Valvular heart disease Flashcards
What are the causes of tricuspid regurgitation?
RV disease
- Right ventricular dysplasia
- Endomyocardial fibrosis
RV dilatation
- Primary pulmonary hypertension
- Secondary pulmonary hypertension (e.g. from lung disease, left sided heart disease)
Right ventricular volume overload
- RA dilatation
- Atrial fibrillation
All leads to tricuspid leaflet maladaptation –> functional tricuspid regurgitation
What are the PE findings in tricuspid regurgitation?
- Pansystolic murmur at LLSE that is louder on inspiration
* SXS RV failure: Palpable (sometimes pulsatile) liver, Giant CV waves, Pitting edema, Ascites
What is the management of tricuspid regurgitation?
Medical therapy: Diuretics to relieve edema
Intervention
• Indications
- Severe symptomatic tricuspid regurgitation
- Asymptomatic + Significantly impaired RV function/ Significantly dilated RV/ Undergoing other cardiac surgery
• Valve repair
• Valve replacement
What are the causes of tricuspid stenosis?
- rheumatic fever
- rare isolated congenital malformations
- carcinoid heart
What are the symptoms and signs in tricuspid stenosis
Symptoms
- fatigue
- leg swelling
- abdominal distension
Signs
- JVP raised with prominent a wave
- split first heart sound
- Mid diastolic murmur loudest at lowest left sternal edge
- louder on inspiration and soften on expiration
- ascites
- pedal edema
What are the investigation findings in tricuspid stenosis?
Transthoracic echogram
- valve thickening or calcification
- restricted mobility with diastolic doming
- right atrial enlargement
What is the cause of pulmonary stenosis?
Congenital
What are the symptoms and signs in pulmonary stenosis?
Symptoms
- fatigue
Signs
- JVP raised with prominent a wave
- widely split S2 (soft delayed P2)
- precordial heave
- ejection systolic murmur loudest at upper left sternal edge: softer on inspiration and louder on expiration (in congenital PS- pliable valves), louder on inspiration (non pliable valves- carcinoid/ rheumatic)
What are the investigation findings in pulmonary stenosis?
ECG
• RV hypertrophy with strain pattern (Tall R wave in V1 and V2)
Chest X-Ray Findings
• Prominent L pulmonary artery
• Lifted apex
How is pulmonary stenosis managed?
Indications for management
- severe symptomatic PS
- asymptomatic + very high pulmonary gradient
Management of Pulmonary Stenosis
• Balloon valvuloplasty
• Valve replacement (avoid as low flow system and easy to form clots)
What is the cause of pulmonary regurgitation?
Primary
- Congenital heart disease (isolated- rare, more commonly including other defects)
- following repair of TOF
- infective endocarditis
- rheumatic heart disease
- carcinoid
Secondary: pulmonary hypertension
What are the signs and symptoms in pulmonary regurgitation?
Symptoms
- fatigue
- leg swelling
- abdominal distension
Signs
- JVP raised with prominent a wave
- Decrescendo diastolic murmur at upper right sternal edge- louder on inspiration
- ascites
- pedal edema
What is the management of pulmonary regurgitation?
Medical therapy: diuretics to reduce fluid overload
Indications for surgery (valve replacement)
- severe symptomatic pulmonary regurgitation
- asymptomatic +
• significantly impaired RV function
• significantly dilated RV
• severe tricuspid regurgitation
• significant arrhythmia
What are the 2 kinds of valves used for valve replacement?
Mechanical Valve
• Need lifelong anticoagulation with warfarin
- If no risk factors: INR aim 2.5 – 3.5 (mitral), 2 – 3 (aortic)
• DOACs contraindicated for mechanical valves
- Not enough studies for FXa inhibitors
- Dabigatran associated with excess thromboembolic and bleeding risk (RE-ALIGN Trial)
• Recommended daily low dose aspirin (75-100mg) – 2014 AHA/ACC guidelines
• Longer durability (preferred for younger patients)
Bioprosthetic valve
• Only require first 3 months of anticoagulation (if no other thromboembolic risk factors e.g. AF) DOACs not contraindicated but not much studies done
• Recommended daily low dose aspirin (75-100mg) – 2014 AHA/ACC guidelines
• Shorter durability (higher rate of deterioration in younger patients)
Bioprosthetic valve preferred if
• Patient’s life expectancy is shorter than lifespan of bioprosthetic valve (avoid reoperation) reasonable if > 70 years old
• Contraindications to warfarin, or cannot be managed properly/not desired by patient
What are the causes of aortic stenosis?
