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valvular heart disease Flashcards

1
Q

what is the definition of mitral stenosis ?

A

inability of mitral valve to open properly when it needs to be open ( in diastole )

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2
Q

what are the causes of mitral stenosis ?

A

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

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3
Q

what are the clinical features of mitral stenosis ?

A

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

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4
Q

why do we have pulm colored cheeks in mitral stenosis ?

A

Low cardiac output + pulmonary hypertension

due to combined hypoxia and cutaneous vasodilation ( Cuz CO2 retention )

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5
Q

what are the mitral stenosis murmurs?

A

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

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6
Q

describe the ECG for mitral stenosis ?

A

P MITRALE

Wide based notched P waves due to left atrial enlargement

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7
Q

what are the x ray features of mitral stenosis ?

A

Butter fly wing appearance

DUE TO PULMONARY CONGESTION AND EDEMA

obliterated cardiac waist due to LA dilation

cardiomegaly to RV dilation

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8
Q

what are the echocardiography features of Mitral stenosis ?

A

thickening of mitral valve

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9
Q

describe the pressure gradient in doppler echo ?

A

In moderate cases —> 5- 10 mmhg gradient between LA and LV

in severe cases —> more than 10 mmhg gradient between LA and LV

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10
Q

what are the treatment regiment in Mitral stenosis ?

A

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 )

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11
Q

what are the requirements for percutaneous balloon mitral valvoplasty ?

A

suitable valve anatomy —> no severe calcifications or deformity , no mitral regurg, NO LA thrombus

high risk for surgery

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12
Q

what is the mitral regurge ?

A

inability of the mitral valve to close properly when it is supposed to close

in ventricular systole

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13
Q

what are the causes of mitral regurge ?

A

rheumatic heart disease

mitral valve prolapse MVP

infective endocarditis

functional —-> LV failure due to dilation of MV rings

Chronic myocardial ischemia –> acute or chronic

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14
Q

what are the clinical features of mitral regurge ?

A

Lung congestion and edema

Right ventricular hypertrophy /failure

left ventricular hypertrophy /failure

LA dilation

palpitation

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15
Q

what are the abnormal heart sounds in mitral regurg?

A

Holosystolic murmur ( through out the whole systole )

weak s1 sound

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16
Q

what are the features of Mitral regurge in ECG ?

A

left ventricular hypertrophy

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17
Q

what are the features of mitral regurge in X ray?

A

cardiomegaly of LV configuration

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18
Q

which investigation is the diagnostic one ?

A

Echocardiography

Cuz it shows the mitral regurge flow into LA

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19
Q

what are the treatments for mitral regurge?

A

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

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20
Q

what is mitral valve prolapse ?

A

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

21
Q

what are the other names of mitral valve prolapse?

A

barlow syndrome

click murmur syndrome

Floppy mitral valve

22
Q

what are the causes of mitral valve prolapse ?

A

unknown cause but :

reduced production of TYPE VI collagen

myxomatous degeneration of the papillary muscles / valve leaflets

23
Q

what are the clinical features of mitral prolapse?

A

Asymptomatic specially if mild

symptomatic :

Palpitation
chest pain
dyspnea
anxiety

24
Q

what are the murmur heard in mitral prolapse?

A

mid systolic click

cuz during systole the valve will prolapse to the atrium

25
Q

what are the complications of mitral prolapse?

A

mitral regurgitation

infective endocarditis

arrhythmia

26
Q

what are the investigation of mitral prolapse ?

A

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

27
Q

what are the treatments of mitral prolapse?

A

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

28
Q

what is aortic stenosis?

A

inability of the aortic valve to open during systole

Worst valve lesion

29
Q

what are the grades of aortic stenosis?

A

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

30
Q

what are the causes of aortic stenosis ?

A

senile aortic stenosis , due to calcifications or degeneration

rheumatic fever

big vegetation in endocarditis

Big lipid deposits in familial hyperlipidemia

congenital —–> bicuspid aortic valve

31
Q

what are the clinical features of aortic stenosis ?

A

low cardiac output

thrill during systole

left ventricle hypertrophy –> HF cuz no increased supply

Pulsus TARDUS —> delayed pulse

Pulsus Parvus —> low amplitude pulse

32
Q

what are 3 classic triads of aortic stenosis ?

A

Heart failure within 2 years

Syncope within 3 years

angina within 5 years

once all 3 appear –> mortality is within 5 years

33
Q

describe the natural history of aortic stenosis ?

A

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

34
Q

what are the murmurs heard in aortic stenosis ?

A

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

35
Q

what are the x ray features of aortic stenosis ?

A

cardiomegaly of LV configuration

post stenotic dilation

36
Q

what is the feature of aortic stenosis on ECG?

A

high QRS voltage

due to left ventricle hypertrophy

37
Q

what can be seen in 2D echo of aortic stenosis ?

A

stenotic tri leaflet AV

bicuspid AV incase of congenital

38
Q

describe the pressure transaortic gradient in AS?

A

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

39
Q

what are the managements of AORTIC stenosis?

A

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

40
Q

what is aortic regurg?

A

inability of aortic valve to close properly during diastole –> incompetent valve

41
Q

what are the causes of chronic aortic regurge?

A

Rheumatic fever

Marfan syndrome –> C.T disorder

SLE

ankylosing spondylitis

ulcerative colitis

Associated with ventricular septum disease

42
Q

what are the causes of acute Aortic regurge ?

A

infective endocarditis

aortic dissection —> REQUIRES SURGERY

43
Q

what are the abnormal heart sounds in aortic regurge?

A

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

44
Q

what are the clinical features of aortic regurge ?

A

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

45
Q

what is seen on ECG in aortic regurg?

A

LVH criteria

46
Q

what is seen on chest x ray due to aortic regurg?

A

cardiomegaly of LV configuration

47
Q

what is the diagnostic investigation of aortic regurg?

A

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

48
Q

what is the treatment of aortic regurg?

A

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 )

hospital (3 decks)

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