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Finals - CardioResp > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What is aortic stenosis

A

narrowing of the aortic valve opening

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2
Q

List the 2 most common causes/risk factors for Aortic stenosis

A
  1. degenerative calcification (most common in > 65)
  2. bicuspid aortic valve (most common in < 65)

Others: William’s syndrome, post-rheumatic disease, HOCM

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3
Q

How does aortic stenosis lead to HF?

A
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4
Q

List 4 clinical features of symptomatic aortic stenosis disease

A
  1. chest pain
  2. exertional dyspnoea
  3. syncope
  4. murmur
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5
Q

Describe the typical murmur heard in aortic stenosis?

How is this decreased?

A

Ejection systolic murmur, classically radiates to the carotids

Decreased following the Valsalva manoeuvre

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6
Q

List 6 examination findings of severe aortic stenosis

A
  1. Narrow pulse pressure
  2. Slow rising pulse
  3. Soft/absent S2
  4. S4
  5. Thrill
  6. LVH or failure
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7
Q

What is the classic triad of symptoms in end-stage aortic stenosis?

A
  1. Heart failure
  2. Syncope
  3. Angina
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8
Q

List 3 ECG findings of aortic stenosis

A

May show evidence of LVH:

  • Increased QRS complex voltage
  • Left axis deviation
  • Poor R-wave progression
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9
Q

Gold standard investigation for diagnosis of aortic stenosis?

A

Echocardiography

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10
Q

How can severity of aortic stenosis be quantified?

A

Doppler echocardiography. Severe if

  • Peak gradient > 40 mmHg
  • Valve area < 1.0 cm^2
  • Aortic jet velocity >4 m/s
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11
Q

How can we assess true severity of aortic stenosis in asymptomatic patients?

A

Exercise testing

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12
Q

What is the role of Cardiac MRI in AS

A

Can be used to provide additional, more detailed information regarding valve morphology, dimensions of the aortic root and the extent of valve calcification

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13
Q

List 2 management interventions for AS

A
  1. Transcatheter aortic valve implantation (TAVI)
  2. Surgical aortic valve replacement (SAVR)
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14
Q

When is TAVI vs SVAR favoured as an intervention in AS

A

TAVI - patients with severe co-morbidities, previous heart surgery, frailty, restricted mobility, and >75

SAVR - patients who are low risk and < 75

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15
Q

To whom is aortic valve replacement offered for AS

A
  1. Symptomatic patients with severe AS
  2. Patients with moderate/severe AS undergoing CABG surgery
  3. Asymptomatic patients with severe AS and LV dysfunction
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16
Q

What is the use of Balloon valvuloplasty in AS?

A

Bridge to surgery in haemodynamically unstable patients OR

Palliation for patients with serious comorbid conditions

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17
Q

What is the role of medical management in AS?

A

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)

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18
Q

What is Aortic regurgitation?

A

The reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve

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19
Q

What is Aortic regurgitation?

A

The reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve

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20
Q

List 2 acute causes of AR

A
  1. Acute rheumatic fever
  2. Infective endocarditis
  3. Aortic dissection
  4. Ruptured Sinus of Valsalva aneurysm

Prosthetic valve dysfunction

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21
Q

List 2 chronic causes of AR

A
  1. Rheumatic heart disease
  2. Syphilis
  3. Arthritis (RA, ankyl spond, reactive)
  4. Severe, uncontrolled HTN
  5. BAV
  6. Infective endocarditis
  7. Marfan`s syndrome
  8. Osteogenesis imperfecta
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22
Q

Pathophysiology of AR

A
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23
Q

How does chronic AR present?

A

Insidiously, patients may be asymptomatic for years:

  • Exertional dyspnoea
  • Orthopnoea
  • PND
  • Stable angina
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24
Q

List 6 peripheral findings on examination of AR

A
  1. Corrigan’s pulse - prominent CA pulsations
  2. De Musset’s sign - bobbing head in sync with heart best
  3. Quincke’s sign - pulsation of nail beds
  4. Traube’s sign - “pistol shot” booming sound on auscultation over femorals
  5. Müller’s sign - pulsations of the uvula
  6. Widened pulse pressure (low diastolic pressure)
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25
Q

List 3 findings on auscultation of the heart in AR

(Hint: 2 murmurs)

A
  1. Early diastolic murmur
  2. Mid-diastolic Austin-Flint murmur - severe AR
  3. Hyperdynamic apex beat
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26
Q

Gold standard investigation for diagnosis of AR?