- Degenerative calcific aortic valve
- Congenital bicuspid aortic valve (most common cause of AS in <65 year old)
- Seen in 2% of population
- Associated with coarctation (in 6%)
- Fusion of 2 coronary cuffs (right, left, non-coronary)
- Type 1: fusion of right and left
- Type 2: fusion of left and non-coronary
- Type 3: fusion of right and non-coronary
- Manifests at 40 – 60 years
- Rheumatic heart disease: GAS infection → develop anti-streptococcal antibodies → recognize tissues in the heart → inflammation and fibrosis of aortic valves → inflammation, fusion and fibrosis of commissures → aortic stenosis
- Less common causes:
- Subvalvular aortic stenosis
- Supravalvular aortic stenosis: William’s syndrome
How does aortic stenosis results in CCF?
Outflow obstruction (pressure overload) → increased intraventricular pressure/ increased end diastolic pressure → LV concentric hypertrophy → decreased compliance → LA pressure increased to fill LV → increased post capillary venous pressure → pulmonary congestion → pulmonary edema
Over long time: decompensation from myocardial ischemia leading to dilated LV with poor EF
What is the natural progression of AS?
Angina (5 years median survival)
Syncope (3 years median survival)
Dyspnea (2 years median survival)
What are the PE findings in Aortic stenosis?
Murmur
• Crescendo-decrescendo ejection systolic murmur
• Best heart at aortic area, radiates to carotids
• Soft S2
• Systolic ejection click loudest at apex
Variants
• Gallavardin phenomenon (may radiate to apex)
• Aortic sclerosis (no radiation to carotids)
Other clinical features • Slow rising pulse, small volume • Heaving apex beat • Narrow pulse pressure, low BP • Complications: congestive cardiac failure, endocarditis
What are the differentials of ESM?
- Aortic sclerosis
- Pulmonary stenosis
- Hypertrophic cardiomyopathy (HCM) –> louder with valsava
- Atrial septal defect
- Coarctation of aorta a/w bicuspid aortic valve
- William’s syndrome
What are the indications of severity of aortic stenosis?
- Early ejection click
- Long systolic murmur & late peaking of murmur
- Systolic thrill in aortic area
- Paradoxical splitting of S2
- S4 (atrial contraction into stiff ventricle)
- Heaving, displaced apex beat
- Narrow pulse pressure
- Slow rising, slow volume pulse (pulsus parvus et tardus)
- LVH leading to elevated end-diastolic pressure -> reduced coronary perfusion -> LHF
- Signs of heart failure: JVP, pulmonary crepitations, pedal edema
What are the CXR findings in a patient with aortic stenosis?
• Post stenotic dilatation
–> ascending aorta projects to right side
• Valve calcification
• +/- Cardiomegaly (late severe aortic stenosis) LV hypertrophy
What are the ECG findings in a patient with aortic stenosis?
Left ventricular hypertrophy (Sokolov lyon) WITH strain pattern (ST depression + T wave inversion in lateral leads)
What are the echo findings in a patient with aortic stenosis?
• Assess etiology • Assess for associated regurgitation • Assess severity - Aortic valve gradient - Aortic valve area • Haemodynamic consequence - Left ventricular hypertrophy - Left ventricular EF
What is the management of a patient with aortic stenosis?
Monitoring
• Mild: every 3-5 years
• Moderate: every 1-2 years
• Severe: 6 monthly to yearly
Intervention
• Indications
- Asymptomatic: LVEF <50%, Patient undergoing CABG
- Symptomatic: Severe AS, End organ damage
• Younger patients: metallic aortic valve replacement + conventional sternotomy
• Older patients: bioprosthetic valve (don’t need long term anticoagulation) + Transfemoral (TAVR) or conventional sternotomy
Medical therapy for those who refuse intervention
• Diuretics –> fluid overload
• ACE-I/ B-blockers –> LV dysfunction
Moderate AS does not cause symptoms
What are the causes of aortic regurgitation?
Acute
• Aortic dissection -> tear progresses proximately to affect valve leaflets
• Infective endocarditis
Chronic
• Disease of Aortic Root
- 1. Genetics: CTD (Marfan’s, Ehler Danlos), bicuspid aortic valve
- 2. Inflammatory: Takayasu arteritis, Giant cell arteritis, Behcet’s
- 3.Increased aortic wall stress: hypertension, phaeochromocytoma, cocaine use, coarctation, trauma, smoking
• Disease of Leaflet
- 1. Bicuspid aortic valve
- 2. RHD
- 3. Chronic IE
How does acute and chronic AR result in CCF?
