided heart failure

Or angina can develop

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5
Q

What are the clinical signs and symptoms associated with aortic valve stenosis?

A

Syncope (exertional)
Angina (chest pain)
Dyspnoea
Signs and symptoms of of congestive heart failure

Ejection systolic murmur, radiating to the carotids

Sustained apex (only displaced if their is left sided heart failure)

Slow rising pulse
narrow pulse pressure

4th heart sound (caused by the atria contracting against stiff, hypertrophied ventricles

May be an ejection click

Quite second heart sound (sever aortic stenosis)

Splitting of second heart sound- aortic valve will open later and close after the pulmonary valve
(aortic valve opens- pulmonary valve opens and closes- aortic valve closes)

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6
Q

Which bleeding disorder can be caused by aortic stenosis? Why does this disorder develop?

A

Von Willebrand syndrome

Due to turbulent flow along the aortic valve. This causes a high sheering force which causes structural changes in the shape of the Von Willebrand protein located in the blood cell.

This causes clotting abnormalities

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7
Q

Which investigation is used to diagnose aortic stenosis other valvular disease?

A

Echocardiogram

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8
Q

Which other investigations would you conduct in someone suspected of having aortic stenosis?

A 
BP
ECG
FBC
U and E's 
Cholesterol
Clotting screen

Chest X ray
Echo
Cardiac catheter ( can assess: valve gradient; LV function; coronary artery disease; risks: emboli generation)

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9
Q

On an ECG what might you see in someone with aortic stenosis?

A

Findings indicating left ventricular hypertrophy (Deep S waves in V1 and V2, Tall R waves in V5 and V6)

A negative P wave in lead V1 - caused by atrial enlargement seen in sever cases of aortic stenosis

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10
Q

How is aortic stenosis treated?

A

Stenosis can be treated with a valvotomy - Stenotic valve leaflets are forced apart (percutaneous balloon valvotomy or open valvotomy)

Symptomatic patients or those with sever AS and deteriorated ECG - Valve replacement

If not fit for surgery
percutaneous valvuloplasty/replacement (TAVI = transcatheter aortic valve implantation) may be attempted. An expandable valve is used

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11
Q

What is the pulse pressure?

A

Difference between the systolic and diastolic pressures

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12
Q

List 3 causes of Ejection systolic murmur

A

Aortic stenosis or sclerosis
Pulmonary stenosis
HOCM

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13
Q

List 3 causes of Ejection systolic murmur

A

Aortic stenosis or sclerosis
Pulmonary stenosis
HOCM (Hypertrophic obstructive cardiomyopathy)

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14
Q

When an doppler echo cardiogram is done for aortic stenosis, what is Echo assessing?

A

The gradient across the valve

The valve area

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15
Q

When a doppler echo cardiogram is done for aortic stenosis, what is the Echo assessing?

A

The pressure gradient across the valve

The valve area

Left ventricular hypertrophy or dilation
Left ventricular contractility in systole and any stiffness or non compliance is diastole

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16
Q

What are the 2 types of aortic valve replacements a patient can have? Which types of patients would be best suited for each valve type? How are patients with these valves treated post surgery?

A

Mechanical valve - Patient requires long term anticoagulation. Has a long life span reducing the need for a second operation. Best for young patients

Bioprosthetic valve- no need for long-term anticoagulation. Limited life span (10 years). A repeat operation is more likely. Best suited for older patients

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17
Q

What is aortic regurgitation?

A

Incompetent aortic valve causing a regurgitant flow of blood in diastole.

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18
Q

At what age is aortic regurgitation most common?

A

fourth and sixth decades of life

Affects males 3x more than women

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19
Q

What are the causes of aortic regurgitation?

A

Valve leaflets -

Bicuspid valve/other congenital abnormality
Degeneration
Infective Endocarditis
Rheumatic heart disease (common in developing world)

Aortic root- 
Aortitis (inflammation of aortic route)
Aortic root dissection (Stanford A)
Dilated aortic root
Connective tissue diseases - includes rheumatoid arthritis
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20
Q

In Endocarditis, which infective causes can lead to aortic dissection?

