Valvular dysfunction Flashcards
Complete the diagram
Complete the diagram of auscultation
What 5 things can you hear in the heart?
- Opening and closing of the heart valves
- Turbulent blood flow
- Through the heart
- Across the valves
- Filling of the heart
- Valvular pathology
- Structural heart disease
What valves make the lub dub noises?
Systole or diastole?
What is the 4 catagories of the epidemeology of valvular heart disease?
DEGENERATIVE VALVE DISEASE
•Reflects aging population
RHEUMATIC VALVE DISEASE
- Post Streptococcal Rheumatic Fever
- Children and young adults
- Disease of poverty, overcrowding
INFECTIVE
- Most common on ‘abnormal’ valves
- Virulent organisms – normal valves, Staph/strep
- Immunocompromised
CONGENITAL VALVE DISEASE
Low, static incidence in all populations
Which valve is affected most in degenerative valvlular heart disease?
Aortic > Mitral
Which valve is affected most in rheumatic valvlular heart disease?
Mitral > Aortic
Which valves is most affected in infective valvular heart disease?
- Any valve (left heart more than right)
- Right – atypical organisms – IVDU
- Bacterial, Fungal, Culture –ve (autoimmune)
What valves is most affected in congenital valvular heart disease?
Any valve
What are the 3 pathologies involved in valvular heart disease?
- CALCIFICATION - immobility of leaflets
- FIBROSIS - fusion of leaflets
- DILATATION of valve ring
What is stenosis?
- Narrowing of valve leaflets
- Valve leaflets fail to open completely
- Leads to build of back pressure and loss of stroke volume
What is regurgitation?
- Failure of leaflets to meet in systole
- Leaflets fail to close completely
- Allows reverse flow of blood during relaxation of the heart
- Also called “incompetence”
What is the most common age of presentation for -
- Congenital syndromes
- Bicuspid valves
- Degenerative
- As always post rheumatic fever
- Congenital syndromes (paediatrics, <60)
- Bicuspid valves (40 -60 years)
- Degenerative (>60)
- As always post rheumatic fever (<60)
What disease is this?
Aortic stenosis
What are the symptoms in a severe aortic stenosis?
(SAD Triad)
Syncope upon exertion,
Angina (chest pain)
Dyspnoea (Shortness of breath - especially on exertion), fatigue, palpitations,
Sudden death (rare in asymptomatic) due to arrhythmias from pressure overload
What are the symptoms in mild-moderate aortic stenosis?
Asymptomatic, Murmur discovered on routine physical exam
How does aortic stenosis cause LV decompensation/dilatation?
Generation of high LV systolic pressure to force blood through the obstruction
Results in left ventricular hypertrophy
Eventual LV decompensation/dilatation
Name the pathology
What 2 heart sounds are heard in aortic stenosis and why are they heard?
Systolic or crescendo/decrescendo murmur
- The valve doesn’t open fully, producing turbulence as blood passes across it.
- This occurs at the beginning of systole where the pressure gradually rises, and as a result the amount of blood and therefore the amount of turbulence gradually rises, peaks and then falls as the ventricle begins to relax
Soft second heart sound
- In more severe cases
- If the valve is stiff and thickened, it doesn’t close properly
What are the 2 types of aortic regurgatation and name some examples
1.Aortic dilatation
- loss of support
- connective tissue disease (e.g. rheumatoid arthritis)
- hypertension, aortic dissection, degenerative, cystic medial necrosis, syphilis
2.Valvular
- Bicuspid valve
- Infective endocarditis
Name the 5 causes of aortic regurgatation
What are the 3 physiological consequences of aortic regurgatation?
- Volume overload - in the ventricle because blood falls back into LV during diastole
- LV dilatation - to accommodate volume, typical result of volume overload
- Late decompensation of LV function
How does aortic regurgatation cause pulmonary oedema?
What 2 heart sounds are heard in aortic stenosis and why are they heard?
Early diastolic murmur
- At the end of systole the pressure in the ventricle drops and the aortic (and pulmonary) valves close.
- If the aortic valve leaflets fail to come together and are damaged blood under high pressure in the aorta rushes back into the ventricle (with turbulence)
- This happens the most when the pressure in the ventricle is the lowest at the beginning of diastole
Concomitant systolic murmur
- Often, not always
- Because in this disorder the aortic valve is often structurally abnormal, there is often turbulence as the blood exits the ventricle during systole
What are the symptoms of aortic regurgatation?
- Often asymptomatic
- Chest pain (due to decreased coronary perfusion and diastolic BP reduces)
- Breathlessness
- Syncope – uncommon
- Catastrophic decompensation if acute – fulminant pulmonary oedema
What are the 3 causes of mitral regurgatation?
