Valvular Heart Disease Flashcards
What are the common Heart Lesions?
What is the natural history and progression of cardiac valve disease?
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Valvular Heart disease Symptoms
What are the clinical features of aortic stenosis? What are the diagnostic investigations?
What are the clinical features of aortic regurgitation? What are the diagnostic investigations?
What are the clinical features of mitral stenosis? What are the diagnostic investigations?
Clinical features:
- Left Atrium hypertrophy
- Pulmonary odema/hypertension
- mitral face
- opening snap and diastolic murmur, rv heave and diastolic thrill
- dysponea, haemoptysis, chest pain, horeseness
Diagnositic Investigations:
- Echo = current mainstay, can watch valves and also can look at the transvalvular pressures
- ECG - P>0.12 and signs of Right Vent Hypertrophy
- Can also use Cardiac Magnetic Resonance
Olden days used cardiac catheterisation
What are the clinical features of mitral regurgitation? What are the diagnostic investigations?
Clinical features:
Acute- Sudden onset of breathlessness, pulmonary oedema, cardiogenic shock
Chronic-Gradual onset of breathlessness, fatigue, (low CO), right heart failure
Investigations:
- Echo
What treatment options are available for valvular heart disease?
most anterior valve?
Pulomonary Valve
MV orifice size?
Usually 4-6 cm2
mv ant or post valve leaflets larger?
Anterior is larger
Aitiology and development of MVD?
Aeitiology:
Rheumatic Heart Disease
Congenital MS
Systemic conditions eg SLE/ Rheumatoid Arthrisis
Development:
Stenosis of the valve - Harder for blood to flow through - Ventricle still working fine but not as much blood is getting through, so increasing atrial pressure compared to ventricle pressure - increases pressure in LA causes dilatation and expansion, inc into the auricles, Causes increased pressure in back flow into pulmonary circulation and can eventually lead to right heart dilatation with Tricuspid regurgitation and pulmonary regurgitation (due to the increased back pressure.
MV stenosis size guideline?
When Mitral Vave Orrifice is less than 2cm2
mv stenoisis severity depends on what?
Depends on the atrial/ventricular pressure gradient (trans-valvular pressure gradient)
The volume of blood going through, CO/HR (trans valvular flow rate)
Mv stenoisis symptoms and signs
Dysponea
Haemoptisis (thin walled vein rupture)
Hoarseness (due to increased atrium size compressing the L recurrent laryngeal nerve)
Mitral face (red cheeks and nose)
prominent a wave on JVP
Opening snap on auscultation followed by murmor in diastole due to increase in pressure of flow)
RV Heave
Tapping Apex beat, diastolic thrill, normal pulse
Systemic embolisation (due to LA and LA apendage enlargement - stagnant blood - blood clots) Infective endocarditis
Mvs invest
ECHO! Valves and transmitral flow
Can also use ECG - p wave >0.12, signs of left atrium hypertrophy
CXR = left atrium enlargement
Can also use cardio magnetic resonance
MvS treatment
Diuretics and restriction of salt intake
If in AF - restore sinus rhythm
Anticoagulatin (preventitive measure for the increased stagnant blood in the left atrium, esp in patients with AF)
Valvotomy (balloon vs surgical, MVR)
mv regurgitation aetiology,
Rheumatic Heart Disease Mitral Valve Prolapse (MVP) Infective endocarditis Degenarative (age) Functional MR due to LV/annular dilatation
mv reg invist
ECG - LA enlargement (P wave >0.12 and tall), RVH - prominent R wave in R preicordial leads
CXR - Cardiomegaly, LA enlargement, mitral annulus
ECHO - structure and pressures
Cardiac resonnance
Mitral regurgitation pathophysiology
Acute: increase vol in ventricles meaning increased systolic pressure, reduced end systolic volume
Chronic: Much the same but it leads to left ventricular hypertrophy
Mitral regurgitation symptoms
Acute: Breathlessness, pulmonary oedema, cardiogenic shock
Chronic: Fatigue, exhaustion, right heart failure, dyspnoea/palpatations due to afib
Signs Mitral regurgitation
Brisk, hyperdynamic apex beat
RV heave
Reduced/non existant s1 (valve leaflets don’t meet), holosystolic blowing murmur radiates to axilla, split s2
prominent jvp if RH failure present
Mitral regurgitation treatment
Acute: reduce pre and afterload - Vasodilator (Sodium Nitroprusside), heart contractility increasor (doboutamine), reduce afterload by inta-aortic balloon (IABP). Surgery within 24-48h
Chronic: follow up, if indicated Mitral valve repair/replacement
How do IABP work?
They inflate during diastole - fools body into thinking there is a higher aosrtic pressure and also helps blood get back into coronary arteries
Deflate during systole (just before aortic valve opens), this reduces the pressure and afterload that the heart has to work against.
Aortic Valve area?
3-4cm2
Aortic valve area in stenosis?
1.5-2cm
Aortic valve stenosis aetiology
Mainly degenarative due to increasing age of population
Rheumatic fever
Higher occurance in bicuspid aortic valve
Aortic stenosis pathophysiology
Aortic stenoiss - increased work for heart to pump out blood - left ventricle hypertrophy - heart failure and more risk of myocardial ischaemia due to increase work of heart and bigger heart muscle.
Aortic stenosis signs and symptms
Symptoms:
- long asymptomatic phase
- dyspnoea on exertion
- diziness, syncope
- chest pain (angina)
Signs
- murmour between s1 and s2 - on systole
- rv heave
- vigurous and sustained apex beat
- low bp
- if rhf present then jvp prominent
- small pulse and slow rising
Investications aortic stenosis
ECHO - can use doppler haemodynamic assesment of pressure gradient
ECG - signs of LVH,LV strain causing ST change
Cardiac magnetic resonance
CXR might see calcification of AS
Aortic stenosis treatment
Only when heart failure has developed (which would mean sortic valve replacement/repair)
Aeiology of aortic regurgitation
Aorta:
- Dilated Aorta (Marfans/hypertension)
- Connective tissue disorders
Leaflets:
- Rheumatic Heart Disease
- Bicuspid
- Endocarditis
- Myxomatous degeneration
Aortic regurgitation symptoms
Acute:
- wall tension can’t adapt, so poorly tollarated
Chronic
- long asymptomatic phase
- Exertional breathlessness
Aortic regurgitation pathophisiology
Blood back from from aorta into ventricle, increased volume and pressure in ventricle, left ventricular hypertrophy and dilatation, increased risk of ischemia due to increased muscle mass and increased oxygen demand, left ventricular heart failure
AR on clinical exam
Large pulse volume and collapsing pulse, wide pulse pressure
Descending murmur after S2 (early diastolic), can be quiet
Hyperdynamic, displaced apex beat
Investigations aortic regurgiation
ECHO! - can use the doppler haemodynamic assesment too
ECG - displaced left axis and signs of LVH, ST/T changes
CXR - cardiomegally in chronic
Can see functioning on cardiac magnetic resonance
Therapy intervention for aortic regurgitation
The only one with real intervention before surgery - vasodilator therapy shown to delay timing for surgical intervention.
Then Aortic valve replacement (more commonly the case)/repair
