Valvular Heart Disease Flashcards
You are taking a history of a patient with COPD, where they mention they’ve had heart problems when they were a child. You ask what it is and she tells you that shes not sure but she had to stay at home for 6 months when she was 2 years old. What did she have?
On examination, what murmur would you hear? Describe it
Scarlet fever/ Rheumatic fever
Mitral stenosis (Diastolic murmur, loudest at the apex and when in the left lateral position. Loud 1st HS with opening snap)
What is the prevalence of AR?
<1% but 3rd most common
What are the main symptoms of AS?
- Dyspnoea
- Angina
- Syncope
What is the most common cause of mitral stenosis?
Prior rheumatic infection (rare in the developed world)
What is the most common murmur in the general population?
Aortic stenosis
What are 2 causes of mitral valve prolapse?
CTD (marfan’s, ehlers danlos)
Ischemia secondary to papillary muscle rupture.
List 5 causes of mitral regurgitation
Primary: Organic causes:
Abnormalities (mitral valve prolapse in Marfan’s and Ehler Danlos, end even pregnancy)
Perforation (Infective endocarditis)
Papillary muscle rupture (post-MI)
Secondary: Functional/ischaemic (LV dilatation from prior MI, heart failure, or cardiomyopathy)
What are the 2 most common presentations of AR?
aortic dissection
IE
(also 2 most common causes)
A rumbling diastolic murmur with an opening snap (1st HS) and louder in the left lateral position
Mitral stenosis
What murmur is associated with pulmonary oedema?
Mitral regurgitation
A blowing diastolic murmur, louder when leaning forward is associated with what murmur?
Aortic regurgitation
What murmur is loudest on expiration?
Mitral regurgitation
Technically left sided murmurs
Describe a perfect auscultation of mitral regurgitation
Pansystolic murmur, loudest at the apex and on expiration, radiating to the axilla Grade 3/6
A laterally displaced apex beat is most associated with what 2 murmurs?
Mitral and aortic regurgitation
What murmur is associated with a crescendo decrescendo pattern and a heaving apex beat?
Aortic stenosis
Describe a perfect auscultation of aortic stenosis
Ejection systolic murmur, loudest at the 2nd ICS right sternal border, radiating to the carotids -Crescendo-decrescendo pattern. Grade 3/6
What murmurs are typically louder on inspiration?
RIght sided murmurs => tricuspid and pulmonary valves
Tricuspid regurgitation and stenosis
What murmurs are loudest on expiration?
LEft sided murmers are louder on expiration => mitral and aortic valves
A soft holosystolic murmur, increasing with inspiration is what murmur?
Tricuspid regurgitation
A slow intensity diastolic murmur increasing with inspiration is associated with what murmur?
Tricuspid Stenosis
What murmur is most likely to be found on a patient with a pulsatile, enlarged liver and positive hepatojugular reflux?
Tricuspid regurgitation
What is the typical presentation of a patient with valvular disease
(for 5/5, must say which valves are most likely for each symptom)
Any valve can present with all of these but to be specific
Mitral: Palpitations
Aortic: Chest pain/discomfort, syncope/presyncope
Both : SOB/Dyspnoea
What is De Musset’s sign?
Head bobbing on inspiration in Aortic Regurg.
You are conducting a clinical exam on a patient with suspected valvular disease. When assessing their BP you notice a narrow PP. What murmur does this suggest?
You note a widened PP. What murmur does this suggest?
Narrow PP AS, Wide PP AR
What is a Water Hammer Pulse? What murmur is it associated with?
It is the same as a collapsing pulse a/w aortic regurgitation
Down’s syndrome is associated with what valvular disease?
Mitral regurgitation
What clinical findings are associated with marphan’s syndrome in a cardio exam? What murmur are you looking for on auscultation?
Tall, thin male
High arched palate
Poor eyesight
Mitral stenosis due to mitral valve prolapse
On examination, you note splinter haemorrhages, fever, roth spots and pallor. What murmur is this patient most likely to have?
IE => Any regurg.
