Valvular Dysfunction Flashcards
1
Q
Stenosis
A
narrowing
2
Q
Regurgitation
A
leaky
3
Q
common causes of valvular heart disease:
A
- degenerative (wears out as you get older)
- congenital (born with it)
- rheumatic disease (after rheumatic fever)
- infective endocarditis (valve infections)
- annular dilation (chronic strain)
4
Q
Heart sounds
A
5
Q
What is the most common aetiology of single valvular heart disease?
A
Degeneration
6
Q
Valvular Heart Disease Investigations:
A
- ECG
- echocardiogram: transthoracic, transoeophageal
- cardiac MR scan
- cardiac catheterisation
7
Q
Aortic Valve:
A
- LV and aorta
- semi lunar valve
- 3 cusps
- attached to a fibrous ring (annulus)
8
Q
Anatomical names vs clinical names for cusps of aorta:
A
- left coronary = left
- right coronary = right
- non-coronary = posterior
9
Q
Aortic Stenosis blood pressure
A
insert
- peak to peak analysis of left ventricle pressure vs
peak of aortic pressure
- severe aortic stenosis = big difference in peaks
- 80mmHg difference = severe
- 35mmHg = moderate
10
Q
What is the most common severe valvular abnormality in the West?
A
aortic stenosis
11
Q
Most common cause for aortic stenosis for over 70s?
A
degeneration of tricuspid valve (50%)
12
Q
Most common cause of aortic stenosis in under 70s?
A
Degeneration of bicuspid valve (congenital defect) (50%)
13
Q
Signs of aortic stenosis (5):
A
- low volume, slow rising carotid pulse
- force impulse at the apex
- soft second heart sound (cusps don’t slam shut)/
absent - ejection systolic murmur = loudest in the aortic area,
radiates to the neck - thrill in the aortic area
14
Q
Aortic Stenosis on an ECG:
A
- left ventricular hypertrophy (thickening):
- tall complexes
- lateral T wave inversion
- 80% of patients with severe AS - Left bundle branch block: (always pathological)
- broad complexes
- many other causes
15
Q
What is the diagnosis?
A
Aortic stenosis
16
Q
Aortic Stenosis Echocardiogram:
- what will you see
- what will classify mild, moderate and severe aortic
stenosis?
A
- left ventricular hypertrophy
- aortic valve: calcified, may be bicuspid, restricted
mobility
17
Q
Aortic Stenosis Treatment (4)(1):
A
- symptomatic patients need a new valve
- as a holding maneuver:
- diuretic for breathlessness
- beta blocker for angina/chest pain - AVOID vasodilators (eg ACE inhibitors and nitrites)
18
Q
Why do we avoid vasodilators when treating aortic stenosis?
A
ACE inhibitors drop preload, preload affects how much the heart expands, decreasing force of contraction and can lead to patient fainting
19
Q
Aortic Stenosis Surgical Treatment:
A
- AVR = surgical valve replacement:
- tissue valves, mechanical valves (need warfarin) - TAVR = transcathetor aortic valve replacement:
- implantation of a tissue valve via a peripheral
artery
20
Q
AVR: mechanical or tissue?
A
- younger patients, patients also needing CABG may
use a mechanical valve as it lasts longer - but would be on warfarin/anticoagulants to prevent
blood clots forming around the valve
21
Q
TAVR advantages:
A
- less invasive
- via femoral artery
- implanted into native valve
- outcomes comparable to surgery for routine patients
- good for patients that are older and have a lot of co-
morbidities that would not be able to have a normal
surgery
22
Q
Mitral valve:
A
- LA and LV
- 2 cusps (anterior and posterior)
- cusp tips attached to left ventricular muscles via
chordae tendineae - attached to a fibrous ring (annulus)
23
Q
Mitral Valve Regurgitation:
- how common to have surgery
- aetiologies
- consequences
A
- second most common indication for valve surgery
- congenital valve leaflet prolapse (floppy valve)
- chordal/ papillary muscle rupture due to MI
- causes torrential significant acute mitral regurgitation
- causes a significant increase in pressure on capillaries
in lungs and results in pulmonary oedema - causes:
- acute MI
- infective endocarditis
- rheumatic
- myocardial ischaemia (LV distortion/ papillary muscle
dysfunction) - annular dilation: LV dilation in heart failure; if left ve
dilates it stretches annulus, cause leaflets to have a
gap when collapsing, so valve leaks
24
Q
Causes of mitral regurgitation:
A
25
Haemodynamic consequences of mitral regurgitation?
- volume overload of LV: LV dilation
- volume overload of LA: LA dilation, atrial rhythm
disturbances
26
Mitral Regurgitation Signs (4)(3):
- displaced, forceful apex beat (LV+)
- palpable parasternal impulse (RV+)
- pansystolic murmur = leaky ventricle:
- loudest in mitral area
- radiates to the left axilla
- thrill in the mitral area
27
Which value dysfunction?
Mitral regurgitation
28
Which value dysfunction?
