Valvular heart disease Flashcards
Management principles of valvular heart disease
Medical
- Prevent endocarditis
- Prevent thromboembolism and arrhythmias
- Reduce preload (diuretics)
- Reduce afterload (vasodilators)
Surgical
- Repair
- Replace
- Tissue (xenograft, homograft)
- Prosthetic
- Bioprosthetic
Why do hearts fail?
- Increased cardiac work causes hypertrophy
- Increased volume load causes dilation
- Effiency decreases after a certain dilatation (Starlings Law)
- Hypertrophy increases ventricular stiffness
- Decreased cardiac output causes catecholamine drive
- Prolonged catcholamine drive results in catecholamine depletion
- Decreased cardiac output reduces GFR causing fluid retention and aldosterone release
- Chronic volume and pressure overload leads to eventual muscle failure.
Forward heart failure manifestations
- Fatigue
- Dyspnoea
- Syncope
- Angina
Backwards heart failure
- Pulmonary oedema
- Right heart strain and failure
- Elevated JVP
- Hepatosplenomegaly
- Ascites
- Peripheral oedema
Metral stenosis aetiology
- Rheumatic
- Congenital
- Calcification
Mitral stenosis haemodynamics
Elevated LA pressure
Elevated pulmonary arterial pressure
- JVP prominent ‘a’ wave and gradual ‘y’ descent
Normal LV diastolic pressure
Mitral stenosis treatment
Medical
- Diuretic - pulmonary congestion
- Control atrial fibrillation
- Prevent thrombo-embolism: anticoagulate all with paroxysmal atrial fibrillation/ atrial fibrillation, sinus rhythm and old.
Surgical
- Balloon mitral valvuloplasty
- Closed mitral valvotomy
- Open mitral valvotomy
- Mitral valve replacement
Mitral regurgitation aetiology
- Mitral valve prolapse
- Rheumatic
- Infective endocarditis
- Ischaemic heart disease
- Collagen vascular disease
- Cadiomyopathy
- Congenital
- Appetite suppressant drugs
Areas of the mitral valve that can be damaged causing mitral regurgitation
Annulus
- Calcification
Leaflet
- Myxomatous degeneration
- Rheumatic deformity
- Infectious perforation
Chordae
- Myxomatous degeneration
- Spontaneous rupture
- Rheumatic shortening
- Infectious destruction
Papillary
- Infarction
- Ischaemic lengthening
Functional
- LV dilatation and PM displacement
Mitral regurgitation haemodynamics
- LV volume overload
- LV dilatation
- LA dilatation (atrial fibrillation)
- Elevated pulmonary pressures
Clinical presentation of acute mitral regurgitation
Symptoms
- SOB
- Orthopnoea
- Decreased CO
Signs
- Variable murmur
- S3
Clinical presentation of chronic MR
Symptoms
- Variable
Signs
- PSM (pre-systolic murmur)
- LV enlargement
- PHT (pressure half-time)
- S3
Mitral regurgitation medical treatment
Diuretics
- Decrease LV filling pressures
- Decrease peripheral oedema
Vasodilators
- Reduce LV afterload
- Increase forward aortic flow
Mitral regurgitation surgical treatment
- Mitral valve repair
- Mitral valve replacement
Aortic stenosis aetiology
Congenital
- 1st-3rd decade
Rheumatic
- 4th decade
Senile calcific degeneration
- 7-8th decade
- 2% incidence
Bicuspid
- 5-6th decade
- 1% incidence
- Males > females
Aortic stenosis pathophysiology
- LV hypertrophy
- Decreased compliance
- Increased LVEDP
- High pulmonary pressures
- Decreased forward output
- Reduced (glomerular filtration rate) leading to fluid retention
- Reduced coronary flow leading to myocardial ischaemia
- LV pressure overload –> LV hypertrophy –> diastolic LV dysfunction/ischaemia
- Systolic function usually preserved until late.
- Systolic function improves with AVR
- Outcome is dependent on symptoms.
Aortic stenosis symptoms and signs
Symptoms
- None
- SOBOE, dizziness, HF, syncope, angina
- GI bleeding (angiodysplasia)
Examination
- Pulse –> decreased amplitude, delay
- Sustained apex
- S2 - soft and single –> paradoxical splitting
- ESM - loud –> late peak –> soft
Aortic stenosis treatment
Medical
- No effective therapy
- Diuretics for LVF
- ACEI relative contraindicated
Surgical
Balloon aortic valvuloplasty
- Improves AVA 0.8cm –> 1.0cm
- Improves symptoms short term
- Procedural mortaltiy 5%
- No improvement in mortality
Aortic valve replacement
- Only if symptomatic
- Severe AS and poor LVF
- In association with CABG
- Mortality 0.6-5%
- 2 year survival 4x greater than medical treatment
Aortic regurgitation aetiology
Valve
- Rheumatic
- Infective endocarditis
- Congenital (bicuspid valve)
- SLE/Rh A
Aortic root disease
- Second degree to dilatation of ascending aorta
- Degerative
- Cystic medial necrosis of aorta
- Marfans
- Aortic dissection
- Symphilitic aortitis
- Ankylosing spondylitis
- Hypertension
Acute aortic regurgitation clinical features
- No time for LV to enlarge (LVEDV N)
- LEDP increased
- Premature closure of MV (quiet S1)
- LV systolic pressure n
- Increase total SV, decrease forward SV
Chronic AR clinical features
- Maintained forward SV
- Volume and pressure overload
- LV decompensation
- May be asymptomatic, LVF, angina
Upon examination
- Hyperdynamic circulation
- Wide pulse pressure
- Dilated LV
- Long EDM
De Musset sign
Head bobs with each heart beat.
SIgn of aortic regurgitation.
Corrigan pulse
Sign of AR.
Collapsing pulse.
Traube sign
Sign of AR.
Pistol shot sound over femoral artery.
Quincke sign
Patient’s fingertips pulsating
Chronic AR treatment
Medical (to decrease afterload)
- Vasodilators
Surgery
- AVR prior to irreversible LV dysfunction