Chronic AR:
• Volume overload → eccentric hypertrophy → decreased LV compliance →
fibrosis and dilatation of LV → LV failure (drop in EF)
• Decreased LV compliance → increased LA pressures to fill LV → increased post capillary venous pressure → pulmonary congestion
Acute AR
• increased LV blood volume → sudden increase in LV diastolic pressure (LV not dilated and non-compliant) → increased LA pressure → increased post capillary venous pressure → pulmonary edema
• Retrograde flow of stroke volume into LV → decreased forward ejection fraction → hypotension
What are the physical examination findings in aortic regurgitation?
Murmur:
• Decrescendo early diastolic murmur heard best at LUSE with patient leaning forward, on expiration
• Soft S2, high-pitched murmur
• Austin flint murmur – low pitched MDM at apex (functional mitral stenosis)
Other clinical features • Bounding and collapsing pulse • Wide pulse pressure • Deviated, thrusting apex beat • Complications: congestive cardiac failure, acute APO, infective endocarditis,
Peripheral signs
• Corrigan: Visible carotid pulsation
• De Musset: Head nodding with each heart beat
• Quincke: Capillary pulsations in the fingernails
• Muller: Systolic pulsations on the uvula
• Duroziez: Compressing the femoral with a stethoscope produces to and fro systolic and diastolic murmurs
• Traube: Pistol shot sound over femoral arteries
• Hill: Higher systolic pressure in the leg than the arm
What are the CXR findings in someone with aortic regurgitation?
Acute
• Pulmonary congestion
• Prominent aorta
Chronic
• Cardiomegaly
• Hypertrophy of LV
What are the ECG findings in someone with aortic regurgitation?
Left ventricular hypertrophy WITHOUT strain pattern (c.f Aortic Stenosis)
What are the echo findings in someone with aortic regurgitation?
• Assess etiology • Assess for associated stenosis • Assess for severity of aortic regurgitation - Regurgitant orifice area - Regurgitant volume • Haemodynamic consequence of aortic regurgitation - Left ventricular EF - Left ventricular size
What is the management of Acute AR?
Medical therapy
• Normotensive /hypertensive: vasodilators e.g. nitroprusside
• Hypotensive: inotropes e.g. dopamine
Intervention: Emergency aortic valve replacement
What is the management of Chronic AR?
Monitoring
• Mild: every 3 – 5 years
• Moderate: every 1 – 2 years
• Severe: 6 monthly to yearly
Intervention
• Indications
- Asymptomatic: EF <50%, Significant dilatation of LV
- Severe symptomatic
• Aortic valve replacement (mechanical vs bioprosthetic)
Medical therapy
• ACE and B blockers –> LV dysfunction
• Fluid overload –> diuretics
What are the causes of MS?
- Rheumatic Heart Disease***: Inflammation → fibrosis of mitral valve → commissural fusion +/- calcification
- Infective Endocarditis
- Calcific Degeneration of Mitral Valve
What are the complications of MS?
- Atrial fibrillation
- Pulmonary hypertension
- Congestive cardiac failure
How does MS result in CCF?
Impairment of flow from LA to LV → increased LA blood volume → LA dilatation → increased precapillary venous pressure → pulmonary congestion → pulmonary edema
How does mitral stenosis result in pulmonary hypertension?
LA dilatation → increased post capillary venous pressure → pulmonary hypertension → RV pressure overload → RV failure
How does MS result in A fib?
LA dilatation → LA remodelling → Atrial fibrillation
What are the physical examination findings in MS?
Murmur
• Mid-diastolic murmur heard best at apex (with bell)
• Loud S1, low-pitched murmur
• Opening snap (abrupt cessation of valve opening)
Other clinical features
• ‘Tapping’ apex beat (from accentuated 1st heart sound)
• Complications: AF, Pulmonary hypertension, Right heart failure
• Mitral facies/malar flush
What are the indications of severity in MS?
Indications of Severity • Earlier opening snap to S2 • Long mid-diastolic murmur • Mitral facies • Pulsus parvus • Pulmonary hypertension, CCF • Atrial Fibrillation
What are the CXR findings in MS?
RV dilatation: Lifting of the apex
Pulmonary hypertension
• Prominent pulmonary vasculature
• Pruning of distal capillaries
LA dilatation
• Double density of right heart border - 1 line by LA and 1 line by RA
• Splaying of carina
• Left atrial appendage pushed out
What is the ECG features in MS?
