Valvular heart disease

Question 1

S1

Answer 1

Closing of atrioventricular valves (tricuspid and mitral)
At start of systolic contraction of ventricles

Question 2

S2

Answer 2

Closing of semilunar valves (pulmonary and aortic)
Once systolic contraction complete

Question 3

S3

Answer 3

0.1 seconds after S2
Rapid ventricular filling
Chrodae tendinae stretch + twang
Normal in young healthy people
Indicates heart failure in elderly

Question 4

S4

Answer 4

Heard before S1
Always abnormal
Stiff hypertrophic ventricule
Turbulent flow from atria contracting against non-compliant ventricle

Question 5

Listening for murmurs

Answer 5

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

Question 6

Murmur assessment

Answer 6

SCRIPT
Site
Character
Radiation
Intensity (grade)
Pitch
Timing

Question 7

Murmur grade

Answer 7

1. Difficult to hear
2. Quiet
3. Easy to hear
4. Palpable thrill
5. Hear with stethoscope barely touching chest
6. Hear with stethoscope off chest

Question 8

Stenosis complications

Answer 8

Mitral stenosis - left atrial hypertrophy
Aortic stenosis - left ventricular hypertrophy
Pushing against stenotic valves - muscles try harder

Question 9

Regurgitation complications

Answer 9

Mitral regurg = left atrial dilatation
Aortic regurg = left ventricular dilatation
Leaky valve allows blood to flow back to chamber - stretches muscles

Question 10

Mitral stenosis

Answer 10

Narrow mitral valve
Difficult for LA to push blood into LV

Question 11

Mitral stenosis causes

Answer 11

Rheumatic heart disease
Infective endocarditis

Question 12

Mitral stenosis murmur

Answer 12

Mid-diastolic
Low pitched
‘rumbling’
After S2
Loud S1 (thick valves require large systolic force to shut) - causes tapping apex beat

Question 13

Mitral stenosis symptoms

Answer 13

Malar flush (back pressure of blood into pulmonary system - high CO2 and vasodilation)
AF - LA strained - electrical disruption

Question 14

Mitral regurgitation

Answer 14

Incompetent mitral valve allows blood to leak back through during systolic contraction of LV

Question 15

Mitral regurgitation complications

Answer 15

Congestive cardiac failure
Reduced ejection fraction + backlog of blood

Question 16

Mitral regurgitation murmur

Answer 16

Pan systolic
High pitched
Whistling
High velocity of blood flow through leaky valve
Radiates to left axilla
S3 may be present

Question 17

Mitral regurgitation causes

Answer 17

Idiopathic weakening with age
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
CT disorders - Ehlers Danlos / Marfan syndrome

Question 18

Aortic stenosis murmur

Answer 18

Ejection-systolic
High pitched (high velocity of systole)
Crescendo-decrescendo
Radiates to carotids

Question 19

Aortic stenosis signs

Answer 19

Slow rising pulse
Narrow pulse pressure
Exertion syncope (difficulty maintaining brain blood flow)

Question 20

Causes of aortic stenosis

Answer 20

Idiopathic calcification with age
Rheumatic heart disease

Question 21

Aortic regurgitation murmur

Answer 21

Austin flint murmur
Apex
Early diastolic
Soft/rumbling
After S2
Blood flows back through aortic valve and over mitral valve - vibrates

Question 22

Aortic regurgitation signs

Answer 22

Corrigan’s/ collapsing pulse (rapidly appearing and disappearing pulse at carotid - blood pumped out and then flows back in)

Question 23

Bioprosthetic valve pros and cons

Answer 23

Limited lifespan of 10 years
From pig

Question 24

Mechanical valve pros and cons

Answer 24

Good lifespan
Lifelong anticoagulation with warfarin (INR 2.5-3.5)
Thrombus formation (blood stagnation)
Infective endocarditis
Haemolysis causing anaemia

Question 25

Mechanical valve sounds

Answer 25

Mitral - click replaces S1
Aortic - click replaces S2

Question 26

Transcatheter aortic valve implantation (TAVI)

Answer 26

Severe aortic stenosis
High risk for open surgery
Stretch stenosed aortic valve with balloon and insert bioprosthetic valve

Question 27

Infective endocarditis after valve replacement

Answer 27

2.5%
High mortality of 15%
Gram positive cocci:
Staphylococcus, streptococcus and enterococcus