A

Strep. viridans, Staph. aureus, Enterococci

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21
Q

Which connective tissue disorders are associated with aortic regurgitation? What is the defective in these conditions and how should people with these conditions be monitored with regards to their risk of developing the condition?

A

Marfan’s syndrome - caused by a defect in the FBN1 gene.

Ehlers-Danlos syndrome - caused by collagen defects.

Both conditions can cause an aortic root dilation which can lead to aortic regurgitation.

Aortic root diameter should be monitored in these patients

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22
Q

Which conditions can cause aortitis?

A

Chronic inflammatory conditions e.g.

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS),

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23
Q

Describe acute aortic regurgitation?

A

Acute -

  • Medical emergency
  • An acute rise in left atrial pressure results in pulmonary oedema & cardiogenic shock
  • Regurgitation of blood during diastole causes an increase in the left ventricular end-diastolic volume (and pressure)

Effects -
Reduced coronary flow - coronaries fill predominantly during diastole, regurgitant flow at this time reduces filling. Results in angina or in severe cases myocardial ischaemia.

Increased end-diastolic pressure - causes increased pulmonary pressures with resulting pulmonary oedema and dyspnoea. In severe cases, cardiogenic shock may occur.

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24
Q

What are the causes of acute aortic regurgitation?

A

Infective endocarditis
Rheumatic fever
Aortic dissection

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25
Q

What is chronic aortic regurgitation?

A
  • Compensatory changes have taken place
  • Patients may remain asymptomatic for many decades
  • Valvular incompetence develops slowly
  • Regurgitation of blood during diastole causes an increase in the left ventricular end-diastolic volume
  • This leads to systolic and diastolic dysfunction, left ventricular dilatation develops with eccentric hypertrophy.
  • The dilation allows for an increased stroke volume compensating for regurgitant flow supported by the ventricular hypertrophy. These changes maintain ejection fraction, with a greater preload leading to greater contractility
  • Eventually further increases in preload cannot be met by greater contractility and heart failure develops.
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26
Q

What is the cause of chronic aortic regurgitation?

A

Rheumatic heart disease
Arthritides
Bicuspid valve
Connective tissue disorders

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27
Q

What are the signs and symptoms of acute and chronic aortic regurgitation?

A

Acute -
- Sudden Dyspnea
- Chest pain (may be MI, angina or aortic dissection)
- Bi basal crackles
- Raised JVP
Essential acute features of hear failure

Chronic-

  • Palpitations
  • Angina
  • Dyspnoea
  • collapsing -water hammer pulse
  • wide pulse pressure
  • Displaced apex beat
  • Ejection diastolic mummer
  • Soft S1 and S2
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28
Q

What are the Eponymous signs for aortic regurgitation?

A

de Musset’s - head nodding with the heart beat.

Quincke’s - pulsation of nail beds.

Traube’s - pistol shot femorals.

Duroziez’s - to and fro murmur heard when stethoscope compresses femoral vessels. 2cm proximal to stethoscope = systolic murmur. 2cm distal to stethoscope = diastolic murmur

Müller’s - pulsation of uvula.

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29
Q

Which best side/ blood tests would you do for aortic regurgitation?

A

Bedside-
Observations
Blood pressure
ECG: left ventricular hypertrophy (deep S-waves in V1 and V2, tall R-waves in V5 and V6) in chronic AR

Bloods- 
FBC
U&Es
Cholesterol
Clotting
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30
Q

Which imaging test would you do for someone with aortic regurgitation and what would you find in these tests?

A

Echocardiogram (transthoracic or transoesophageal)-

  • left ventricular hypertrophy (chronic Aortic regurgitation)
  • Origin and width of regurgitation jet
  • Detection of aortic valve pathology

Chest x ray -

  • Cardiomegaly
  • Sighns of heart failure
  • May show dilated ascending aorta

CT/MRI-

  • MRI may be used to estimate the regurgitant fraction
  • In patients with aortic dilatation, gated multi-slice CT is the imaging of choice to characterise aortic dilatation and the maximum diameter.

