Valvular heart disease Flashcards
What is aortic stenosis
narrowing of the aortic valve opening
List the 2 most common causes/risk factors for Aortic stenosis
- degenerative calcification (most common in > 65)
- bicuspid aortic valve (most common in < 65)
Others: William’s syndrome, post-rheumatic disease, HOCM
How does aortic stenosis lead to HF?
List 4 clinical features of symptomatic aortic stenosis disease
- chest pain
- exertional dyspnoea
- syncope
- murmur
Describe the typical murmur heard in aortic stenosis?
How is this decreased?
Ejection systolic murmur, classically radiates to the carotids
Decreased following the Valsalva manoeuvre
List 6 examination findings of severe aortic stenosis
- Narrow pulse pressure
- Slow rising pulse
- Soft/absent S2
- S4
- Thrill
- LVH or failure
What is the classic triad of symptoms in end-stage aortic stenosis?
- Heart failure
- Syncope
- Angina
List 3 ECG findings of aortic stenosis
May show evidence of LVH:
- Increased QRS complex voltage
- Left axis deviation
- Poor R-wave progression
Gold standard investigation for diagnosis of aortic stenosis?
Echocardiography
How can severity of aortic stenosis be quantified?
Doppler echocardiography. Severe if
- Peak gradient > 40 mmHg
- Valve area < 1.0 cm^2
- Aortic jet velocity >4 m/s
How can we assess true severity of aortic stenosis in asymptomatic patients?
Exercise testing
What is the role of Cardiac MRI in AS
Can be used to provide additional, more detailed information regarding valve morphology, dimensions of the aortic root and the extent of valve calcification
List 2 management interventions for AS
- Transcatheter aortic valve implantation (TAVI)
- Surgical aortic valve replacement (SAVR)
When is TAVI vs SVAR favoured as an intervention in AS
TAVI - patients with severe co-morbidities, previous heart surgery, frailty, restricted mobility, and >75
SAVR - patients who are low risk and < 75
To whom is aortic valve replacement offered for AS
- Symptomatic patients with severe AS
- Patients with moderate/severe AS undergoing CABG surgery
- Asymptomatic patients with severe AS and LV dysfunction
What is the use of Balloon valvuloplasty in AS?
Bridge to surgery in haemodynamically unstable patients OR
Palliation for patients with serious comorbid conditions
What is the role of medical management in AS?
Cannot improve outcome of AS, only used where patients are unfit for SAVR or TAVI, and have symptoms of HF
Involves standard treatment HF (ACEi, BB, diuretics)
What is Aortic regurgitation?
The reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve
What is Aortic regurgitation?
The reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve
List 2 acute causes of AR
- Acute rheumatic fever
- Infective endocarditis
- Aortic dissection
- Ruptured Sinus of Valsalva aneurysm
Prosthetic valve dysfunction
List 2 chronic causes of AR
- Rheumatic heart disease
- Syphilis
- Arthritis (RA, ankyl spond, reactive)
- Severe, uncontrolled HTN
- BAV
- Infective endocarditis
- Marfan`s syndrome
- Osteogenesis imperfecta
Pathophysiology of AR
How does chronic AR present?
Insidiously, patients may be asymptomatic for years:
- Exertional dyspnoea
- Orthopnoea
- PND
- Stable angina
List 6 peripheral findings on examination of AR
- Corrigan’s pulse - prominent CA pulsations
- De Musset’s sign - bobbing head in sync with heart best
- Quincke’s sign - pulsation of nail beds
- Traube’s sign - “pistol shot” booming sound on auscultation over femorals
- Müller’s sign - pulsations of the uvula
- Widened pulse pressure (low diastolic pressure)
List 3 findings on auscultation of the heart in AR
(Hint: 2 murmurs)
- Early diastolic murmur
- Mid-diastolic Austin-Flint murmur - severe AR
- Hyperdynamic apex beat
Gold standard investigation for diagnosis of AR?
Echocardiogram
List 3 ECG findings of AR
- Left axis
- Tall R-waves
- TWI (Left)
- S-waves (Right)
List 3 chest X-ray findings of AR
- Cardiomegaly
- aortic calcification
- aortic root dilatation
Medical management for AR
Useful in slowing aortic root dilatation and reducing risk progression
- Diuretics, digoxin, salt restriction
- Vasodilators
- Tx of the cause
What is the Surgical Management for AR
Tissue-type or mechanical AVR
Which patients with AR are eligible for surgery?
- Severe acute AR - prompt intervention
- Chronic severe AR in symptomatic patients
- Chronic severe AR in asymptomatic patients with
- poor LVEF ≤ 50%, LV
- end systolic diameter > 50mm or
- when undergoing other CVS surgery
What is Mitral stenosis?
Impaired opening of the mitral valve affecting blood flow from the left atrium to ventricle
What is the most common cause of Mitral stenosis
Rheumatic heart disease/ fever
Streptococcal antigens 2o to bacterial infection cross-react with the valve tissue, causing damage
List 2 rarer cause of MS
- Mucopolysaccharidoses
- Carcinoid
- Congenital (Parachute valve)
- Infective endocarditis
List 4 clinical features of MS
- Gradual exertional dyspnoea and reduced exercise tolerance
- Haemoptysis may occur
- Angina
- Embolic events
List 4 findings on auscultation in MS
- Loud S1
- Loud P2
- Opening snap heard at apex
- Mid-late Diastolic murmur
Describe the murmur heard in MS
Rumbling mid-diastolic murmur, loudest at the apex on deep expiration
List 4 physical findings of MS
- Mitral facies
- Low volume pulse
- Tapping apex beat, RV heave
- Elevated JVP
- AF
When does the onset of MS symptoms tend to occur?