You are conducting a cardio examination on a patient the intern says “has a murmur”. Go through the exam stating the findings you will be looking for in each part. (5/5 by saying which signs are specific to a certain murmur if applicable)
You do not need to say each murmur
General inspection: Dyspnoea, Head bobbing (AR),
Closer inspection: BP (Narrow PP AS, Wide PP AR), High arched palate (MR), facies of Down’s Syndrome (MR), Stigmata of IE (Any regurgitation), raised JVP
Palpation: Parasternal heave (HF), displaced apex beat (HF, CM)
Offer: Ankle oedema, sacral oedema
Auscultation: All the murmurs, HF (reduced breath sounds, bibasal crackles, wheezing)
How would you treat mitral stenosis?
Pharmacological: Diuretics (improves dyspnoea + Beta blocker + Amiodarone + Warfarin
Surgical: Percutaneous Balloon Mitral Valvuloplasty, Percutaneous valvotomy.
–> if surgery failed or if another surgery is being done at same time (eg. CABG)–> open mitral valve replacement
Your differentials for any systolic murmur is all the other systolic murmurs. likewise for diastolic. What are your differentials for a continuous murmur?
PDA or fistula
A patient is presenting acutely with suspected valvular disease. What valves are most likely causing an acute presentation?
AR or MR
What is the general acute management of valvular disease?
Treating the underlying cause. Most likely IE, MI, trauma, aortic dissection, request urgent surgical opinion, and assess for signs of heart failure
What is the general management approach to all valvular disease? Conservative, pharma, surgical
the management of the majority of VHD is conservative due to it being a slow degenerative problem => the risk-benefit ratio needs to be calculated and discussed.
Pharmacological treatment is typically directed at the underlying disease
Surgical management is typically reserved for severe cases or when another surgery such as CABG will be performed anyways
How would you treat Mitral regurgitation?
Pharmacological: only if also HF -> treat as HF
Surgical repair only performed if acute MR or symptomatic severe chronic MR. Otherwise only done if there is another surgery to be done there anyways e.g. CABG
Surgical Tx - open valve replacement or if C/I -> endovascular mitral clip.
What is the most common valvular disease in hospitalised patients?
Aortic stenosis
What are the main causes of aortic stenosis?
Congenital: Congenital bicuspid aortic valve
Acquired: Calcified normal tri-leaflet aortic valve
A patient has a bicuspid aortic valve with an ejection systolic murmur radiating to the carotids, louder on expiration. What other cardiac sign on examination will this patient probably have?
Bicuspid valve is consistent with turner’s syndrome. These patients will likely have radio-femoral delay due to coarctation of the aorta as well
Collapsing pulse is also correct as bicuspid aortic valve is also associated with aortic regurgitation => Waterhammer/collapsing pulse
What clinical sign (not auscultation) tests for aortic regurgitation?
What does this sign also confirm?
Waterhamer pulse/Collapsing pulse
Consistent with AR or PDA => also consistent with PDA
State the causes of aortic regurgitation
Very rare
Congenital bicuspid aortic valve
Infective endocarditis (all the regurg)
Aortopathies (marphans’s, aortic dissection, Syphilis)
What are the indications for surgical tx of AS?
asymptomatic with mean gradient across valve >40mmhg
or symptomatic AS
How do you determine the mean gradient across the aortic valve?
TTE
What is the management of aortic stenosis?
Pharmacological: Highly a/w CVD so treat underlying disease. HTN drugs, statins etc..
Surgical:
Younger -> SAVR (open surgical aortic valve replacement)
Older/multiple comorbidities -> TAVI
if not fit for either: Balloon valvuloplasty/Percutaneous valvulotomy. (High risk of stroke though) (just like mitral stenosis)
What are the indications for treatment of AR?
Acute AR - surgical emx
Chronic AR
LV dilatation > 5.5cm
What is the management of aortic regurgitation?
Pharmacological: Symptomatic tx with Diuretics +ACE/ARBs (reduces aortic root dilatation for patients with marfans + good for the tx of HF which also causes dilatation)
Surgical repair if severely symptomatic and reduced ejection fraction
Tricuspid stenosis is very rare as it is associated with rheumatic disease (just like mitral stenosis). Tricuspid regurgitation on the other hand may be seen in normal individuals as well as a bunch of pathological causes. State 5, separating them as primary and secondary
Primary:
Infective endocarditis (all regurg)
Ebstein’s anomaly
Carcinoid syndrome
Traumatic Injury
Secondary:
Increased right ventricular pressure/volume => secondary LV dilatation or pulmonary HTN (RHF)
Note: This is similar to mitral regurgitation due to LV dilatation
Pulmonary valve abnormalities are rare in adults and mostly seen in paediatrics. What might cause that?