Angiography -
- In patients with chronic AR undergoing surgery, pre-operative angiography is indicated. Typically this is in the form of coronary angiography (invasive procedure) to assess for concomitant coronary artery disease that may require bypass.

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31
Q

How is acute aortic regurgitation treated?

A

Aortic valve replacement or repair should be performed as soon as possible.

32
Q

How is chronic aortic regurgitation treated?

A

Reduce systolic hypertension e.g Ace inhibitors
Echo every 6-12 months to monitor

Surgical management required if -
- Sever AR with significant enlargement of the ascending aorta or

  • Symptomatic severe AR or
  • Severe AR with LVEF ≤ 50% or LVEDD > 70mm or LVESD > 50mm (may be adjusted for body size)
  • Marfan’s with aortic root disease with a maximal ascending aorta diameter ≥ 50mm
  • infective endocarditis refractory to medical therapy

Surgical option = mechanical or bio prosthetic valve replacement

ascending aorta dilatation management depends on the anatomical pattern, patients may need root replacement with reimplantation of the coronary vessels either with preservation of the native valve or with replacement or a supracommissural tube graft replacement.

33
Q

What is mitral valve stenosis?

A

Valvular obstruction to flow from the left atrium to left ventricle due to stenosis of the mitral valve

34
Q

What are the causes of mitral stenosis?

A 
Rheumatic fever (Most common)
Congenital MS
Mitral annular calcification
Radiation associated MS
Carcinoid associated valve disease
Fabry's disease
mucopolysaccharidoses,
endocardial fibroelastosis
Prosthetic valve
35
Q

What is the normal mitral valve orifice area? At which point do symptoms begin to develop?

A

Normal- ~4–6cm

Symptoms present >2cm

36
Q

What is the pathophysiology of mitral stenosis?

A

There is raised pressure in the atria that may occur only during exercise or in more severe disease at rest.
Left atrial enlargement occurs in the presence of chronically elevated atrial pressures predisposing patients to both atrial fibrillation and atrial thrombosis. Raised atrial pressures translate to raised pulmonary venous pressures and pulmonary hypertension which can eventually lead to right sided heart failure.

37
Q

What are the signs and symptoms of mitral stenosis?

A

Exertional dyspnoea

Haemoptysis - as a result of vascular congestion and can result from the rupture of thin walled bronchial veins.

Chest pain is occasionally seen, often a result of angina from underlying coronary artery disease and hypertrophic myocardium having increased oxygen demands.

A mid-diastolic murmur is characteristic - best heard with the bell of the stethoscope with the patient lying on their left side whilst breath is in held expiration.

Ortner syndrome - a horse voice that occurs secondary to left atrial enlargement causing a left recurrent laryngeal nerve palsy.

Fatigue 
Palpitations 
Atrial fibrillation
Mitral facies (malar flush)
Pulmonary hypertension:
Right ventricular heave
Prominent a-wave
Right heart failure:
Raised JVP
Peripheral oedema
Hepatomegaly

Dysphagia
Bronchial obstruction
Systemic emboli

Malar flush on cheeks (decreased cardiac output)
Low volume pulse
Tapping, non displaced, apex beat
Right ventricular heave (parasternal heave)
can also be caused by atrial enlargement but very rarely
Loud S1 sound (opening snap)
Severity: the more severe the stenosis, the longer the diastolic murmur, and
the closer the opening snap is to S2.

38
Q

Patients with mitral stenosis are at greater risk of Thromboembolism. Why?

A

Clots that develop in a dilated left atrium, often in the presence of atrial fibrillation, may throw off emboli into the systemic circulation. As such patients may present with a stroke

39
Q

Which tests are conducted to assess mitral stenosis and what would they show?

A

Echocardiogram is diagnostic and used to assess disease severity. Valve area, mean gradient, PA pressure

Transoesophageal echocardiogram- an be performed to look for left atrial thrombosis either after an embolic episode (e.g. stroke) or prior to percutaneous mitral commissurotomy.