A

Echocardiogram

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27
Q

List 3 ECG findings of AR

A
  1. Left axis
  2. Tall R-waves
  3. TWI (Left)
  4. S-waves (Right)
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28
Q

List 3 chest X-ray findings of AR

A
  1. Cardiomegaly
  2. aortic calcification
  3. aortic root dilatation
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29
Q

Medical management for AR

A

Useful in slowing aortic root dilatation and reducing risk progression

  1. Diuretics, digoxin, salt restriction
  2. Vasodilators
  3. Tx of the cause
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30
Q

What is the Surgical Management for AR

A

Tissue-type or mechanical AVR

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31
Q

Which patients with AR are eligible for surgery?

A
  1. Severe acute AR - prompt intervention
  2. Chronic severe AR in symptomatic patients
  3. Chronic severe AR in asymptomatic patients with
  • poor LVEF ≤ 50%, LV
  • end systolic diameter > 50mm or
  • when undergoing other CVS surgery
32
Q

What is Mitral stenosis?

A

Impaired opening of the mitral valve affecting blood flow from the left atrium to ventricle

33
Q

What is the most common cause of Mitral stenosis

A

Rheumatic heart disease/ fever

Streptococcal antigens 2o to bacterial infection cross-react with the valve tissue, causing damage

34
Q

List 2 rarer cause of MS

A
  1. Mucopolysaccharidoses
  2. Carcinoid
  3. Congenital (Parachute valve)
  4. Infective endocarditis
35
Q

List 4 clinical features of MS

A
  1. Gradual exertional dyspnoea and reduced exercise tolerance
  2. Haemoptysis may occur
  3. Angina
  4. Embolic events
36
Q

List 4 findings on auscultation in MS

A
  1. Loud S1
  2. Loud P2
  3. Opening snap heard at apex
  4. Mid-late Diastolic murmur
37
Q

Describe the murmur heard in MS

A

Rumbling mid-diastolic murmur, loudest at the apex on deep expiration

38
Q

List 4 physical findings of MS

A
  1. Mitral facies
  2. Low volume pulse
  3. Tapping apex beat, RV heave
  4. Elevated JVP
  5. AF
39
Q

When does the onset of MS symptoms tend to occur?

List 2 things which may precipitate this

A

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)

40
Q

What may be seen on Chest X-ray in MS

A

Left atrial enlargement

41
Q

List 4 ECG changes which may be seen in MS

A
  1. P-mitrale (broad notched P wave due to left atrial enlargement)
  2. RV hypertrophy
  3. Right axis deviation
  4. Atrial fibrillation - due to LA enlargement
42
Q

List 2 x-ray changes which may be seen in heart failure

A

May show evidence of pulmonary oedema and LA enlargement

43
Q

List 4 other Investigations for MS

A
  1. ECG
  2. CXR
  3. Echocardiogram
  4. Cardiac MRI - may show valvular vegatations
44
Q

What scoring system is used on Echo evaluation for MS

A

Wilkins score:

  • Valve thickness
  • Calcification
  • Subvalvar apparatus
  • Mobility
45
Q

What is the risk in MS is left untreated?

A

Raised LA pressures, subsequent raised pressures in pulmonary vasculature and the right heart

Leading to pulmonary hypertension and RHF

46
Q

What is the management for asymptomatic MS

A

Medical management:

  1. Regular Echo to assess progression
  2. AF - anticoagulation and rate-control
  3. Diuretics and ββ for symptomatic relief in decompensated states (eg. illness), or prior to intervention
  4. Avoid unusual physical stress and salt restriction
47
Q

What is the management for symptomatic MS?

