Valvular heart disease Flashcards
What are the 4 heart sounds? [4]
What are they caused by and when do they occur? [4]
S1:
closure of AVN (tricuspid and mitral valve) at start of systolic contraction of ventricles
S2:
closure of semi-lunar valves (aortic and pulmonary valves) at the end of systole
S3:
0.1 secs after S2. Caused by rapid ventricular filling causing chordae tendinae to twang close.
S4:
Directly before S1. Always abnormal: indicates stiff / hypertrophic ventricle. Turbulent flow from atria trying to get blood in
What length of prolapse does mitral valve start creating symptoms at in mitral valve prolapse? [1]
2cm2 during systole
Name 3 reasons that could be the pathology behind mitral valve prolapse [3]
Describe the physiology occuring in mitral valve prolapse [1]
What are symptoms and severity of mitral valve prolapse? [1]
Whats a sign of mitral valve prolapse? [1]
Pathology:
- histologically normal valves
- myxomatous degeneration (efect in the mechanical integrity of the leaflet due to the altered synthesis and/or remodeling by type VI collagen)
- Marfan, Ehlers danlos
Physiology:
- valve leaflet(s) prolapses back into LA during systole, sometimes producing Mitral Rerguit.
Symptoms:
- Usually asymptomatic
Sign:
- Late ejection click
Name 3 reasons that could be the pathology behind mitral valve prolapse [3]
Describe the physiology occuring in mitral valve prolapse [1]
What are symptoms and severity of mitral valve prolapse? [1]
Whats a sign of mitral valve prolapse? [1]
Pathology:
- histologically normal valves
- myxomatous degeneration (efect in the mechanical integrity of the leaflet due to the altered synthesis and/or remodeling by type VI collagen)
- Marfan, Ehlers danlos
Physiology:
- valve leaflet(s) prolapses back into LA during systole, sometimes producing Mitral Rerguit.
Symptoms:
- Usually asymptomatic
Sign:
- Late ejection click
Severity:
- Usually asymptomatic and no treatment needed
Define aortic stenosis [1]
Name 3 causes of aortic stenosis [3]
Definition:
Narrowing of the aortic valve resulting in obstruction to the left ventricular stroke volume, leading to symptoms of chest pain, breathlessness, syncope and fatigue
Causes:
- Calcific disease (hardening of aortic valve)
- Congenital bicuspid aortic valve (BAV) (valve has 2 leaflets instead of 3 due to genetic disease - this is the most common congenital heart disease) resulting in stenosis
- Rheumatic heart disease
Signs [5] & Symptoms [4] of Aortic stenosis?
Symptoms:
- Dyspnoea - increase in diastolic pressure in stiff non-compliant LV. LV is thicker because has to use more energy to expel blood (hypertrophy)
- Angina - increase O2 demand of hypertrophied LV
- Syncope - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion (less blood is leaving)
- LVF - contractile failure as ventricle dilates – causes heart failure
- Sudden death - ventricular arrhythmias
Signs:
- slow rising carotid pulse
- S4 ejection click
- Late diastole (trying to eject blood)
Describe the murmur that occurs from aortic stenosis [4]
Systolic ejection murmur (S1 –> S2)
Prominant S4 ejection click
High pitched
Crescendo / decresendo
Radiates to carotids
What investigations would you conduct (and see) for aortic stenosis? [4]
Echocardiogram
- area of valve: if less than 1cm2
- Speed / gradient of LV into aorta more than 64 mm Hg
ECG:
- Inverted T wave in lateral leads (LV hypertrophy)
CXR
- imaging of valve
Pressure signals: (put a catheter into LV and measure gradient of LV –> aorta)
- prominant a wave
What would indicate need for surgery for AS? [3]
- Any symptoms of AS
- Echocardiographic evidence of worsening LV dilatation
- Peak systolic pressure gradient (the difference between peak left ventricular [LV] and peak aortic systolic pressures) >50 mmHg
TAVI now taking over from heart surgery for people not suitable (frail).
What are two overiding causes of aortic regurgitation? [2]
Aortic leaflet disease [1]
Aortic root dilating disease [1]
What are 4 causes of aortic valve lealeft disease [4]
Calcific disease – stiffness of valve (hard to open / close)
Congenital bicuspid valve
Rheumatic disease
Infective endocarditis. Infection of aortic valve
Describe the pathophysiology behind aortic rurgigation
Aortic regurgitation is reflux of blood from the aorta through the aortic valve into the left ventricle during diastole
- If net cardiac output is to be maintained, the total volume of blood pumped into the aorta must increase and, consequently, the left ventricular size must enlarge resulting in left ventricle dilation and hypertrophy
- Progressive dilation leads to heart failure
- Furthermore due to the fact that the remaining blood in the root of the aorta supplies the coronary arteries via the coronary sinus during diastole - regurgitation causes diastolic blood pressure to fall and thus coronary perfusion decreases
- Also the large left ventricular size is mechanically less efficient, so that the demand for oxygen is greater and cardiac ischaemia develops
What are 3 causes of aortic regurgitation caused by aortic root dilating disease? [3]
Ankylosing spondylitis (is an inflammatory disease that, over time, can cause some of the bones in the spine (vertebrae) to fuse)
Marfan syndrome (cant make strong CT)
Aortic dissection
What are the symptoms of aortic regurgitation [3] ?
Symptoms:
- Often none
- Dyspnoea
- Angina: increased O2 demand of dilated hypertrophied LV
Describe signs of aortic regurgitation
Heart murmur:
- Early diastolic, soft / subtle murmur at left sternal border
- Systolic ejection murmur; due to increased flow across the aortic valve
- Corrigans pulse / collapsing pulse: rapidly appears then dissapears
- Apex beat displaced laterally
What investigations for aortic regurgitation?
Echocardiogram:
- Aortic root size compared to LV. Aortic root often much larger than normal)
- LV dimensions (LV dilation)
Doppler
- detection and quantification of regurgitant flow
What are the signs of mitral stenosis?
- Mid-diastolic rumbling murmur: low velocity of blood flow (due to narrow area - rumbles way through). LENGTH OF RUMBLE CORRELATES TO THE INTENSITY
- Loud S1 caused by thick valves closing
- Tapping apex beat that is palpatable (due to loud S1)
- Atrial fibrillation: left atrium can’t push through stenotic valve - disrupts electrical signal
- Increase in JVP, basal creps, ankle oedema
What investigations would you do to ID mitral stenosis?
ECG:
- Left atrial enlargement
Echocardiogram:
* GOLD STANDARD for diagnosis
* Assess mitral valve mobility, gradient and mitral valve area
What is mitral stenosis valvuloplasty?
Percutaneous mitral balloon valvotomy:
* Catheter is inserted into the right atrium via the femoral vein under local anaesthesia
* The interatrial septum is then punctured and the catheter advanced into the left atrium and across the mitral valve
* The balloon is inflated and puts pressure on valve thereby separating the leaflets thereby increasing the size of the mitral valve opening thus enabling more blood to flow from left atrium into left ventricle
Describe the signs of mitral regurgitation xx
- Pan-systolic murmur
-
Prominent third extra heart sound (S3) in congestive heart failure/left
atrium overload - High pitched whistling
- increased JVP, basal creps, ankle oedema due to backlog of blood
- radiates to the left axilla
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Which of the following is depicted in this heart murmur?
Mitral regurgiation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
Label A-D
