Valvular Dysfunction Flashcards
Stenosis
narrowing
Regurgitation
leaky
common causes of valvular heart disease:
- degenerative (wears out as you get older)
- congenital (born with it)
- rheumatic disease (after rheumatic fever)
- infective endocarditis (valve infections)
- annular dilation (chronic strain)
Heart sounds
What is the most common aetiology of single valvular heart disease?
Degeneration
Valvular Heart Disease Investigations:
- ECG
- echocardiogram: transthoracic, transoeophageal
- cardiac MR scan
- cardiac catheterisation
Aortic Valve:
- LV and aorta
- semi lunar valve
- 3 cusps
- attached to a fibrous ring (annulus)
Anatomical names vs clinical names for cusps of aorta:
- left coronary = left
- right coronary = right
- non-coronary = posterior
Aortic Stenosis blood pressure
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
What is the most common severe valvular abnormality in the West?
aortic stenosis
Most common cause for aortic stenosis for over 70s?
degeneration of tricuspid valve (50%)
Most common cause of aortic stenosis in under 70s?
Degeneration of bicuspid valve (congenital defect) (50%)
Signs of aortic stenosis (5):
- 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
Aortic Stenosis on an ECG:
- 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
What is the diagnosis?
Aortic stenosis
Aortic Stenosis Echocardiogram:
- what will you see
- what will classify mild, moderate and severe aortic
stenosis?
- left ventricular hypertrophy
- aortic valve: calcified, may be bicuspid, restricted
mobility
Aortic Stenosis Treatment (4)(1):
- 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)
Why do we avoid vasodilators when treating aortic stenosis?
ACE inhibitors drop preload, preload affects how much the heart expands, decreasing force of contraction and can lead to patient fainting
Aortic Stenosis Surgical Treatment:
- AVR = surgical valve replacement:
- tissue valves, mechanical valves (need warfarin) - TAVR = transcathetor aortic valve replacement:
- implantation of a tissue valve via a peripheral
artery
AVR: mechanical or tissue?
- 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
TAVR advantages:
- 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
Mitral valve:
- LA and LV
- 2 cusps (anterior and posterior)
- cusp tips attached to left ventricular muscles via
chordae tendineae - attached to a fibrous ring (annulus)
Mitral Valve Regurgitation:
- how common to have surgery
- aetiologies
- consequences
- 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
Causes of mitral regurgitation:
Haemodynamic consequences of mitral regurgitation?
- volume overload of LV: LV dilation
- volume overload of LA: LA dilation, atrial rhythm
disturbances
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
Which value dysfunction?
Mitral regurgitation
Which value dysfunction?
Aortic stenosis
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)
What is the diagnosis?
Mitral regurgitation
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
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
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
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
Aortic Regurgitation Causes (2)(3)(4):
- Valvular:
- bicuspid valve
- infective endocarditis
- rheumatic - Aortic Disease:
- hypertension
- aortic dissection
- connective tissue disease (ankylosing spondylitis)
- syphilis
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
Which value dysfunction?
Aortic regurgitation
aortic Regurgitation ECG:
- left ventricular hypertrophy
Aortic Regurgitation echocardiogram:
- bicuspid valve?
- aortic dilation
- LV dilation/ dysfunction
Aortic Regurgitation Severity
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
Aortic Regurgitation causes diagram
insert
Mitral stenosis cause:
- rheumatic (most common)
- degenerative
- congenital
- leaflet thickening and fusion
Mitral Stenosis Effect:
- pressure overload on:
- left atrium (atrial fibrillation)
- pulmonary vasculature: pulmonary
hypertension,
right heart failure
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
Which value dysfunction?
.mitral stenosis
Mitral Stenosis Imaging
insert
Mitral Stenosis ECG:
- P mitrale (big, M shaped P waves)
- atrial fibrillation
Mitral Stenosis echocardiogram:
- commisural fusion +/- calcification/ immobility
- LA dilation
- right heart dilation
Mitral Stenosis Severity
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
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
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 +++
Tricuspid Stenosis:
- very rare
- rheumatic valve disease
Pulmonary Stenosis:
- uncommon
- usually congenital
- may occur as a part of balloon dilation eg Fallot’s
tetralogy - treatment: transcatheter balloon dilation (as a child)
Pulmonary Regurgitation:
- uncommon
- may be secondary to:
- pulmonary hypertension
- balloon dilation