- Valvular - prolapse, infective, degenerative
- Chordal rupture/papillary muscle failure – acute/chronic
- Annular dilatation - secondary to left ventricular dilatation (i.e. functional or ischaemic)
What are the physiological consquences of mitral regurgatation?
- Volume overload in left ventricle
- Pressure overload of right heart
- Left ventricular dilatation - response to volume overload
- Decompensation - pulmonary oedema
How does mitral regurgitation cause volume overload in left ventricle?
- During systole blood is ejected backwards into the left atrium
- Extra blood in atrium leads to elevation of left atrial pressure and increased ventricular filling during subsequent diastole
How does mitral regurgatation cause pressure overload of right heart?
- Can lead to right ventricular hypertrophy or right heart failure
- Transient elevation of left atrial pressure during systole
What are the 2 possible results of calcification, fibrosis and dilatation?
Stenosis
Regurgitation
Which is chronic mitral regurgitation and which is acute mitral regurgitation?
What heart sounds are heard in mitral regurgitation and why are they heard?
Pan-systolic Murmur
•If the leaflets fail to coapt
- either because the annulus is stretched (with a ‘hole’ in the middle), or
- because the leaflets are damaged or abnormal,
- blood leaks back into the left atrium with turbulence as it passes across the abnormal valve
- Blood regurgitates back in atrium almost immediately and for the whole of systole because the left atrium is a low pressure chamber and during systole the left ventricle is under high pressure
What are the symptoms of mitral regurgitation?
- Breathlessness due to back pressure of pulmonary circulation
- Lethargy and reduced exercise tolerance due to breathlessness and reduced cardiac output
- Palpitations – atrial fibrillation due to pressure overload in atrium
- Peripheral oedema – decompensation
- Chest pain – concomitant CAD
What is mitral prolapse?
Initially valve shuts during the early part of systole but then, either because the leaflet is too ‘baggy’ or because of abnormal sub-valvar apparatus the leaflet prolapses back into the left atrium potentially allowing though a jet of regurgitation
What does this show?
Mitral valve prolapse
Initially valve shuts during the early part of systole but then, either because the leaflet is too ‘baggy’ or because of abnormal sub-valvar apparatus the leaflet prolapses back into the left atrium potentially allowing though a jet of regurgitation
What 2 heart sounds are heard in mitral valve prolapse and why are they heard?
- Mid-systolic‘click’ – as the leaflet prolapses back into the left atrium
- Late systolic murmur - if blood then continues to flow into the left atrium after initial jet of regurgitation
What 7 things can cause mitral stenosis?
- Almost always due to rheumatic fever - problem with leaflets as well as the sub-valvular apparatus
- Congenital
- Storage diseases
- Malignancy (e.g. carcinoid)
- Previous endocarditis
- Mitral valve calcification (i.e. degenerative)
- Systemic disease (e.g. SLE, RA)
What are the physiological consequences of mitral stenosis?
- Lung/right heart consequences. Breathlessness, congestion, etc due to pressure back up because of failure of ejection of left atrial volume
- Left ventricle physiology usually preserved
When does mitral stenosis cause LV function to be compromised?
- atrial contraction lost (low LV filling) or
- when high circulating volume (high right heart pressure)
What 3 heart sounds are heard in mitral valve prolapse and why are they heard?
Mid-diastolic rumbling murmur
•during diastole, stenosis restricts blood flowing across the mitral valve from the LA into LV
Opening snap
•as the restricted leaflets ‘snap’ open
Loud first heart sound
- if the leaflets are stiff but still relatively mobile
- as leaflets “slam” shut
What are the symptoms of mitral stenosis?
Breathlessness
Peripheral oedema
Haemoptysis
Palpitations
Systemic emboli
Fatigue
Compressive symptoms: stridor, dysphagia
What is a BAV?
BAV: balloon aortic valvuloplasty
What is a TAVI?
TAVI: transcatheter aortic valve implantation
What techniques are there to assess heart murmours?
Excersise testing
Stress echocardiogram
MRI
Multislice CT
Cardiac cathereterisation (to evaluate valve function)
What are the 2 types of valve replacement?
Prosthetic
Animal
How do you know which valve is metallic (relacement valve) and which murmour is pathological?
- First heart sound metallic – mitral
- Second heart sound metallic – aortic
- Systolic murmurs common and not necessarily pathological
- Diastolic murmurs usually pathological
Which valves undergo trans-catheter valve replacement?
- Pulmonary (congenital heart disease)
- Aortic
- New technology
- Patients considered high risk for conventional AVR
- Procedures under local anaesthetic
- Shorter recovery time
•Mitral valve - mitraclip
What procedure is this?
Trans-catheter valve replacement
