Valvular heart disease Flashcards
What type of murmur do you get with aortic stenosis?
Ejection systolic murmur
What does an ejection systolic murmur in AS sound like?
“Burr de”
Audible gap between the murmur and HS2
Second sound is quiet in severe stenosis
Signs of AS
Slow rising pulse Low volume pulse Low pulse pressure JVP not elevated Forceful apex beat but not displaced (pressure overload)
Causes of AS
Most common: degenerative calcific aortic stenosis (affecting a normal valve)
Congenital bicuspid valve with degenerative changes (occurs earlier)
Rheumatic heart disease (least common)
What happens to the ventricle in aortic stenosis?
The ventricle is pumping against a stenotic aortic valve which requires more force, increased pressure so the ventricle wall thickens into the ventricle
What happens to the ventricle in aortic regurgitation?
AR –> Volume overload in the ventricle –> ventricle dilates, wall of ventricle gets thinner and apex is displaces outwards
Causes of pressure overload to the left ventricle
Hypertension
Aortic stenosis
Coarctation of the aorta
Hypertrophic cardiomyopathy (with LV outflow tract obstruction: subvalvular stenosis)
How can you gauge the severity of AS?
Triad of:
Exercise induced syncope, angina and breathlessness
Their presence infers high severity
Aortic stenosis treatment
Valve replacement is definitive treatment
Transcatheter aortic valve insertion (TAVI) offered to those unfit for cardiopulmonary bypass
What is the difference between aortic stenosis and aortic sclerosis?
Aortic stenosis: the ejection systolic murmur radiates to the neck, powerful apex beat, LVH on echocardiogram
Aortic sclerosis: leaflet thickening –> blood turbulence –> systolic turbulence but no radiation to the neck –> no change in orifice size
Causes of mitral regurgitation
Leaflet: congenital, endocarditis, degenerative
Papillary muscle and chordae: MV prolapse, ACS, Marfan’s
Annular dilatation: cardiomyopathy, ischaemic heart disease with HF
Signs of mitral regurgitation
Apex beat is displaced (volume overload)
Quiet first heart sound
Pan systolic murmur radiates LOUDLY to axilla
Second heart sound not heard separately
What murmur is present in MR
Pan systolic murmur
“Burrrrr”
MR treatment
Mild and moderate: medical treatment with ACEi, diuretics +/- anticoagulants
Severe: valve repair
Summary of systolic murmurs: aortic sclerosis
Ejection systolic murmur - aortic area
No radiation into carotids
Normal pulse
Normal apex
Summary of systolic murmurs: aortic stenosis
Ejection systolic murmur - aortic area
Radiates to carotids
Powerful non-displaced apex
Slow rising pulse in carotids
Summary of systolic murmurs: mitral regurgitation
Pansystolic murmur at apex
Radiates to axilla
Displaced apex
Normal pulse
How does bacterial tonsillitis cause RHD and diastolic murmurs
Group A beta haemolytic streptococcus throat infection
After 2-4 weeks –> acute rheumatic fever:
- antibodies form to the strep M protein which cross react with heart, joints and brain (molecular mimicry)
- particularly in those with HLA DR7
- pericarditis and Aschoff body granulomas
After 10-20 years (during which time there are subclinical episodes and/or auto-immune processes) –> chronic rheumatic heart disease:
- leaflet thickening and fusion of commisures
- -> Mitral stenosis
- -> Aortic regurgitation
Signs of mitral stenosis
Malar flush --> associated with pulmonary arterial HTN AF --> high LA pressure JVP not raised until late Apex beat not displaced Apex beat is tapping in quality
Mitral stenosis murmur sounds like:
“LUB de de”
LOUD first heart sound (high left atrial pressure keeps valve open until late in diastole, systole then slams it shut)
Opening snap (high pitched sound just after HS2)
Best heard at lower left sternal edge with diaphragm
Mitral stenosis mid-diastolic murmur sounds like:
LUB de-derrrr
Rumbling low pitched and mid-diastolic if mild stenosis
Severe disease, murmur may extend later into the diastole
Where is it best to hear MS mid-diastolic murmur
Very slowly move bell held very lightly around apex region (very localised)
What manoeuvre accentuates a MS murmur?
Patient on their left side, listen with the bell
What manoeuvre is used for aortic regurgitation?
Patient sitting forward, at the end of expiration, using the diaphragm