A

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

48
Q

What are the 3 definitive surgical treatment options for symptomatic MS

A
  1. Balloon valvuloplasty - valve must be pliable and non-calcified
  2. Percutaneous mitral valvotomy - moderate disease
  3. Open valve repair/replacement - severe disease who are not eligible for PCI but not high risk for surgery
49
Q

What is Mitral Regurgitation?

A

When blood leaks back through the mitral valve on systole

50
Q

List 4 risk risk factors for MR

A
  • Female
  • Lower BMI
  • Age
  • Renal dysfunction
  • Prior MI
  • Prior mitral stenosis or valve prolapse
  • Collagen disorders eg. Marfan’s, EDS
51
Q

List 4 causes of MR

A
  1. Following coronary artery disease or post-MI
  2. Mitral valve prolapse
  3. Infective endocarditis
  4. Rheumatic fever
  5. Congenital
52
Q

Pathophysiology of MR

A

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

53
Q

How does MR present?

A

Most patients are asymptomatic, but when symptoms do arise they may incl:

  • Shortness of breath
  • Exertional dyspnoea
  • Fatigue
  • Weakness
54
Q

List 2 auscultation findings of MVP

A

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

55
Q

List 3 examination findings of MR

A
  1. Quiet S1, sever MR may cause wide splitting of S2
  2. Pansystolic murmur
  3. Sharp carotid upstroke
  4. Hyperdynamic displaced apex beat
56
Q

Describe the typical murmur heard in MR

A

“Blowing” pansystolic murmur which radiates to left axilla

Best heart at Apex

57
Q

How can we increase murmur heard in MR

A

Expiration and on rolling to the left

58
Q

Compare the presentation and findings of acute vs chronic MR

A
59
Q

How is a definitive diagnosis of MR made?

A

Echocardiogram

60
Q

List 4 potential ECG findings of MR

A
  1. P-mitrale (broad notched P wave due to LA enlargement)
  2. LV hypertrophy
  3. Left axis deviation
61
Q

List 2 potential chest x-ray findings in MR

A

Pulmonary oedema and LA enlargement

62
Q

How is the mechanism causing MR classified?

A

Carpentier

63
Q

How is asymptomatic MR treated?

A

Monitor with echo

64
Q

What is the definitive management of MR

A
  1. Mitral valve repair (mitral valvuloplasty) - preferred as it avoids use of prostheses
  2. Mitral valve replacement
65
Q

Compare the pros and cons of a mechanical valve vs bioprosthetic valve

A

Mechanical - lifelong anticoagulation but long-lasting. May cause mild hemolysis

Bioprosthetic - limited durability but no need for anticoagulation

66
Q

What is Barlows syndrome?

A

Another term for Mitral valve Prolapse

67
Q

List 4 symptoms of MVP

A
  1. palpitations
  2. dizziness
  3. syncope
  4. chest discomfort
68
Q

List 2 auscultation findings of MVP

A

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

69
Q

List 4 causes of Tricuspid regurgitation

A
  • RV infarction
  • pulmonary hypertension eg. COPD
  • rheumatic heart disease
  • infective endocarditis (especially IVD users)
  • Ebstein’s anomaly
  • carcinoid syndrome
70
Q

How does TR present?

A

Due to reduced CO:

  • ascites
  • painful congestive hepatomegaly
  • oedema
71
Q

List 4 examination findings of TR

A
  1. pan-systolic murmur
  2. prominent/giant V waves in JVP
  3. pulsatile hepatomegaly
  4. left parasternal heave
72
Q

Management of TR?

A

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
73
Q

Tricuspid Stenosis - Rare

A
74
Q

What is pulmonary stenosis?

A

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

75
Q

List the most common cause of pulmonary stenosis

A

Congenital, associated with:

  1. Noonan syndrome (valvular)
  2. Williams syndrome (supravalvular)
  3. Tetralogy of Fallot (valvular)
76
Q

List 2 rarer causes of pulmonary stenosis

A
  1. Congenital rubella infection
  2. Carcinoid syndrome
77
Q

Pulmonary Regurgitation

A

Finals - CardioResp (18 decks)

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