List 2 things which may precipitate this
Related to degree of valvular stenosis, usually precipitated by exercise, stress, infection, pregnancy or fast AF
Symptoms begin when valve area falls ≤ 2.5cm2 (normal area 4-6cm 2)
What may be seen on Chest X-ray in MS
Left atrial enlargement
List 4 ECG changes which may be seen in MS
- P-mitrale (broad notched P wave due to left atrial enlargement)
- RV hypertrophy
- Right axis deviation
- Atrial fibrillation - due to LA enlargement
List 2 x-ray changes which may be seen in heart failure
May show evidence of pulmonary oedema and LA enlargement
List 4 other Investigations for MS
- ECG
- CXR
- Echocardiogram
- Cardiac MRI - may show valvular vegatations
What scoring system is used on Echo evaluation for MS
Wilkins score:
- Valve thickness
- Calcification
- Subvalvar apparatus
- Mobility
What is the risk in MS is left untreated?
Raised LA pressures, subsequent raised pressures in pulmonary vasculature and the right heart
Leading to pulmonary hypertension and RHF
What is the management for asymptomatic MS
Medical management:
- Regular Echo to assess progression
- AF - anticoagulation and rate-control
- Diuretics and ββ for symptomatic relief in decompensated states (eg. illness), or prior to intervention
- Avoid unusual physical stress and salt restriction
What is the management for symptomatic MS?
NYHA class II symptoms and mild MS: managed medically
NYHA class II symptoms and moderate MS (MVA ≤ 1.5cm2 or mean gradient ≥ 5mmHg): balloon valvuloplasty
NYHA class III-IV symptoms and severe MS: balloon valvuloplasty or surgery
What are the 3 definitive surgical treatment options for symptomatic MS
- Balloon valvuloplasty - valve must be pliable and non-calcified
- Percutaneous mitral valvotomy - moderate disease
- Open valve repair/replacement - severe disease who are not eligible for PCI but not high risk for surgery
What is Mitral Regurgitation?
When blood leaks back through the mitral valve on systole
List 4 risk risk factors for MR
- Female
- Lower BMI
- Age
- Renal dysfunction
- Prior MI
- Prior mitral stenosis or valve prolapse
- Collagen disorders eg. Marfan’s, EDS
List 4 causes of MR
- Following coronary artery disease or post-MI
- Mitral valve prolapse
- Infective endocarditis
- Rheumatic fever
- Congenital
Pathophysiology of MR
Abnormality prevents the valve from closing
Blood flows back into the LA during systole
The regurgitant output flows into the LV + the normal blood flow → volume overload
How does MR present?
Most patients are asymptomatic, but when symptoms do arise they may incl:
- Shortness of breath
- Exertional dyspnoea
- Fatigue
- Weakness
List 2 auscultation findings of MVP
Mid-systolic click due to sudden tensing of mitral valve apparatus as the leaflets prolapse into the LA during systole
Followed by late systolic murmur due to regurgitation
List 3 examination findings of MR
- Quiet S1, sever MR may cause wide splitting of S2
- Pansystolic murmur
- Sharp carotid upstroke
- Hyperdynamic displaced apex beat
Describe the typical murmur heard in MR
“Blowing” pansystolic murmur which radiates to left axilla
Best heart at Apex
How can we increase murmur heard in MR
Expiration and on rolling to the left
Compare the presentation and findings of acute vs chronic MR
How is a definitive diagnosis of MR made?
Echocardiogram
List 4 potential ECG findings of MR
- P-mitrale (broad notched P wave due to LA enlargement)
- LV hypertrophy
- Left axis deviation
List 2 potential chest x-ray findings in MR
Pulmonary oedema and LA enlargement
How is the mechanism causing MR classified?
Carpentier
How is asymptomatic MR treated?
Monitor with echo
What is the definitive management of MR
- Mitral valve repair (mitral valvuloplasty) - preferred as it avoids use of prostheses
- Mitral valve replacement
Compare the pros and cons of a mechanical valve vs bioprosthetic valve
Mechanical - lifelong anticoagulation but long-lasting. May cause mild hemolysis
Bioprosthetic - limited durability but no need for anticoagulation
What is Barlows syndrome?
Another term for Mitral valve Prolapse
List 4 symptoms of MVP
- palpitations
- dizziness
- syncope
- chest discomfort
List 2 auscultation findings of MVP
Mid-systolic click due to sudden tensing of mitral valve apparatus as the leaflets prolapse into the LA during systole
Followed by a late systolic murmur in the presence of regurgitation
List 4 causes of Tricuspid regurgitation
- RV infarction
- pulmonary hypertension eg. COPD
- rheumatic heart disease
- infective endocarditis (especially IVD users)
- Ebstein’s anomaly
- carcinoid syndrome
How does TR present?
Due to reduced CO:
- ascites
- painful congestive hepatomegaly
- oedema
List 4 examination findings of TR
- pan-systolic murmur
- prominent/giant V waves in JVP
- pulsatile hepatomegaly
- left parasternal heave
Management of TR?
If no pulmonary hypertension - does not require surgery
Severe TR
- with RHD: ring annuloplasty
- functional: annuloplasty or valve replacement (controversial)
- due to intrinsic tricuspid valve disease: valve replacement
Tricuspid Stenosis - Rare
What is pulmonary stenosis?
Obstructs blood flow from the RV into the pulmonary bed
Results in a pressure gradient greater than 10 mmHg across the pulmonary valve during systole
List the most common cause of pulmonary stenosis
Congenital, associated with:
- Noonan syndrome (valvular)
- Williams syndrome (supravalvular)
- Tetralogy of Fallot (valvular)
List 2 rarer causes of pulmonary stenosis
- Congenital rubella infection
- Carcinoid syndrome
Pulmonary Regurgitation
