Valvular Dysfunction Flashcards
how is the heart heard
Opening and closing of heart valves
S1 lub and S2 dub
what does sounds heard between the two heart sounds indicate
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
why do people get heart disease
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)
what valves are affected in degenerative heart disease
aortic more commonly than mitral
what valves are affected in rheumatic heart disease
mitral more common than aortic
what valves are affected in infective heart disease
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
what valves are affected in congenital valve disease
any valve
what is the most common valve disease (Europe)
Aortic stenosis – 80% due to degeneration
Mitral regurgitation is 2nd most common
Then aortic regurgitation, lastly mitral stenosis
what could be valve pathology
Degenerative changes Calcification – immobilises leaflets Fibrosis – fusion of leaflets Dilatation of valve ring Results in stenosis and regurgitation
what is stenosis
narrowing of valve leaflets, fail to open completely, build up of back pressure and loss of stroke volume
what is regurgitation
leaflets don’t meet in systole, fail to close completely, reverse flow of blood as heart relaxes aka incompetence
when does aortic stenosis occur
Congenital paeds and <60
Bicuspid valves 40-60
Degenerative >60
Post rheumatic fever <60
what are features of aortic stenosis
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
how does mild to moderate aortic stenosis present
murmur on routine exam
how does aortic stenosis sound
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)
what are causes of aortic regurgitation
Aortic dilatation (loss of support, CT disease eg rheumatoid arthritis), hypertension/ aortic dissection/ degeneration/ cystic medial necrosis/ syphilis Valvular– bicuspid valve or infective endocarditis
what are the consequences of aortic regurgitation
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
what is the path-physiology of aortic regurgitation
LV failure, dilates LA, hypertension as blood pushed back, pulmonary oedema
how can aortic regurgitation be heard
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)
what are symptoms of aortic regurgitation
Often asymptomatic
Chest pain (CA decreased perfusion and diastolic BP decreases)
Breathlessness
Syncope – uncommon
Catastrophic decompensation if acute – fulminant pulmonary oedema
what are causes of mitral regurgitation
Valvular (prolapse, infective degenerative)
Chordal rupture/ papillary muscle failure – acute/chronic
Annular dilation – secondary to left ventricular dilation (func or ishchaemic)
what are consequences of mitral regurgitation
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
how can mitral regurgitation be heard
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)
what are symptoms of mitral regurgitation
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
what is mitral valve prolapse
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
what causes mitral stenosis
almost always rheumatic fever
Could be congenital, storage diseases, malignancy, prev endocarditis, mitral valve calcification, systemic disease (eg SL(lupus)E, RA)
what are the consequences of mitral stenosis
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))
how is mitral stenosis heard
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)
what are symptoms of mitral stenosis
Lung (breathlessness, peripheral oedema, haemoptysis)
Palpitations, systemic emboli, fatigue, compressive symptoms (stridor, dysphagia)
how is valve disease managed
Medical – HF or arrythmias
Surgical – valve repair or replacement
Percutaneous - BAV or TAVI
how are patients evaluated for valve disease
Clinical assessment (symptoms- comorbidities, education and auscultation) Echocardiography – key examination to confirm diagnosis and assess severity, compare findings with clinical assessment
what are other types of patient evaluation
Exercise testing Stress echo MRI Multislice CT Cardiac Catheterisation (evaluate valve function)
what are the types of valve replacement
Mechanical
Biological
how do heart sounds change wit prosthetic valves
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
what is trans-catheter valve replacement used for
Pulmonary (congenital heart disease)
Aortic (new tech for those too high risk for conventional surgery, under local anasthetic, shorter recovery)
can the mitral valve be replaced by trans-catheter
mitraclip (for mitral regurgitation, emerging)
