Valvular heart disease Flashcards by patrick ellis

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

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What length of prolapse does mitral valve start creating symptoms at in mitral valve prolapse? [1]

2cm2 during systole

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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

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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]

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

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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

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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)

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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

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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

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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).

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What are two overiding causes of aortic regurgitation? [2]

Aortic leaflet disease [1]

Aortic root dilating disease [1]

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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

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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

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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

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What are the symptoms of aortic regurgitation [3] ?

Symptoms:
- Often none
- Dyspnoea
- Angina: increased O2 demand of dilated hypertrophied LV

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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

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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

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What would indications would trigger surgery for AR? [2]

Any symptoms of AR
Echocardiographic evidence of worsening LV dilatation

Describe the pathophysiology of mitral stenosis

Thickening and immobility of the valve leads to obstruction of blood flow from the left atrium to the left ventricle
In order for sufficient cardiac output to be maintained, the left atrial pressure increases and left atrial hypertrophy and dilatation occur
Consequently pulmonary venous, pulmonary arterial and right heart pressures also increase
The increase in pulmonary capillary pressure is followed by the development of pulmonary oedema - this is seen particularly when atrial fibrillation occurs, due to the elevation of left atrial pressure and dilatation, with tachycardia and loss of coordinated atrial contraction

What are the causes [1] and symptoms [4] of mitral stenosis?

Causes:
- Rheumatic fever

Symptoms:
- Afib - lead to palpitations
- Progressive dyspnoea - due to left atrial dilation resulting in pulmonary congestion
- Systemic emboli - due to atrial fibrillation.
- Right ventricular failure: due to the development of pulmonary hypertension

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

noncalcified valve
no mitral regurgitation
LA thrombus

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

What are causes of mitral regurgitation?

Mitral valve leaflet disease
- Mitral valve prolapse (leaflets prolapse during systole)
- Rheumatic disease
- Infective endocarditis – infection. Disease / bacteria stop closure of the valve)

Subvalvar disease
- Chordal rupture (chordae tendinae)
- Papillary muscle dysfunction (usually ischaemic)
- Papillary muscle rupture

Functional MR
- LV dilatation

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**

What are symptoms of mitral regurgitation?

**Symptoms** Dyspnoea, orthopnoea due to increase in left atrial pressure Palpitations due to atrial fibrillation Systemic emboli due to static blood within dilated fibrillating left atrium predisposes to thrombosis

What would indicate someone is suitable for mitral regurgitation surgery? [3] What medical treatment would you conduct for mitral regurgitation? [3]

**Surgery:** Symptoms that fail to respond to medical treatment Worsening cardiovascular complications pulmonary hypertension (MS) LV dilatation (MR) **Medication:** Fluid retention - **diuretics** AF (MS, MR) - **digoxin, beta-blockers, verapamil** **Anticoagulants** to protect against systemic embolisation (AF)

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries. Mitral regurgiation Mitral stenosis Aortic regurgitation Aortic stenosis

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries. **Mitral regurgiation** Mitral stenosis Aortic regurgitation Aortic stenosis

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble. Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic stenosis

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble. Mitral regurgitation **Mitral stenosis** Aortic regurgitation Aortic stenosis

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries. Which of the following is this patient most likely to have? Mitral regurgiation Mitral stenosis Aortic regurgitation Aortic stenosis

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries. Which of the following is this patient most likely to have? Mitral regurgiation Mitral stenosis Aortic regurgitation **Aortic stenosis**

During which of the following does aortic stenosis normally cause an ejection click / heart sound? S1 S2 S3 S4

During which of the following does aortic stenosis normally cause an ejection click? S1 S2 S3 **S4**

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble. Which of the following is most likely for the above patient? Mitral regurgiation Mitral stenosis Aortic regurgitation Aortic stenosis

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble. Which of the following is most likely for the above patient? 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

Which of the following is depicted in this heart murmur? Mitral regurgiation **Mitral stenosis** Aortic regurgitation Aortic stenosis

Which of the following radiates to the left axilla? Mitral regurgiation Mitral stenosis Aortic regurgitation Aortic stenosis

Which of the following radiates to the left axilla? **Mitral regurgiation** Mitral stenosis Aortic regurgitation Aortic stenosis

Which of the following radiates to the carotids? Mitral regurgiation Mitral stenosis Aortic regurgitation Aortic stenosis

Which of the following radiates to the carotids? Mitral regurgiation Mitral stenosis Aortic regurgitation **Aortic stenosis**

What would you see on a pressure signal test when investigating arotic stenosis? [1]

prominent a wave

Label A-D