Valvular Dysfunction: Prevalence, Symptoms and Principles of Treatment

Question 1

What happens to the valves in normal circulation?

Answer 1

In normal circulation, the valves open fully to allow blood to flow through and close tightly to prevent backward flow.

Question 2

What are the two main types of valve disease?

Answer 2

Stenosis: The valve doesn’t open all the way, resulting in reduced blood flow.
Regurgitation: The valve doesn’t close completely, causing blood to leak backward.

Question 3

What are the common causes of valvular heart disease?

Answer 3

Degenerative: Valves wear out over time.
Congenital: Valvular abnormalities present at birth.
Rheumatic disease: Develops after rheumatic fever.
Infective endocarditis: Valve infections.
Annular dilation: Chronic strain on the valves.

Question 4

What are some symptoms of heart valve disease?

Answer 4

Breathlessness
Lightheadedness
Chest pain

Question 5

What are the two primary heart sounds and their characteristics?

Answer 5

S1: It is the “lub” sound and is caused by the closure of the mitral and tricuspid valves. It marks the start of systole.
S2: It is the “dub” sound and is produced by the closure of the aortic and pulmonary valves. It signifies the end of systole.

Question 6

What are the characteristics of left heart murmurs?

Answer 6

Aortic Stenosis: Systolic murmur.
Aortic Regurgitation: Diastolic murmur.
Mitral Stenosis: Diastolic murmur.
Mitral Regurgitation: Systolic murmur.

Question 7

What are some common investigations for evaluating heart conditions?

Answer 7

ECG (Electrocardiogram)
Echocardiogram (Transthoracic and Transesophageal)
Cardiac MRI Scan
Cardiac Catheterization

Question 8

Where is the aortic valve located and what type of valve is it?

Answer 8

The aortic valve is located between the left ventricle (LV) and the aorta. It is a semi-lunar valve consisting of three cusps: the left coronary, right coronary, and non-coronary cusps. It is attached to a fibrous ring called the annulus.

Question 9

What is aortic stenosis and its significance?

Answer 9

Aortic stenosis is the most common severe valve abnormality in the western world and is the most common indication for valve surgery. It results in pressure overload on the left ventricle (LV).

Question 10

What are the signs of aortic stenosis?

Answer 10

Low volume, slow rising pulse.
Forceful impulse at the apex.
Soft second heart sound.
Ejection systolic murmur:
Loudest in the aortic area.
Radiated to the neck.
Thrill in the aortic area.

Question 11

What are some diagnostic methods for aortic and mitral valve disease?

Answer 11

Echocardiography: Transthoracic and transesophageal echocardiograms.
Doppler ultrasound.
Cardiac catheterization.
Magnetic resonance imaging (MRI) of the heart.
Electrocardiogram (ECG).

Question 12

What ECG findings are associated with aortic stenosis?

Answer 12

Left ventricular hypertrophy: Tall complexes and lateral T-wave inversion.
Left bundle branch block: Broad complexes, but it can have other causes as well.

Question 13

What are the echocardiogram findings in aortic stenosis?

Answer 13

Left ventricular hypertrophy.
Calcified aortic valve with restricted mobility.

Question 14

What are the medical treatment options for aortic stenosis?

Answer 14

There are no good medical options for aortic stenosis. Symptomatic patients typically require a new valve.
As a holding maneuver, diuretics may be used for breathlessness, and beta-blockers may be used for angina.
Vasodilators (e.g., ACE inhibitors) should be avoided.

Question 15

What are the surgical and interventional treatment options for aortic stenosis?

Answer 15

Surgical valve replacement (AVR): It can involve tissue valve replacement (pig, cow, human) or mechanical valve replacement (requires warfarin). This is suitable for younger patients and those needing coronary artery bypass grafting (CABG).
Transcatheter aortic valve replacement (TAVR): It involves implanting a tissue valve via a peripheral artery. This is suitable for older patients and those with co-morbidities. Outcomes are comparable to surgery for routine patients, and TAVR is becoming the treatment of choice for most patients.

Question 16

Where is the mitral valve located and what is its anatomy?

Answer 16

The mitral valve is located between the left atrium (LA) and the left ventricle (LV). It has more complex anatomy than the aortic valve. It consists of two leaflets, the anterior and posterior leaflets, with their tips attached to the LV muscle through chordae and papillary muscles. The mitral valve is also attached to a fibrous ring called the annulus.

Question 17

What are the causes of mitral regurgitation?

Answer 17

Degenerative mitral regurgitation caused by mitral valve prolapse.
Degenerative mitral regurgitation caused by flail leaflet.
Volume overload of the left ventricle (LV), leading to LV dilation.
Volume overload of the left atrium (LA), resulting in LA dilation and atrial rhythm disturbances.
Congenital valve leaflet prolapse.
Chordal rupture/papillary muscle rupture.
Infective endocarditis.
Rheumatic heart disease.
Myocardial ischemia causing LV distortion or papillary muscle dysfunction.
Annular dilation, often seen in heart failure with LV dilation.

Question 18

What is the significance of mitral regurgitation?

Answer 18

Mitral regurgitation is the second most common indication for valve surgery. It can lead to various complications and is associated with different underlying causes.

Question 19

What are the signs of mitral regurgitation?

Answer 19

Displaced, forceful apex beat indicating left ventricular enlargement.
Palpable parasternal impulse suggesting right ventricular enlargement.
Pan systolic murmur, loudest in the mitral area, radiating to the left axilla.
Thrill in the mitral area.

Question 20

What ECG findings are associated with mitral regurgitation?

Answer 20

Broad P waves (P mitrale) indicating left atrial dilation.
Left ventricular hypertrophy with tall complexes and lateral T-wave inversion.
Left bundle branch block, although it can have many other causes.
Atrial arrhythmias, such as atrial fibrillation.

