Valvular Heart Disease

Question 1

What causes mitral stenosis?

Answer 1

Rheumatic heart disease / arthritis.
Congenital.
SLE.

Question 2

What is the pathophysiology of mitral stenosis?

Answer 2

The MV orifice shrinks.
AV pressure gradient increases.
LA pressure increases, PVR increases.
Pulmonary artery pressure increases, causing PHT, right heart dilatation, and tricuspid/pulmonary regurgitation.

Question 3

What is the severity of mitral stenosis?

Answer 3

Depends on pressure gradient and flow.
Affected by CO and HR.
Tachycardia (exercise, illness, pregnancy, AF).

Question 4

What are the signs and symptoms of mitral stenosis?

Answer 4

Systemic embolisation (LA enlargement).
IE, mitral facies, normal pulse, tapping apex beat, diastolic thrill, RV heave.
SOB, haemoptysis, chest pain, hoarseness.

Question 5

What are the investigations for mitral stenosis?

Answer 5

ECG cath (P>0.12s = RVH).
CXR (LA enlargement).
ECHO (leaflet thickening, commissure fusion).
Cardiac MRI.

Question 6

What is the treatment for mitral stenosis?

Answer 6

Diuretics and reduced salt intake.
AF - restore sinus rhythm, control ventricular rate, and anticoagulants.
Valvotomy and replacement.

Question 7

What causes mitral regurgitaiton?

Answer 7

Rheumatic heart disease.
MV prolapse.
IE.
Degeneration.
LV and annular dilatation.

Question 8

What is the pathophysiology of mitral regurgitation?

Answer 8

Increased preload, afterload, and contractility.
Regurgitant vol increases, LV compensates.

Acute - wall tension falls.
Chronic - LVH develops.

Reduced LA compliance - PHT.
Increased LA compliance - AF.

Question 9

What are the signs and symptoms of mitral regurgitation?

Answer 9

Acute - valve perforation, SOB, pulmonary oedema, cardiogenic shock.
Chronic - fatigue, exhaustion, right HF, SOB, palpitations (AF).

Prominent JVP (RHF), brisk apex beat, RV heave, pansystolic murmur (radiates to axilla).

Question 10

What are the investigations for mitral regurgitation?

Answer 10

ECG (P>0.12s = RVH).
CXR (LA enlargement, cardiomegaly, mitral annulus calcification).
Cardiac cath.
ECHO - shows severity of MR.

Question 11

What is the treatment for mitral regurgitation?

Answer 11

Acute - reduce preload and afterload (sodium nitroprusside, intra-aortic balloon pump).
Chronic - lack of evidence for beneficial therapy; preserve LV function.
MV apparatus repair or MV replacement.

Question 12

What are the causes of aortic stenosis?

Answer 12

Degeneration - linked to atherosclerosis, leads to thickened and calcified cusps.
Rheumatic - commissure fusion, retraction and stiffening of cusps.
Bicuspid AV.

Question 13

What is the pathophysiology of aortic stenosis?

Answer 13

Increased LV systolic pressure.
Severe hypertrophy and LV mass.
Increased LV end diastolic pressure.
LA pressure increases - PHT.
Increased myocardial O2 used.
Myocardial ischaemia and LV failure.

Question 14

What are the signs and symptoms of aortic stenosis?

Answer 14

Slow rising pulse, prominent JVP (RHF), low BP, sustained apex beat, RV heave, harsh HS that radiates to carotids.
Anginal like chest pain, syncope, exertional pre-syncope, dizziness, SOB on exertion, HF.

Question 15

What are the investigations and treatment of aortic stenosis?

Answer 15

ECG - LVH voltage criteria, ST changes (LV strain).
CXR - AV calcification.
Cardiac cath.
ECHO - shows AV cusp mobility, LV function and hypertrophy.
Doppler assessment of pressure gradient.

Treatment - limited to those with HF.
AV replacement or repair.

Question 16

What are the causes of aortic regurgitation?

Answer 16

Dilated aorta (CT disorders, hypertension).
Bicuspid leaflets.
Rheumatic heart disease.
Endocarditis.
Myxomatous degeneration.

Question 17

What is the pathophysiology of aortic regurgitation?

Answer 17

LV accommodates SV and regurgitation vol.
Increased LV end diastolic volume and LV systolic pressure.
LV hypertrophy and dilatation occur.
Increased myocardial O2 demand.
Myocardial ischaemia and LV failure.

Question 18

What are the signs of aortic regurgitation?

Answer 18

Collapsing pulse.
Wide pulse pressure.
Displaced apex beat.
Soft murmur.

Question 19

What are the investigations for aortic regurgitation?

Answer 19

ECG - ST changes (LV strain).
CXR - cardiomegaly (chronic AR).
ECHO - AV cusp anatomy (thickening, prolapsing, number of cusps, vegetations).
LV function (dilatation and hypertrophy).
Doppler (haemodynamic assessment for regurgitant flow).

Question 20

What is the treatment of aortic regurgitation?

Answer 20

Vasodilator therapy - delays timing for surgical intervention.
AV replacement or repair.