Chest X ray -
Left atrial enlargement
Signs of pulmonary hypertension and right sided heart failure

ECG-
Atrial fibrillation (not always)
Signs of left atrial enlargement - p mitrale, a broad, notched P wave, negative component in V1

Right sided hypertrophy present = right axis deviation, tall R waves in V1

Stress testing -
Stress testing is sometimes used in those who are asymptomatic or have minor symptoms as well as those whose symptoms are discordant with echo findings. This may take the form of an exercise stress echo or dobutamine stress test.

40
Q

Which findings on an x ray would indicate atrial enlargement?

A

Double right heart border

Splayed trachea

Prominence of the atrial appendage

41
Q

How is mitral stenosis treated?

A

Percutaneous mitral commissurotomy -
a balloon delivered by a catheter enters at the right femoral vein. This balloon is then inflated in various stages to help alleviate the stenosis.

In those not suitable for PMC, open surgery may be considered and discussed with the patient.

Patient with AF or paroxysmal AF can tend to follow the routine management of this condition. In stable patients pre-intervention, cardioversion is not indicated as the results are not sustained. Patients should receive appropriate anticoagulation.

patients with ‘moderate to severe mitral stenosis and persistent atrial fibrillation should be kept on vitamin K antagonist (VKA) treatment and not receive NOACs. Patients in sinus rhythm may obtain anticoagulation if thrombus is in the left atrium and history of systemic embolism or if Left atrium is enlarged

42
Q

What are the contraindications for percutaneous mitral commissurotomy?

A

Valve area >1.5cm2

Left atrial thrombus

Absence of commissural fusion

Severe or bi-commissural calcification

More than mild mitral regurgitation

Severe concomitant aortic stenosis requiring surgery

Severe combined tricuspid regurgitation/stenosis requiring surgery

Concomitant coronary artery disease requiring surgery

43
Q

Under which circumstances is percutaneous mitral commissurotomy indicated?

A

PMC tends to be reserved for patients with clinically significant MS and a valve area < 1.5cm2 in those who are symptomatic or at high-risk of embolism or haemodynamic decompensation.

44
Q

What is mitral regurgitation?

A

Incompetence of the mitral valve causing blood to leak through due to abnormalities to the valve leaflets, subvalvular apparatus or left ventricle.

45
Q

What is primary and secondary mitral valve regurgitation?

A

Primary- pathology affecting components of the valve itself. Degenerative disease is the most common cause.

Secondary- caused by changes to left ventricular geometry. This results in distortion of the subvalvular apparatus and valve leaflets. Dilated and ischaemic cardiomyopathies are the most common cause.

46
Q

What is chronic mitral regurgitation?

A

There is gradual worsening of the regurgitant fraction that initially allows for compensatory mechanisms to occur. Eventually failure may result and the patient enters a decompensated state:

  • Compensate - Left ventricle and left atrium dilate.
  • The compliant and dilated left ventricle undergoes eccentric hypertrophy and is able to maintain a larger stroke volume and as such ejection fraction.
  • The compliant and dilated left atrium prevents rises in atrial and therefore pulmonary pressures.

Decompensated -

  • eventually such changes cannot maintain normal cardiac function and the remodelling becomes increasingly pathological
  • The heart fails, ejection fraction falls and pulmonary pressures rise
47
Q

What is acute mitral regurgitation?

A

There are fast and significant changes to flow without time for any adaptation or remodelling to occur as is seen in chronic MR.

The new regurgitation causes increased pressure within a non-compliant left atrium.

This causes a rise in pulmonary pressure resulting in pulmonary oedema

Ejection fracture falls as blood goes back through the regurgitating valve in stead of going through the aortic valve. A tachycardic response may be raised to help compensate for the reduced ejection fraction in an attempt to return the cardiac output to normal. This is rarely sufficient and cardiogenic shock can occur.

48
Q

What are the clinical features of acute mitral regurgitation?