- P mitrale
- RV hypertrophy (dominant R waves in V1 and V2)
- Atrial fibrillation
What is the Echo features in MS?
- Assess etiology
- Assess for associated regurgitation
- Assess for severity of mitral stenosis
- Haemodynamic consequence of mitral stenosis
What is the management of MS?
Monitoring
• Mild: every 3-5 years
• Moderate: every 1-2 years
• Severe: 6 monthly to yearly
Intervention
• Indications
- Asymptomatic: High thromboembolic risk (history of systemic embolism, new AF), High risk of haemodynamic decompensation (significant or new onset pulmonary HTN, desire for pregnancy, need for major non cardiac surgery)
- Symptomatic
• Percutaneous mitral valve commissurotomy (for pliable valve), mitral valve replacement (for calcified mitral valve)
Medical therapy
• Diuretics: fluid overload
• For AF
- Rate control: b-blockers, CCB, digoxin
- Anticoagulation for stroke prevention (use warfarin. No NOACS as this is valvular AF)
• Prolong diastole to ensure adequate LV filling: b-blockers, CCB, digoxin
• ACE-I not indicated as there is no LV failure
What are the causes of MR?
Acute
• Myocardial infarction with papillary rupture
• Infective endocarditis
Chronic
• Degenerative (Mitral valve prolapse): Myxomatous valve can stretch and degenerate causing prolapse (doesn’t close well and leaks)
• Ischemic. Leaflet tethering: restricted leaflet closure because LV dilated → chordae tendinae doesn’t extend and pulls on leaflet so valves can’t close well
• Rheumatic Heart Disease
• Connective tissue disorder: Marfan’s, SLE, RA
• Functional Mitral Regurgitation
- Dilated left ventricle → leaflet tethering
- Dilated left atrium → annular dilatation
How does acute MR result in complications?
Increased LA blood volume → LA not dilated (non-compliant LA) → Increased LA pressures → Increased post capillary venous pressure → pulmonary edema (backflow of blood into lungs)
Backflow of blood from LV to LA → decreased forward EF → hypotension
How does chronic compensated MR result in complications?
Increased LA blood volume → LA dilatation → minimally increased LA pressures→ no significant pulmonary edema
LA dilatation → AF
How does chronic decompensated MR result in complications?
Chronic volume overload → eccentric hypertrophy of LA → decreased LA compliance → increased LA pressure → increased post capillary venous pressure → APO
Increased post capillary venous pressure → increased pre capillary venous pressure → pulmonary HTN
LA dilatation → AF
LV volume → LVH and dilatation → decreased LVEF → hypotension
What is the Physical Examination findings in Mitral Regurgitation?
Murmur
• Pansystolic murmur, best heard at apex, blowing sound
• Radiation to axilla (or carotids if posterior leaflet rupture)
• Soft S1, loud P2
Other clinical features
• Deviated, thrusting apex beat
• Pulse with sharp upstroke but small amplitude
• APO in acute MR due to non-compliant left atrium, AF in chronic MR
• Complications of AF, LVH, pulmonary hypertension, CCF, S3
What are the DDx of PSM?
- Tricuspid regurgitation (a/w large ‘v’ waves)
- Ventricular septal defect
What are the CXR findings of MR?
LA dilatation
• Double density of right heart border
• Splaying of carina
• Left atrial appendage pushed out
LV dilatation
• Apex pushed laterally
Pulmonary hypertension
• Prominent pulmonary vasculature
Increased left atrial pressure
• Upper lobe diversion
What are the ECG findings of MR?
- P mitrale → left atrial dilatation
* Atrial fibrillation
What are the echo findings of MR?
Severity of mitral regurgitation
• Regurgitant volume and fraction
• Regurgitant orifice area
Haemodynamic consequence of mitral regurgitation • Left atrial size • Left ventricular size • Pulmonary artery systolic pressure • RV size and function
What is the management of MR?
Monitoring if asymptomatic
• Mild: every 3-5 years
• Moderate: every 1-2 years
• Severe: 6 monthly to yearly
Intervention
• Indications
- Symptomatic severe MR
- Asymptomatic: End organ damage (LV EF <60%), Significantly dilated left ventricle, New onset AF, new onset pulmonary HTN, Undergoing other cardiac surgery
• Mitral valve repair → first choice if valve suitable
• Mitral valve replacement (metallic, bioprosthetic)
Medical therapy:
• LV dysfunction : ACE-I, → blockers
• AF: anticoagulation (non-valvular so can use NOACs)
• Fluid overload: diuretics
