Valvular heart disease Flashcards
S1
Closing of atrioventricular valves (tricuspid and mitral)
At start of systolic contraction of ventricles
S2
Closing of semilunar valves (pulmonary and aortic)
Once systolic contraction complete
S3
0.1 seconds after S2
Rapid ventricular filling
Chrodae tendinae stretch + twang
Normal in young healthy people
Indicates heart failure in elderly
S4
Heard before S1
Always abnormal
Stiff hypertrophic ventricule
Turbulent flow from atria contracting against non-compliant ventricle
Listening for murmurs
Bell = low pitched, diaphragm = high pitched
Pulmonary: 2nd ICS, left sternal border
Aortic: 2nd ICS, right sternal border
Tricuspid: 5th ICS, left sternal border
Mitral: 5th ICS, mid clavicular line
Erb’s point: 3rd ICS on left sternal border - best for S1/S2
Special manoeuvres
Mitral stenosis - patient on LHS
Aortic regurgitation - patient sat up, leaning forward, holding expiration
Murmur assessment
SCRIPT
Site
Character
Radiation
Intensity (grade)
Pitch
Timing
Murmur grade
- Difficult to hear
- Quiet
- Easy to hear
- Palpable thrill
- Hear with stethoscope barely touching chest
- Hear with stethoscope off chest
Stenosis complications
Mitral stenosis - left atrial hypertrophy
Aortic stenosis - left ventricular hypertrophy
Pushing against stenotic valves - muscles try harder
Regurgitation complications
Mitral regurg = left atrial dilatation
Aortic regurg = left ventricular dilatation
Leaky valve allows blood to flow back to chamber - stretches muscles
Mitral stenosis
Narrow mitral valve
Difficult for LA to push blood into LV
Mitral stenosis causes
Rheumatic heart disease
Infective endocarditis
Mitral stenosis murmur
Mid-diastolic
Low pitched
‘rumbling’
After S2
Loud S1 (thick valves require large systolic force to shut) - causes tapping apex beat
Mitral stenosis symptoms
Malar flush (back pressure of blood into pulmonary system - high CO2 and vasodilation)
AF - LA strained - electrical disruption
Mitral regurgitation
Incompetent mitral valve allows blood to leak back through during systolic contraction of LV
Mitral regurgitation complications
Congestive cardiac failure
Reduced ejection fraction + backlog of blood
Mitral regurgitation murmur
Pan systolic
High pitched
Whistling
High velocity of blood flow through leaky valve
Radiates to left axilla
S3 may be present
Mitral regurgitation causes
Idiopathic weakening with age
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
CT disorders - Ehlers Danlos / Marfan syndrome
Aortic stenosis murmur
Ejection-systolic
High pitched (high velocity of systole)
Crescendo-decrescendo
Radiates to carotids
Aortic stenosis signs
Slow rising pulse
Narrow pulse pressure
Exertion syncope (difficulty maintaining brain blood flow)
Causes of aortic stenosis
Idiopathic calcification with age
Rheumatic heart disease
Aortic regurgitation murmur
Austin flint murmur
Apex
Early diastolic
Soft/rumbling
After S2
Blood flows back through aortic valve and over mitral valve - vibrates
Aortic regurgitation signs
Corrigan’s/ collapsing pulse (rapidly appearing and disappearing pulse at carotid - blood pumped out and then flows back in)
Bioprosthetic valve pros and cons
Limited lifespan of 10 years
From pig
Mechanical valve pros and cons
Good lifespan
Lifelong anticoagulation with warfarin (INR 2.5-3.5)
Thrombus formation (blood stagnation)
Infective endocarditis
Haemolysis causing anaemia
Mechanical valve sounds
Mitral - click replaces S1
Aortic - click replaces S2
Transcatheter aortic valve implantation (TAVI)
Severe aortic stenosis
High risk for open surgery
Stretch stenosed aortic valve with balloon and insert bioprosthetic valve
Infective endocarditis after valve replacement
2.5%
High mortality of 15%
Gram positive cocci:
Staphylococcus, streptococcus and enterococcus