A
  • Rapid development of heart failure in inadequate cardiac output
  • Flash pulmonary oedema
  • Patient may be in shock and breathless
  • Condition is potentially life threatening
49
Q

What are the clinical features/ symptoms of chronic mitral regurgitation?

A
  • May be asymptomatic for many years
  • Heart failure will cause symptoms to develop
  • symptoms tend to involve dyspnoea and orthopnoea that results from pulmonary hypertension
  • Fatigue and malaise are common.
  • Peripheral oedema due to right sided heart failure
50
Q

What are the signs of mitral regurgitation?

A
  • Laterally displaced apex beat
  • Systolic thrill in sever cases
  • Pan systolic murmur
  • Sighs of heart failure
    (e. g bi basal crackles, peripheral oedema)
51
Q

Which investigations would you conduct for someone with mitral regurgitation and what would you see in each?

A

Chest X - ray-

  • left atrial (double right heart dorder) and ventricular enlargement
  • Cardiomegaly (not see in acute cases)
  • Signs of pulmonary oedema

ECG-

  • In acute case - normal or show indications of recent myocardial infarction
  • Chronic condition p-mitrale - a broad, notched p-wave with a negative component in V1 - (reflecting left atrial enlargement) and signs of left ventricular hypertrophy.
  • Arrhythmia’s, most commonly atrial fibrillation, are sometimes present.

Echocardiogram -
visualisation of the incompetent valve and can confirm the underlying aetiology. Left atrial and ventricular enlargement may be seen in chronic MR.

Cardiopulmonary Exercise testing
- assess a patients overall functional capacity. Exercise echocardiography is used to demonstrate changes in MR during exercise.

Cardiac MRI-
- may be used when echocardiogram is inadequate.

Cardiac catheterisation
- used for evaluation of the coronary vessels prior to valvular surgery. Right sided catheterisation can be used to confirm pulmonary hypertension.

52
Q

How is primary mitral regurgitation managed?

A

Acute -

Medical stabilisation-

  • Sodium nitroprusside - reduces afterload
  • Inotropic agents e.g Dobutamine and an intra-aortic balloon - hypotension

Surgery (depends on patients clinical state and underlying aetiology) -

  • Surgical repair - infective endocarditis and chordal rupture
  • Surgical replacement - papillary muscle rupture

Chronic -

Medical therapy -
- In patients with chronic MR and heart failure, ACE inhibitors, beta-blockers and spironolactone may all be considered

  • Cardiac resynchronisation therapy (CRT) is used when appropriate
  • If AF control rate with beta blockers and anticoagulated. History of embolism = prosthetic valve

Surgical
- considered in symptomatic patients with a LVEF > 30%.
aim to repair or replace the valve before LV is irreversibly
impaired.

  • Can also be considered in other patients - specialist call
  • Other surgical measures include ventricular assist devices, cardiac restraint devices and heart transplantation.
53
Q

How is secondary mitral regurgitation managed?

A
  • management should be guided by MDT

- Medical therapy should follow heart failure management. CRT should be considered when appropriate

54
Q

What is the most common valvular pathology?

A

Mitral valve prolapse

55
Q

What are the signs and symptoms of Mitral valve prolapse?

A
  • Usually asymptomatic. May develop atypical chest pain,
    palpitations, and autonomic dysfunction symptoms

Signs
Mid-systolic click and/
or a late systolic murmur

56
Q

What are the complications of Mitral valve prolapse?

A

Mitral regurgitation, cerebral emboli, arrhythmias, sudden death

57
Q

How is Mitral valve prolapse diagnosed and treated?

A

Echo is diagnostic. ECG may show inferior T-wave inversion.

  • blockers may help palpitations and chest pain. Surgery if severe MR.
58
Q

What are the causes of pulmonary stenosis?

A
  • Usually congenital (Turner syndrome, Noonan syn-
    drome, Williams syndrome, Fallot’s tetralogy, rubella)
  • Acquired causes: rheumatic fever, carcinoid syndrome
59
Q

What are the signs and symptoms of pulmonary stenosis?

