Valvular diseases and heart sounds Flashcards
What are the causes of aortic stenosis?
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
Which other conditions is a Bicuspid aortic valve (BAV) also associated with?
aortic coarctation, Aortic root dilatation and, potentially, aortic dissection
What are the risk factors for calcified aortic stenosis?
hypercholesterolaemia
hypertension
Smoking
diabetes
What happens to the heart over time in those with aortic stenosis?
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
What are the clinical signs and symptoms associated with aortic valve stenosis?
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)
Which bleeding disorder can be caused by aortic stenosis? Why does this disorder develop?
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
Which investigation is used to diagnose aortic stenosis other valvular disease?
Echocardiogram
Which other investigations would you conduct in someone suspected of having aortic stenosis?
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)
On an ECG what might you see in someone with aortic stenosis?
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
How is aortic stenosis treated?
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
What is the pulse pressure?
Difference between the systolic and diastolic pressures
List 3 causes of Ejection systolic murmur
Aortic stenosis or sclerosis
Pulmonary stenosis
HOCM
List 3 causes of Ejection systolic murmur
Aortic stenosis or sclerosis
Pulmonary stenosis
HOCM (Hypertrophic obstructive cardiomyopathy)
When an doppler echo cardiogram is done for aortic stenosis, what is Echo assessing?
The gradient across the valve
The valve area
When a doppler echo cardiogram is done for aortic stenosis, what is the Echo assessing?
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
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?
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
What is aortic regurgitation?
Incompetent aortic valve causing a regurgitant flow of blood in diastole.
At what age is aortic regurgitation most common?
fourth and sixth decades of life
Affects males 3x more than women
What are the causes of aortic regurgitation?
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
In Endocarditis, which infective causes can lead to aortic dissection?
Strep. viridans, Staph. aureus, Enterococci
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?
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
Which conditions can cause aortitis?
Chronic inflammatory conditions e.g.
Rheumatoid arthritis (RA) and ankylosing spondylitis (AS),
Describe acute aortic regurgitation?
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.
What are the causes of acute aortic regurgitation?
Infective endocarditis
Rheumatic fever
Aortic dissection
What is chronic aortic regurgitation?
- 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.
What is the cause of chronic aortic regurgitation?
Rheumatic heart disease
Arthritides
Bicuspid valve
Connective tissue disorders
What are the signs and symptoms of acute and chronic aortic regurgitation?
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
What are the Eponymous signs for aortic regurgitation?
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.
Which best side/ blood tests would you do for aortic regurgitation?
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
Which imaging test would you do for someone with aortic regurgitation and what would you find in these tests?
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.
How is acute aortic regurgitation treated?
Aortic valve replacement or repair should be performed as soon as possible.
How is chronic aortic regurgitation treated?
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.
What is mitral valve stenosis?
Valvular obstruction to flow from the left atrium to left ventricle due to stenosis of the mitral valve
What are the causes of mitral stenosis?
Rheumatic fever (Most common) Congenital MS Mitral annular calcification Radiation associated MS Carcinoid associated valve disease Fabry's disease mucopolysaccharidoses, endocardial fibroelastosis Prosthetic valve
What is the normal mitral valve orifice area? At which point do symptoms begin to develop?
Normal- ~4–6cm
Symptoms present >2cm
What is the pathophysiology of mitral stenosis?
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.
What are the signs and symptoms of mitral stenosis?
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.
Patients with mitral stenosis are at greater risk of Thromboembolism. Why?
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
Which tests are conducted to assess mitral stenosis and what would they show?
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.
Which findings on an x ray would indicate atrial enlargement?
Double right heart border
Splayed trachea
Prominence of the atrial appendage
How is mitral stenosis treated?
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
What are the contraindications for percutaneous mitral commissurotomy?
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
Under which circumstances is percutaneous mitral commissurotomy indicated?
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.
What is mitral regurgitation?