Tetralogy of fallot
Give 5 risk factors for valvular disease in general
Age
Genetic: Bicuspid aortic valve, Mitral valve prolapse => Marfan’s, Ehler Danlos, Down’s, Turner’s
Infectious => Rheumatic fever, infective endocarditis
Cardiovascular -> Previous MI, HTN, HF
CKD (causes HTN)
Which imaging technique allows for the calculation of gradients across valves leading to the assessment of severity of valvular disease?
Doppler ECHO
What is the role of an Exercise ECHO in a patient with valvular disease?
Grades MR severity as MR becomes more severe with tachycardia
What imaging techniques are used in the investigation of valvular disease? List them and indicate which is the gold standard + reasoning.
ECHO (TTE/TOE) including Doppler ECHO (grades severity of disease) and Exercise ECHO (grades MR severity)
CT-TAVI - CT transcatheter aortic valve implantation (assesses if percutaneous approach to valve repair is possible)
Coronary angiogram (underlying coronary artery disease - AS)
Coronary CT angio (Calcium score - severe AS)
Cardiac MRI (Gold standard)
What would you expect to find on TTE of MS?
dilated LA
What imaging technique is used to calculate the Calcium score?
What valvular disease is it most relevant in?
What is the calcium score? Run me through it
Coronary CT angiogram. Mostly to assess for the calcium score relevant in severe aortic stenosis
The calcium score assesses the risk of heart disease
Normal: <100
Moderate: >100
Severe >1000
What is the difference between a coronary angiogram and a coronary CT angiogram when investigating for valvular disease?
Tip: State what each does/what its used for
A coronary angiogram is an invasive procedure involving passing a catheter through the femoral or radial artery. It is both a highly detailed diagnostic tool as well as a therapeutic intervention if needed such as stenting.
A Coronary CT angiogram involves injecting a contrast dye and creating a 3D image of the coronary arteries. This is strictly a diagnostic tool and is used in the calculation of the Calcium score.
What investigations are you going to carry out for a patient presenting with valvular disease? (include reasoning where applicable)
Bedside: ECG, ABG, Urine dipstick
Bloods:
Fasting lipids and HbA1c (RF for CVD)
LFTs (raised LFTs from hepatic congestion secondary to HF)
Imaging:
ECHO (TTE/TOE) including Doppler ECHO (grades severity of disease) and Exercise ECHO (grades MR severity)
CT-TAVI - CT transcatheter aortic valve implantation (assesses if percutaneous approach to valve repair is possible)
Coronary angiogram (underlying coronary artery disease - AS)
Coronary CT angio (Calcium score - severe AS)
Cardiac MRI (Gold standard)
For how long, ideally, would a replaced valve last?
Mechanical valve: 20+
Biological: 10-15 but depends on valve and patient factors
What are the main complications of surgical repair of a valve
Acute congestive HF
Infection of prosthetic valves (given prophylactic Ab)
Thrombosis (lifelong anticoag)
Re-stenosis (esp 10 years after replacement)
Valve dehiscence
What is the treatment of tricuspid stenosis?
What is the treatment of tricuspid regurgitation?
No tx for tricuspid stenosis
Tricuspid regurg is just surgical repair only for those with severe symptomatic tricuspid regurgitation and only when performing another left-sided surgery
+ Pulmonary valve tx is just refer to specialised centre experienced with adult congenital heart disease
What anticoagulant is prescribed for those with metallic valves?
What about for bioprosthetic valves?
Warfarin for metallic valves
DOAC for bio-prosthetic
Acute severe mitral regurgitation patient is brought to theatre. What procedure is best performed to acutely manage the instability in the short term? Longer term?
What are the contra-indications to this procedure?
Intra-aortic balloon (as it deflates, that is systole, as it inflates, diastole. Must be placed in between the subclavian and renal arteries to prevent occlusion)
LVAD (may be permanent or a bridge to transplant just like HF)
Contraindications = anything affecting aorta (any procedure, AAA saccular or fusiform, aortitis, takayasu arteritis)