A

Dyspnoea; fatigue; oedema; ascites

Signs
 - Dysmorphic facies (congenital causes); 
- prominent a wave in JVP; 
 - RV heave
In mild stenosis,
- ejection click
- ejection systolic murmur (which radiates to the left shoulder);
- widely split S2.

In severe stenosis,

  • murmur becomes longer and obscures A2.
  • P2 becomes softer and may be inaudible
60
Q

How is pulmonary stenosis Diagnosed?

A

ECG: Right axis deviation , P-pulmonale, RV Hypertrophy , RBBB

ECHO

CXR: prominent pulmonary arteries caused by post-stenotic dilatation

Cardiac
catheterization is diagnostic

61
Q

How is pulmonary stenosis treated?

A

Pulmonary valvuloplasty or valvotomy

62
Q

What is the causes and symptoms of pulmonary regurgitation?

A

Causes: Any cause of pulmonary hypertension

Signs: Decrescendo murmur in early diastole at the left sternal edge

63
Q

What are the causes of Tricuspid regurgitation?

A
  • Functional (RV dilatation; eg due to pulmonary
    hypertension induced by LV failure or PE);
  • rheumatic fever;
  • infective endocarditis (IV
    drug abuser);
  • carcinoid syndrome;
  • congenital (eg ASD, AV canal, Ebstein’s anomaly
    (downward displacement of the tricuspid valve
  • drugs (eg ergot-
    derived dopamine agonists, ; fenfluramine)
64
Q

What are the symptoms of Tricuspid regurgitation?

A 
Symptoms 
- Fatigue; 
- hepatic pain
on exertion (due to hepatic congestion); 
- ascites; 
- oedema 
- symptoms of the
causative condition

Signs

  • Giant v waves
  • prominent y descent in JVP
  • RV heave;
  • pansystolic murmur, heard best at lower sternal edge in inspiration;
  • pulsatile hepatomegaly;
  • jaundice;
  • ascites
65
Q

How is Tricuspid regurgitation managed?

A
  • Drugs: diuretics for systemic congestion;
  • Drugs to treat underlying cause.
  • Valve repair or replacement
66
Q

What is the cause of Tricuspid stenosis?

A

Causes: Main cause is rheumatic fever

congenital, infective endocarditis

67
Q

What are the symptoms and signs of Tricuspid stenosis?

A

Symptoms: Fatigue, ascites, oedema.

Signs: Giant a wave and slow y descent in
JVP
opening snap, early diastolic murmur heard at the left sternal edge in
inspiration.

AF can also occur

68
Q

How is Tricuspid stenosis diagnosed and treated?

A

Diagnosis: Echo. Treatment: Diuretics; surgical repair.

69
Q

What are the ECG findings for pulmonary hypertension?

A
  • Right axis deviation
  • Positive QRS complexes (‘dominant R waves’) in V1 and V2 suggesting right ventricular hypertrophy
  • ST depression and T-wave inversion in the right precordial leads (V1–3) suggesting right ventricular strain
  • Peaked P waves (P pulmonale) suggesting right atrial hypertrophy.
70
Q

When a patient has a dual pace maker, how will it show on an ECG?

A

Pacing spikes occur before each P wave and each QRS complex.

Paced QRS complexes are broad as the impulse starts in the ventricles

71
Q

What causes a raised JVP with normal waveform?

A

Fluid overload, right heart failure

72
Q

What causes a fixed raised JVP with absent pulsation?

A

superior vena cava obstruction

73
Q

What causes a large a wave?

A

Pulmonary hypertension, pulmonary stenosis

74
Q

What causes a cannon a wave?

A

When the right atrium contracts against a closed tricuspid valve

—complete heart block, single chamber ven-
tricular pacing, ventricular arrhythmias/ectopics.

75
Q

What causes an absent a wave?

A

Atrial fibrillation

76
Q

What causes Large v waves?

A

Tricuspid regurgitation—look for earlobe movement

77
Q

What causes an absent JVP?

A 
If there is reduced
circulatory volume (eg dehydration, haemorrhage) the JVP may be absent.

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