Valvular Heart Disease Flashcards
Describe components of the mitral valve?
Anterior MVL and Posterior MVL
Annulus
Papillary muscles and chordae tendinae
Opening is 4-6 cm2
Describe the aetiology of Mitral stenosis
Rheumatic Heart Disease
Congenital MS
Systemic conditions - SLE and RA
Describe the pathophysiology of mitral stenosis
Atria to ventricle pressure gradient increases so LA pressure increases
Pulmonary venous and capillary pressures increase so PVR increases
PaP increases and PHT develops
RH dilatation with TR and PReg
What decides the severity of mitral stenosis?
Trans-valvular pressure gradient and trans-valvular flow rate (CO and HR)
What can cause tachycardia?
Exercise, acute illness, pregnancy and atrial fibrillation
What are the clinical manifestations of mitral stenosis?
Dyspnoea (mild exertional to pulmonary oedema), Haemoptysis, Systemic embolization, IE, Chest pain and hoarseness (compression of L recurrent laryngeal nerve by large LA)
How does systemic embolization occur in MS?
LA and LAA enlargement so blood flow becomes stagnant here
What signs can be seen on clinical examination of patient with Mitral stenosis?
Mitral facies (purple discolouration), normal pulse, prominent a wave for JVP, tapping apex beat and diastolic thrill, RV heave and heart sound found in diastole (very quiet)
What changes can be seen on an ECG of a patient with mitral stenosis?
P> 0.12 secs can show RVH
What investigations are used for mitral stenosis?
ECG and Cardiac catheterisation
CXR
Echo and Cardiac magnetic resonance
What changes on CXR can be seen - mitral stenosis?
heart border is larger due to LA and LAA enlargement
What can be seen on echo of patient with mitral stenosis?
Thickening and scarring of the leaflets
Fusion of the commissures
Describe the medical treatment for a patient with mitral stenosis
Diuretics and restriction of Na intake
AF - SR restoration or ventricular rate control
Anticoagulation
What interventional treatment can be used for mitral stenosis?
Valvotomy and MVR
Describe the aetiology for mitral regurgitation
Rheumatic heart disease, mitral valve prolapse, IE, Degenerative with age, and functional MR due to LV and annular dilatation
Describe the pathophysiology of mitral regurgitation
Effective Regurgitant Orifice is not fixed so effects preload, afterload and LV contractibility
LV compensation then acute or chronic MR
Describe pathophysiology of acute mitral regurgitation
ESP and ESV decrease which decreases wall tension
Describe the pathophysiology of chronic mitral regurgitation
EDV increases and ESV returns to normal
Eccentric LVH develops
What are the clinical manifestations of acute MR?
Breathlessness due to pulmonary oedema and cardiogenic shock
Describe the clinical manifestations of chronic MR
Fatigue, exhaustion due to low CO and right heart failure
Dyspnoea or palpitations due to AF
What can be seen on examination of patient with mitral regurgitation?
Pulse is normal or reduced in HF, JVP is prominent if right heart failure, brisk and hyperdynamic apex beat, RV heave and S2 is split so early A2 and loud P2
Describe the extra heart sound in mitral regurgitation?
Holosystolic, blowing, loud at apex, radiating to axilla and no relationship in intensity and severity
What are some lab investigations used for mitral regurgitation?
ECG - LA enlargement is P>0.12 secs and tall, RVH is prominent R waves
CXR - cardiomegaly, LA enlargement, calcification
Cardiac catheterisation and LV angiography
What can be seen on echo of Mitral regurgitation?
LV dimensions
Cause of MR - leaflet dysfunction, papillary muscles or annular disease
Severity of MR and Pap (pulmonary arterial pressure)
What can be measured on CMR imaging?
Accurate cardiac volumes and volumetric determination of Reg vol.
What is the medical treatment for mitral regurgitation?
Acute - preload and afterload reduction
Chronic - Haemodynamic improvement and LV function preservation
What is the interventional treatment for MR?
Mitral valve apparatus repair and mitral valve replacement
Describe the aortic stenosis aetiology
Degenerative, rheumatic heart disease and bicuspid (congenital)
AVA < 1.5-2 cm2 instead of normal 3-4cm2
Describe the rheumatic pathophysiology of aortic stenosis
Adhesion, fusion of the commissures and retraction and stiffening of the free cusp margins
Describe the degenerative pathophysiology of aortic stenosis
Linked to atherosclerosis, is a slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins
Describe aortic stenosis pathophysiology
Increased LV systolic pressure - severe concentric hypertrophy and Increased LV mass - increases LVEDP (end diastolic pressure) - increased MVO2 - myocardial ischaemia - LV failure
What are the symptoms of aortic stenosis?
Long asymptomatic phase, life expectancy decreases when symptoms appear
Chest pain, syncope, dizziness, breathlessness on exertion and HF
What can be seen on examination of patient with aortic stenosis?
Small volume pulse which is slow rising, JVP prominent if RH failure and low BP, vigorous and sustained apex beat, RV heave and less audible S2
Describe the heart sound heard in aortic stenosis
S2 - less audible A2
Late peaking, loud at base, harsh and radiating to carotids
What lab investigations are used in aortic stenosis?
ECG - LVH voltage criteria, ST/T changes showing LV strain
CXR - calcification
Cardiac catheterisation - peak LV aortic gradient
What can be measured and seen on echo for aortic stenosis?
Demonstrates AV cusp mobility
LV function and hypertrophy
Doppler haemodynamic assessment of pressure gradient and aortic valve area
Describe the medical and interventional treatment of aortic stenosis
Medical - if develop heart failure
Interventional - aortic valve replacement or repair
Describe the aetiology of aortic regurgitation - aorta
Dilated aorta - Marfan’s, hypertension
Connective tissue disorder
Describe the aetiology of aortic regurgitation - leaflets
Bicuspid aortic valve, rheumatic heart disease, endocarditis and myxomatous degeneration
Describe the pathophysiology of aortic regurgitation
LV accommodates both SV and RegVol - increased LVEDV and LV systolic pressure - LV hypertrophy and LV dilatation
Causes increased MVO2 - myocardial ischaemia - LV failure
What are the symptoms of chronic AR?
Long asymptomatic phase then exertional breathlessness
What are the symptoms of acute AR?
Poorly tolerated as wall tension so cannot acutely adapt
What can be seen on clinical examination of aortic regurgitation?
Pulse is large volume and collapsing, wide pulse pressure, hyperdynamic and displaced apex beat
Describe the heart sound in aortic regurgitation
Normal S1 and S2
Early diastolic, decrescendo, soft murmur
Very quiet
What are the lab investigations for AR?
ECG - ST/T changes for LV strain and LAD
CXR - cardiomegaly in chronic AR
Cardiac catheterisation
What does Echo demonstrate in AR?
Demonstrates AV cusp anatomy (thickening, no of cusps and vegetations)
LV function, dilatation and hypertrophy
Doppler haemodynamic assessment of regurgitant flow
What is the medical treatment and interventional treatment for AR?
Vasodilator therapy will delay timing for surgical intervention
Aortic valve replacement
