Valvular heart disease

Question 1

what is the only bicuspid valve?

Answer 1

mitral

Question 2

how wide is the diameter of the mitral valve?

Answer 2

4-6cm

Question 3

what is the difference between stenosis and regurgitation?

Answer 3

stenosis is narrowing and regurgitation is leakage

Question 4

what is the most common aetiology for AS?

Answer 4

rheumatic heart disease (caused by rheumatic fever)

congenital MS (rare) - patient born with it

systemic conditions such as rheumatic arthritis

Question 5

describe the pathophysiology of Mitral stenosis?

Answer 5

MV orifice decreases (less than 2cm squared), so Atrium to ventricle pressure gradient increases, then left atrium pressure increases so pulmonary venous and capillary pressures increase, so pulmonary venous resistance increases then increase in pulmonary artery pressure.

Question 6

what brings on tachycarida in patients with MS?

Answer 6

exercise, acute illness, pregnancy, and atrial fibrillation

Question 7

what are the clinical manifestations of MS?

Answer 7

shortness of breath (dyspnoea) due to mild exertional (SOB on exercise) or pulmonary oedema

haemoptysis - caused by the rupture of the thin-walled veins in pulmonary circulation (due to pressure)

systemic embolization - caused by LA enlargement and stagnant blood flow happens, resulting in clots within then they can go into the systemic circulation and cause stroke ECT

infected valve

chest pain

and hoarse voice (compression of left recurrent laryngeal nerve)

Question 8

clinical examination signs of MS?

Answer 8

pulse is normal
mitral facies (purple/reddish look on cheeks and nose)
JVP - prominent a wave
tapping apex beat and diastolic thrill due to murmur (5th left intercostal space)
RV heave

Question 9

what does AS appear as on an ECG and CXR?

Answer 9

taller QRS complex in leads V1 and 2

P wave is greater than 0.12 seconds

LA enlargement

Question 10

what do we use, in terms of imaging, to diagnose MS?

Answer 10

echocardiography

can see thickening and scarring of the valve leaflets and anterior leaflet moves up in an ‘elbowing’ fashion

look over the recording of this scan

Question 11

how do we treat mitral stenosis?

Answer 11

diuretics and restriction of sodium intake

AF: sinus rhythm restoration or try restore heart rate if very fast (ventricular rate)

ANTICOAGULATION: all those with AF, so if atria is enlarged anti coagulate

Question 12

what is the causes of mitral regurgitation?

Answer 12

rheumatic heart disease and infection

mitral valve prolapse

degenerative - degenerates the valve with age

functional MR - due to LV enlarges then annulus enlarges as result

Question 13

what are the clinical manifestations of MR (acute and chronic)?

Answer 13

acute MR - valve perforation (hole in the valve) and damage to the papillary muscle and breathlessness - pulmonary oedema or cardiogenic shock

chronic MR - fatigue, exhaustion (low CO), right heart failure and dyspnoea or palpitations due to atrial fibrillation

Question 14

what are the signs of MR on examination?

Answer 14

normal or reduced pulse in heart failure

JVP - prominent if RH failure is present

brisk and hyperdynamic apex beat

RV heave

auscultation: reduced S1 (because valve leaflets cannot find one another), splits at S2 (early AV2, loud PV2) - so in summary, holosystolic, blowing loud at the apex and radiating to axilla

Question 15

when looking at MR on ECG, what features are prominent?

Answer 15

P wave greater than 0.12 seconds, tall

RVH leads to prominent R wave in right precordial leads

Question 16

how do we treat MR?

Answer 16

acute MR: preload and afterload (2 determinants of CO) reduction bay be life-saving - should prescribe vasodilators like sodium nitroprusside, And dobutamine to increase heart rate)

in chronic - no therapy so refer them for interventional treatment (such as mitral valve apparatus repair or valve replacement)

Question 17

what is the most common congenital heart abnormality?

Answer 17

bicuspid aortic stenosis

Question 18

what are the symptoms of aortic stenosis?

Answer 18

angina
dizziness
breathlessness on exertion
heart failure

Question 19

clinical examination of aortic stenosis?

Answer 19

pulse - small volume and slowly rising

JVP - prominent if RH failure present , low blood pressure

vigorous and sustained apex beat

RV heave

has a normal S1, S2 less audible

Question 20

upon CXR, what can be seen on AS?

Answer 20

calcification of AV

Question 21

what is the medical treatment for AS and when is it given?

Answer 21

aortic valve replacement or repair

only limited to those who develop heart failure

Question 22

what is aortic regurgitation?

Answer 22

a leaky aortic valve

Question 23

what are the 2 main streams aortic regurgitation can be divided into?

Answer 23

aortic diseases - dilated aorta (Marfan’s, hypertension), connective tissue disorders

leaflets - bicuspid aortic valve, rheumatic heart disease, endocarditis, and myxomatous degeneration

Question 24

explain the pathophysiology of AR

Answer 24

left ventricle will have accommodates both stroke volume and regurgitate volume, leading to increase in left ventricular end diastolic volume and LV systolic pressure which will result in LV hypertrophy and LV dilation, therefore an increased myocardial oxygen consumption, resulting in ischaemia and then LV failure

Question 25

what is the signs of aortic regurgitation upon clinical examination?

Answer 25

large vol. and collapsing pulse
side pulse pressure (means systolic high, and diastolic low because a lot of ejected volume comes back into ventricle from aorta)
hyperdynamic, displaced apex beat
early diastolic, decrescendo soft murmur (very hard to listen to)

Question 26

what will aortic regurgitation appear as on ECG and CXR?

Answer 26

ST/T wave changes (LV strain), and left axis deviation

CXR: cardiomegaly (mostly in chronic AR)