valvular heart disease Flashcards
what is the definition of mitral stenosis ?
inability of mitral valve to open properly when it needs to be open ( in diastole )
what are the causes of mitral stenosis ?
Rheumatic heart disease –> most common cause ( 95% ) of the cases
Other causes :
Congenital
Calcific —> degenerative
Functional causes :
Austin flint murmur –> Aortic regurg
Carry coombs murmur in rheumatic valvulitis
increased flow through Mitral valve —> like mitral regurg
what are the clinical features of mitral stenosis ?
Pulmonary hypertension –> cuz blood cant leave left atrium
pulmonary congestion
systemic congestive in severe stenosis
Atrial dilation –> fibrillation
Malar flush due to low cardiac output and pulmonary hypertension
Thrombus in valve —> emboli —> neurological damage , absent pulse , sudden blindness
why do we have pulm colored cheeks in mitral stenosis ?
Low cardiac output + pulmonary hypertension
due to combined hypoxia and cutaneous vasodilation ( Cuz CO2 retention )
what are the mitral stenosis murmurs?
Mid diastolic murmur –> rumbling , localized over apex
Low pitched —> use Stethoscope BELL
position the patient on Lateral side and listen after breath holding expiration
Opening snap following S2 ( diastole )
S1 –> systole —> S2 —> diastole —> S1
Accentuated S1
describe the ECG for mitral stenosis ?
P MITRALE
Wide based notched P waves due to left atrial enlargement
what are the x ray features of mitral stenosis ?
Butter fly wing appearance
DUE TO PULMONARY CONGESTION AND EDEMA
obliterated cardiac waist due to LA dilation
cardiomegaly to RV dilation
what are the echocardiography features of Mitral stenosis ?
thickening of mitral valve
describe the pressure gradient in doppler echo ?
In moderate cases —> 5- 10 mmhg gradient between LA and LV
in severe cases —> more than 10 mmhg gradient between LA and LV
what are the treatment regiment in Mitral stenosis ?
Prophylaxis against endocarditis
anticoagulation if atrial fibrillation or after embolization
diuretics for congestive symptoms
Valve replacement for symptomatic cases regardless in moderate or severe case or cases not suitable for percutaneous techniques
percutaneous balloon mitral valvoplasty ( inoue )
what are the requirements for percutaneous balloon mitral valvoplasty ?
suitable valve anatomy —> no severe calcifications or deformity , no mitral regurg, NO LA thrombus
high risk for surgery
what is the mitral regurge ?
inability of the mitral valve to close properly when it is supposed to close
in ventricular systole
what are the causes of mitral regurge ?
rheumatic heart disease
mitral valve prolapse MVP
infective endocarditis
functional —-> LV failure due to dilation of MV rings
Chronic myocardial ischemia –> acute or chronic
what are the clinical features of mitral regurge ?
Lung congestion and edema
Right ventricular hypertrophy /failure
left ventricular hypertrophy /failure
LA dilation
palpitation
what are the abnormal heart sounds in mitral regurg?
Holosystolic murmur ( through out the whole systole )
weak s1 sound
what are the features of Mitral regurge in ECG ?
left ventricular hypertrophy
what are the features of mitral regurge in X ray?
cardiomegaly of LV configuration
which investigation is the diagnostic one ?
Echocardiography
Cuz it shows the mitral regurge flow into LA
what are the treatments for mitral regurge?
prophylaxis against rheumatic fever and infective endocarditis
adjunctive medical treatment : vasodilators to reduce regurgitant volume and pulmonary congestion , diuretics in case of congestive symptoms
Interventional treatment : mitral clips —> interventional device for percutaneous , transseptal edge to edge reconstruction of the mitral valve in pateints with severe regurgitation not eligible for surgery
Surgery : repair or replacement —> if symptomatic or reduced LV function
what is mitral valve prolapse ?
clinical syndrome caused by an abnormality of the mitral valve apparatus that causes its prolapse into the atrium IN SYSTOLE
So during systole the valve prolapse to the atrium
common 2-6% of population
what are the other names of mitral valve prolapse?
barlow syndrome
click murmur syndrome
Floppy mitral valve
what are the causes of mitral valve prolapse ?
unknown cause but :
reduced production of TYPE VI collagen
myxomatous degeneration of the papillary muscles / valve leaflets
what are the clinical features of mitral prolapse?
Asymptomatic specially if mild
symptomatic :
Palpitation
chest pain
dyspnea
anxiety
what are the murmur heard in mitral prolapse?
mid systolic click
cuz during systole the valve will prolapse to the atrium
what are the complications of mitral prolapse?
mitral regurgitation
infective endocarditis
arrhythmia
what are the investigation of mitral prolapse ?
2D echo —> late systole will have one leaflet or both prolapsed into the left atrium
doppler —> mitral regurgitation due to backflow of blood into LA due to prolapse of the posterior MV leaflet
what are the treatments of mitral prolapse?
