Valvular Dysfunction

Question 1

how is the heart heard

Answer 1

Opening and closing of heart valves

S1 lub and S2 dub

Question 2

what does sounds heard between the two heart sounds indicate

Answer 2

turbulent blood flow heard between two heart sounds (hear nothing in healthy patients)
Hit valve and changes direction of blood flow
Due to filling of heart, valvular pathology and structural heart disease

Question 3

why do people get heart disease

Answer 3

Degenerative heart disease (aging population)
Rheumatic valve disease (post streptococcal rheumatic fever, children and young adults, disease of poverty/ overcrowding)
Infective (virulent organisms eg staph or strep, immunocompromised)
Congenital valve disease (low static incidence in all populations)

Question 4

what valves are affected in degenerative heart disease

Answer 4

aortic more commonly than mitral

Question 5

what valves are affected in rheumatic heart disease

Answer 5

mitral more common than aortic

Question 6

what valves are affected in infective heart disease

Answer 6

any valve (L more than R), right by atypical organism (IVDU high risk) – flows back into RA to tricuspid valve. 
Also secondary loss of supporting structures

Question 7

what valves are affected in congenital valve disease

Answer 7

any valve

Question 8

what is the most common valve disease (Europe)

Answer 8

Aortic stenosis – 80% due to degeneration
Mitral regurgitation is 2nd most common
Then aortic regurgitation, lastly mitral stenosis

Question 9

what could be valve pathology

Answer 9

Degenerative changes 
Calcification – immobilises leaflets
Fibrosis – fusion of leaflets
Dilatation of valve ring 
Results in stenosis and regurgitation

Question 10

what is stenosis

Answer 10

narrowing of valve leaflets, fail to open completely, build up of back pressure and loss of stroke volume

Question 11

what is regurgitation

Answer 11

leaflets don’t meet in systole, fail to close completely, reverse flow of blood as heart relaxes aka incompetence

Question 12

when does aortic stenosis occur

Answer 12

Congenital paeds and <60
Bicuspid valves 40-60
Degenerative >60
Post rheumatic fever <60

Question 13

what are features of aortic stenosis

Answer 13

Symptoms due to obstruction of flow caused by decreased cardiac output
SAD triad
Syncope – exertion
Angina
Dysponea (SOB – esp exertion)
Fatigue, palpitations, sudden death (rare if asymptomatic) from arrythmias/pressure overload.
Pressure overload – high LV systolic pressure -LV hypertrophy and eventual decompensation/dilatation

Question 14

how does mild to moderate aortic stenosis present

Answer 14

murmur on routine exam

Question 15

how does aortic stenosis sound

Answer 15

Systolic or crescendo/decrescendo murmur – valve not fully open = turbulence at beginning of systole, peaks and falls as ventricles relax
Severe AS – soft 2nd heart sound (valve doesn’t close properly)

Question 16

what are causes of aortic regurgitation

Answer 16

Aortic dilatation (loss of support, CT disease eg rheumatoid arthritis), hypertension/ aortic dissection/ degeneration/ cystic medial necrosis/ syphilis
Valvular– bicuspid valve or infective endocarditis

Question 17

what are the consequences of aortic regurgitation

Answer 17

Vol overload (in ventricle because blood falls back into LV during diastole)
LV dilatation (accommodate volume, results from vol overload)
Late decompensation of left ventricle function

Question 18

what is the path-physiology of aortic regurgitation

Answer 18

LV failure, dilates LA, hypertension as blood pushed back, pulmonary oedema

Question 19

how can aortic regurgitation be heard

Answer 19

Early diastolic murmur (ventricle pressure drops, aortic leaflets fail so blood flows back, happens most when pressure in ventricle lowest)
Concomitant, systolic murmur (may be turbulence as blood exits the ventricle during systole)

Question 20

what are symptoms of aortic regurgitation

Answer 20

Often asymptomatic
Chest pain (CA decreased perfusion and diastolic BP decreases)
Breathlessness
Syncope – uncommon
Catastrophic decompensation if acute – fulminant pulmonary oedema

Question 21

what are causes of mitral regurgitation

Answer 21

Valvular (prolapse, infective degenerative)
Chordal rupture/ papillary muscle failure – acute/chronic
Annular dilation – secondary to left ventricular dilation (func or ishchaemic)

Question 22

what are consequences of mitral regurgitation

Answer 22

Volume overload in left ventricle (blood ejected back into left atrium, elevates pressure and increases ventricular filling during diastole)
Pressure overload in right heart (right ventricular hypertrophy or failure, transient elevation of left atrial pressure in systole)
Left ventricular dilation – vol overload
Decompensation – pulmonary oedema

Question 23

how can mitral regurgitation be heard

Answer 23

Pan-systolic murmur – leaflets fail to close so blood goes back into left atrium with turbulence as it passes across abnormal valve, whole of systole back LA is low pressure chamber and in systole LV is under high pressure)

Question 24

what are symptoms of mitral regurgitation

Answer 24

Breathlessness (back pressure in pulmonary circulation)
Lethargy and reduced exercise tolerance (breathlessness and reduced CO)
Palpitations – atrial fibrillation (pressure overload)
Peripheral oedema – decompensation
Chest pain – concomitant CAD

Question 25

what is mitral valve prolapse

Answer 25

Valve shuts in early systole, leaflet too baggy/ abnormal, leaflet prolapses into left atrium, allowing regurgitation
Heard as mid-systolic click (as leaflet prolapses back into LA) or late systolic murmur (blood continues to flow into left atrium after initial regurgitation

Question 26

what causes mitral stenosis

Answer 26

almost always rheumatic fever
Could be congenital, storage diseases, malignancy, prev endocarditis, mitral valve calcification, systemic disease (eg SL(lupus)E, RA)

Question 27

what are the consequences of mitral stenosis

Answer 27

Lung/heart consequences
Breathlessness, congestion (back pressure from LA failed ejection)
LV pathology usually preserved (compromised when atrial contraction is lost or high circulating volume (high right heart pressure))

Question 28

how is mitral stenosis heard

Answer 28

Mid diastolic rumbling (stenosis restricts blood flow from LA to LV)
Opening snap – hear restricted leaflets open
Loud 1st heart sound (stiff but mobile, slam shut)

Question 29

what are symptoms of mitral stenosis

Answer 29

Lung (breathlessness, peripheral oedema, haemoptysis)

Palpitations, systemic emboli, fatigue, compressive symptoms (stridor, dysphagia)

Question 30

how is valve disease managed

Answer 30

Medical – HF or arrythmias
Surgical – valve repair or replacement
Percutaneous - BAV or TAVI

Question 31

how are patients evaluated for valve disease

Answer 31

Clinical assessment (symptoms- comorbidities, education and auscultation)
Echocardiography – key examination to confirm diagnosis and assess severity, compare findings with clinical assessment

Question 32

what are other types of patient evaluation

Answer 32

Exercise testing 
Stress echo 
MRI
Multislice CT
Cardiac Catheterisation (evaluate valve function)

Question 33

what are the types of valve replacement

Answer 33

Mechanical

Biological

Question 34

how do heart sounds change wit prosthetic valves

Answer 34

Depends on valve
Position
1st heart sound metallic is mitral and 2nd is aortic
Systolic murmurs common but not necessarily pathological
Diastolic murmurs usually pathological

Question 35

what is trans-catheter valve replacement used for

Answer 35

Pulmonary (congenital heart disease)

Aortic (new tech for those too high risk for conventional surgery, under local anasthetic, shorter recovery)

Question 36

can the mitral valve be replaced by trans-catheter

Answer 36

mitraclip (for mitral regurgitation, emerging)