Aortic stenosis
29
Mitral Regurgitation ECG:
- broad P waves "P mitrale": LA dilation
- Left ventricular hypertrophy: tall complexes, lateral T
wave inversion
- LEFT BUNDLE BRANCH BLOCK: broad complexes,
other causes
- atrial arrhythmias (atrial fibrillation)
30
What is the diagnosis?
Mitral regurgitation
31
Mitral Regurgitation Echocardiogram:
- what can you see?
- classification of severity?
- INSERT
- left ventricular dilation
- left atrial dilation
- mitral valve: prolapse, chordal rupture,
calcified/thickened
- severity of leaky valves is harder than for narrow
valves
- insert
32
Mitral Regurgitation Treatment:
- symptomatic patients need a new valve
- holding maneuver/ too ill for surgery:
- diuretic for breathlessness
- ACE inhibitor for LV dilation
- Beta blocker and anticoagulation for atrial fibr
33
Mitral Regurgitation Surgical (3):
- what options are unsuitable under which conditions?
- invasiveness
- MVR: surgical valve replacement: mechanical, tissue,
for degenerate valves are unsuitable for repair
- Surgical Valve Repair: treatment of choice for MVLP or
chordal rupture, minimally invasive
- transcatheter options: not yet established, mitraclip
for very symptomatic patients with no surgical options
34
Aortic Regurgitation is and haemodynamic consequences:
- leaflets fail to close completely
- blood leaks back from the aorta into LV: leakage in
DIASTOLE
- left ventricular volume overload: LV dilation, LV
dysfunction
35
Aortic Regurgitation Causes (2)(3)(4):
- Valvular:
- bicuspid valve
- infective endocarditis
- rheumatic
- Aortic Disease:
- hypertension
- aortic dissection
- connective tissue disease (ankylosing spondylitis)
- syphilis
36
Aortic Regurgitation Signs:
- pulse: large volume, collapsing
- BP: high systolic, low diastolic
- displaced forceful apex beat (LV+)
- early diastolic murmur:
- at the lower left sternal border, best heard
during expiration
37
Which value dysfunction?
Aortic regurgitation
38
aortic Regurgitation ECG:
- left ventricular hypertrophy
39
Aortic Regurgitation echocardiogram:
- bicuspid valve?
- aortic dilation
- LV dilation/ dysfunction
40
Aortic Regurgitation Severity
41
Aortic Regurgitation Treatment:
- symptomatic patients need a new valve
- holding maneuver/ too ill for surgery:
- diuretic for breathlessness
- ACE inhibitor for LV dilation/ dysfunction
- surgical valve replacement:
- often also require repair of the proximal aorta
- no good transcatheter options
42
Aortic Regurgitation causes diagram
insert
43
Mitral stenosis cause:
- rheumatic (most common)
- degenerative
- congenital
- leaflet thickening and fusion
44
Mitral Stenosis Effect:
- pressure overload on:
- left atrium (atrial fibrillation)
- pulmonary vasculature: pulmonary
hypertension,
right heart failure
45
Mitral Stenosis Signs (3):
- loud 1st heart sound
- parasternal heave (RV+)
- low pitched rumbling/mid late diastolic murmur:
- loudest in the mitral area
- louder with the patient lying on their left
46
Which value dysfunction?
.mitral stenosis
47
Mitral Stenosis Imaging
insert
48
Mitral Stenosis ECG:
- P mitrale (big, M shaped P waves)
- atrial fibrillation
49
Mitral Stenosis echocardiogram:
- commisural fusion +/- calcification/ immobility
- LA dilation
- right heart dilation
50
Mitral Stenosis Severity
51
Mitral Stenosis Treatment:
- surgical only for patients who remain symptomatic
despite medical Rx
- diuretics for breathlessness/ oedema
- atrial fibrillation:
- rate control (beta blockers)
- anticoagulation with warfarin (high thrombotic
risk)
- cardioversion to sinus rhythm
52
Mitral Stenosis Surgical:
- replacement usually best option as most structures
are thickened so repair is difficult
- MVR: mechanical valve replacement, tissue valve
- Trans-catheter balloon valvotomy:
- treatment of choice for non-calcified valve
- unsuitable if valve is also regurgitant
- surgical valvotomy: first form of valve surgery, rarely
performed now, into femoral artery, cut through from LV to LA
53
Tricuspid Regurgitaiton:
- common but rarely a primary pathology
- usually secondary to annular dilation due to: left heart
disease pulmonary hypertension, all as a result of pulmonary
hypertension
- elevated JVP +++
54
Tricuspid Stenosis:
- very rare
- rheumatic valve disease
55
Pulmonary Stenosis:
- uncommon
- usually congenital
- may occur as a part of balloon dilation eg Fallot's
tetralogy
- treatment: transcatheter balloon dilation (as a child)
56
Pulmonary Regurgitation:
- uncommon
- may be secondary to:
- pulmonary hypertension
- balloon dilation