Incompetence of the mitral valve causing blood to leak through due to abnormalities to the valve leaflets, subvalvular apparatus or left ventricle.
What is primary and secondary mitral valve regurgitation?
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.
What is chronic mitral regurgitation?
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
What is acute mitral regurgitation?
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.
What are the clinical features of acute mitral regurgitation?
- Rapid development of heart failure in inadequate cardiac output
- Flash pulmonary oedema
- Patient may be in shock and breathless
- Condition is potentially life threatening
What are the clinical features/ symptoms of chronic mitral regurgitation?
- 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
What are the signs of mitral regurgitation?
- Laterally displaced apex beat
- Systolic thrill in sever cases
- Pan systolic murmur
- Sighs of heart failure
(e. g bi basal crackles, peripheral oedema)
Which investigations would you conduct for someone with mitral regurgitation and what would you see in each?
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.
How is primary mitral regurgitation managed?
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.
How is secondary mitral regurgitation managed?
- management should be guided by MDT
- Medical therapy should follow heart failure management. CRT should be considered when appropriate
What is the most common valvular pathology?
Mitral valve prolapse
What are the signs and symptoms of Mitral valve prolapse?
- Usually asymptomatic. May develop atypical chest pain,
palpitations, and autonomic dysfunction symptoms
Signs
Mid-systolic click and/
or a late systolic murmur
What are the complications of Mitral valve prolapse?
Mitral regurgitation, cerebral emboli, arrhythmias, sudden death
How is Mitral valve prolapse diagnosed and treated?
Echo is diagnostic. ECG may show inferior T-wave inversion.
- blockers may help palpitations and chest pain. Surgery if severe MR.
What are the causes of pulmonary stenosis?
- Usually congenital (Turner syndrome, Noonan syn-
drome, Williams syndrome, Fallot’s tetralogy, rubella) - Acquired causes: rheumatic fever, carcinoid syndrome
What are the signs and symptoms of pulmonary stenosis?
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
How is pulmonary stenosis Diagnosed?
ECG: Right axis deviation , P-pulmonale, RV Hypertrophy , RBBB
ECHO
CXR: prominent pulmonary arteries caused by post-stenotic dilatation
Cardiac
catheterization is diagnostic
How is pulmonary stenosis treated?
Pulmonary valvuloplasty or valvotomy
What is the causes and symptoms of pulmonary regurgitation?
Causes: Any cause of pulmonary hypertension
Signs: Decrescendo murmur in early diastole at the left sternal edge
What are the causes of Tricuspid regurgitation?
- 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)
What are the symptoms of Tricuspid regurgitation?
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
How is Tricuspid regurgitation managed?
- Drugs: diuretics for systemic congestion;
- Drugs to treat underlying cause.
- Valve repair or replacement
What is the cause of Tricuspid stenosis?
Causes: Main cause is rheumatic fever
congenital, infective endocarditis
What are the symptoms and signs of Tricuspid stenosis?
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
How is Tricuspid stenosis diagnosed and treated?
Diagnosis: Echo. Treatment: Diuretics; surgical repair.
What are the ECG findings for pulmonary hypertension?
- 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.
When a patient has a dual pace maker, how will it show on an ECG?
Pacing spikes occur before each P wave and each QRS complex.
Paced QRS complexes are broad as the impulse starts in the ventricles
What causes a raised JVP with normal waveform?
Fluid overload, right heart failure
What causes a fixed raised JVP with absent pulsation?
superior vena cava obstruction
What causes a large a wave?
Pulmonary hypertension, pulmonary stenosis
What causes a cannon a wave?
When the right atrium contracts against a closed tricuspid valve
—complete heart block, single chamber ven-
tricular pacing, ventricular arrhythmias/ectopics.
What causes an absent a wave?
Atrial fibrillation
What causes Large v waves?
Tricuspid regurgitation—look for earlobe movement
What causes an absent JVP?
If there is reduced circulatory volume (eg dehydration, haemorrhage) the JVP may be absent.