Question 21

What are the echocardiogram findings in mitral regurgitation?

Answer 21

Left ventricular dilation.
Left atrial dilation.
Mitral valve abnormalities, including prolapse, chordal rupture, and calcification/thickening.
Assessing the severity of leaky valves is more challenging compared to narrow valves.

Question 22

What are the medical treatment options for mitral regurgitation?

Answer 22

Symptomatic patients typically require a new valve.
As a holding maneuver or when patients are not suitable for surgery:
Diuretics may be used for breathlessness.
ACE inhibitors may be prescribed for left ventricular dilation.
Beta-blockers and anticoagulation may be used for atrial fibrillation.

Question 23

What are the surgical intervention options for mitral regurgitation?

Answer 23

Surgical valve replacement (MVR): It can involve mechanical valve replacement or tissue valve replacement. Degenerate valves that are unsuitable for repair may require replacement.
Surgical valve repair: This is the treatment of choice for mitral valve leaflet prolapse (MVLP) or chordal rupture. It can be performed minimally invasively.
Transcatheter options: While not yet an established treatment, mitraclip may be used for very symptomatic patients with no surgical option.

Question 24

What happens in mitral regurgitation?

Answer 24

In mitral regurgitation, the leaflets of the mitral valve fail to close completely, allowing blood to leak back from the left ventricle (LV) into the left atrium (LA). The leakage occurs during diastole, resulting in left ventricular volume overload, LV dilation, and LV dysfunction.

Question 25

What are the causes of aortic regurgitation?

Answer 25

Valvular causes:
Bicuspid valve.
Infective endocarditis.
Rheumatic heart disease.
Aortic diseases:
Hypertension.
Aortic dissection.
Connective tissue diseases (e.g., ankylosing spondylitis).
Syphilis.

Question 26

What are the signs of aortic regurgitation?

Answer 26

Pulse: Large volume and “collapsing” pulse.
Blood Pressure: High systolic, low diastolic.
Displaced forceful apex beat indicating left ventricular (LV) enlargement.
Early diastolic murmur heard at the lower left sternal border, best heard in expiration.

Question 27

What ECG and echocardiogram findings are associated with aortic regurgitation?

Answer 27

ECG: Left ventricular hypertrophy.
Echo: Possible bicuspid valve, aortic dilation, and left ventricular dilation/dysfunction.

Question 28

What are the treatment options for aortic regurgitation?

Answer 28

Symptomatic patients typically require a new valve.
As a holding maneuver or for patients who are not suitable for surgery:
Diuretics may be used for breathlessness.
ACE inhibitors may be prescribed for left ventricular dilation/dysfunction.
Surgical valve replacement is the standard treatment and often requires repair of the proximal aorta.
There is currently no good trans-catheter option available for aortic regurgitation.

Question 29

What are the causes and effects of mitral stenosis?

Answer 29

Aetiology:
Rheumatic heart disease.
Degenerative causes.
Congenital abnormalities.
Mitral leaflet thickening and fusion occur.
It leads to pressure overload on the left atrium, resulting in atrial fibrillation.
It also causes pressure overload on the pulmonary vasculature, leading to pulmonary hypertension and right heart failure.

Question 30

What are the signs of mitral stenosis?

Answer 30

Loud first heart sound.
Parasternal heave indicating right ventricular enlargement.
Low-pitched rumbling mid/late diastolic murmur, loudest in the mitral area, and louder with the patient lying on their left side.

Question 31

What ECG and echocardiogram findings are associated with mitral stenosis?

Answer 31

ECG: Presence of P mitrale (big, M-shaped P waves) and often atrial fibrillation.
Echo: Commisural fusion with or without calcification/immobility, as well as left atrial and right heart dilation.

Question 32

What are the medical treatment options for mitral stenosis?

Answer 32

Surgical treatment is reserved for patients who remain symptomatic despite medical treatment.
Diuretics can be used for breathlessness and edema.
For atrial fibrillation, rate control with beta-blockers and anticoagulation with warfarin (due to the high thrombotic risk) are recommended. Cardioversion to restore sinus rhythm may also be considered.

Question 33

What are the surgical and interventional treatment options for mitral stenosis?

Answer 33

Surgical valve replacement (MVR): It can involve mechanical valve replacement or tissue valve replacement using valves from pig or cow.
Trans-catheter balloon valvotomy: This is the treatment of choice for non-calcified valves and is unsuitable if the valve is also regurgitant.
Surgical valvotomy: It was the first form of valve surgery but is rarely performed now.

Question 34

What are the characteristics of tricuspid valve disease?

Answer 34

Tricuspid regurgitation:
It is common but rarely a primary pathology.
It is usually secondary to annular dilation caused by left heart disease or pulmonary hypertension.
Elevated jugular venous pressure (JVP) is often observed.
Tricuspid stenosis:
It is very rare and typically associated with rheumatic valve disease.

Question 35

What are the characteristics of pulmonary valve disease?

Answer 35

Pulmonary stenosis:
It is uncommon and usually congenital.
Treatment may involve transcatheter balloon dilation, especially in children.
It may occur as part of complex diseases like Fallot’s tetralogy.
Pulmonary regurgitation:
It is uncommon and may be secondary to pulmonary hypertension or balloon dilation.

Question 36

What are the characteristics of right heart murmurs?

Answer 36

Pulmonary valve murmurs:
Pulmonary stenosis: Systolic murmur.
Pulmonary regurgitation: Diastolic murmur.
Tricuspid valve murmurs:
Tricuspid stenosis: Diastolic murmur.
Tricuspid regurgitation: Systolic murmur.