BB –> reduce chest pain by inhibiting heart
treatment of associated arrhythmias
prophylaxis against endocarditis —-> if associated with Mitral regurge
Surgery :
mitral valve repair —> better
replacement
what is aortic stenosis?
inability of the aortic valve to open during systole
Worst valve lesion
what are the grades of aortic stenosis?
normally the aortic valve is 3-4 cm
severe AS –> it becomes less than 1 cm
critical AS —> becomes less than 0.7 cm
symptoms usually occur when valve area is reduced to 25% of its normal size
what are the causes of aortic stenosis ?
senile aortic stenosis , due to calcifications or degeneration
rheumatic fever
big vegetation in endocarditis
Big lipid deposits in familial hyperlipidemia
congenital —–> bicuspid aortic valve
what are the clinical features of aortic stenosis ?
low cardiac output
thrill during systole
left ventricle hypertrophy –> HF cuz no increased supply
Pulsus TARDUS —> delayed pulse
Pulsus Parvus —> low amplitude pulse
what are 3 classic triads of aortic stenosis ?
Heart failure within 2 years
Syncope within 3 years
angina within 5 years
once all 3 appear –> mortality is within 5 years
describe the natural history of aortic stenosis ?
Latent period ——-> no symptoms ( Asymptomatic stage )
onset of symptoms —> severe reduction of survival if no treatment
AV replacement ——> higher survival %
without AV replacement ———> HF 2Y, Syncope 3Y, Angina 5Y
what are the murmurs heard in aortic stenosis ?
Ejection systolic murmur —> mid systole murmur
its heard at :
over the aortic area
radiates up to carotids and down to lower left sternal border
harsh murmur due to increased pressure within a thrill
increased by leaning forward
what are the x ray features of aortic stenosis ?
cardiomegaly of LV configuration
post stenotic dilation
what is the feature of aortic stenosis on ECG?
high QRS voltage
due to left ventricle hypertrophy
what can be seen in 2D echo of aortic stenosis ?
stenotic tri leaflet AV
bicuspid AV incase of congenital
describe the pressure transaortic gradient in AS?
mild Aortic stenosis will have pressure gradient LESS than 20
moderate aortic stenosis will have pressure gradient between 20-40 mmHG
Severe aortic stenosis has pressure gradient HIGHER than 40
ECHO color doppler can estimate the gradient across the stenotic AV and classify As severity accordingly
what are the managements of AORTIC stenosis?
general :
IE prophylaxis before dental procedures
Diuretics for congestive symptoms but no vasodilators ( CUZ REFLEX TACHYCARDIA ), vasodilators were used in mitral regurge
Surgical —> valve replacement
in symptomatic patients with severe AS , at rest or during exercise
Evidence of LV impairment
Interventional : Transcutaneous aortic valve implantation TAVI :
if patient has severe aortic stenosis while having high risk for surgery
Suitable anatomy of valve and aorta
what is aortic regurg?
inability of aortic valve to close properly during diastole –> incompetent valve
what are the causes of chronic aortic regurge?
Rheumatic fever
Marfan syndrome –> C.T disorder
SLE
ankylosing spondylitis
ulcerative colitis
Associated with ventricular septum disease
what are the causes of acute Aortic regurge ?
infective endocarditis
aortic dissection —> REQUIRES SURGERY
what are the abnormal heart sounds in aortic regurge?
Early diastolic murmur
Austin flint murmur –> Mid diastolic murmur
Decrescendo murmur :
over the erb point –> 3rd left space
radiates to the lower left sternal border
blowing in character
high pitch
increased by leaning forward
what are the clinical features of aortic regurge ?
Decreased diastolic pressure
INCREASED systolic pressure
WIDEN PULSE PRESSURE
Left ventricle hypertrophy and failure
Slowly progressive disease
peripheral manifestation :
throbbing pain
head nodding —> de musset sign
collapsed carotid pulse —> corrigan sign
water hammer pulse
capillary pulsation –> quick sign
pistol shot —> traube sign
to and fro bruit over femolar –> durozeiz sign
HILL SIGN —> BP DIFFERENCE OVER 40 MM BETWEEN POPLITEAL AND BRACHIAL
Shortness of breath
palpitation due to increased systolic force
what is seen on ECG in aortic regurg?
LVH criteria
what is seen on chest x ray due to aortic regurg?
cardiomegaly of LV configuration
what is the diagnostic investigation of aortic regurg?
Echocardiography :
2D echo : evaluation of AV morphology
measurement of LV dimensions
assessment of cardiac function
COLOR doppler echo :
Shows AR as mosaic color jet in left ventricle
what is the treatment of aortic regurg?
surgery : replacement IN CASE OF symptomatic patients at rest or during exercise
Evidence of LV dysfunction of significant dilation
Prophylaxis for infective endocarditis
adjunctive medical treatment with vasodilators to improve symptoms ( in AS no vaso but in MR we give )
