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CAM201 Clinical Skills > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

Management principles of valvular heart disease

A

Medical

  • Prevent endocarditis
  • Prevent thromboembolism and arrhythmias
  • Reduce preload (diuretics)
  • Reduce afterload (vasodilators)

Surgical

  • Repair
  • Replace
    • Tissue (xenograft, homograft)
    • Prosthetic
    • Bioprosthetic
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2
Q

Why do hearts fail?

A
  • 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.
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3
Q

Forward heart failure manifestations

A
  • Fatigue
  • Dyspnoea
  • Syncope
  • Angina
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4
Q

Backwards heart failure

A
  • Pulmonary oedema
  • Right heart strain and failure
  • Elevated JVP
  • Hepatosplenomegaly
  • Ascites
  • Peripheral oedema
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5
Q

Metral stenosis aetiology

A
  • Rheumatic
  • Congenital
  • Calcification
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6
Q

Mitral stenosis haemodynamics

A

Elevated LA pressure

Elevated pulmonary arterial pressure

  • JVP prominent ‘a’ wave and gradual ‘y’ descent

Normal LV diastolic pressure

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7
Q

Mitral stenosis treatment

A

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
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8
Q

Mitral regurgitation aetiology

A
  • Mitral valve prolapse
  • Rheumatic
  • Infective endocarditis
  • Ischaemic heart disease
  • Collagen vascular disease
  • Cadiomyopathy
  • Congenital
  • Appetite suppressant drugs
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9
Q

Areas of the mitral valve that can be damaged causing mitral regurgitation

A

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
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10
Q

Mitral regurgitation haemodynamics

A
  • LV volume overload
  • LV dilatation
  • LA dilatation (atrial fibrillation)
  • Elevated pulmonary pressures
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11
Q

Clinical presentation of acute mitral regurgitation

A

Symptoms

  • SOB
  • Orthopnoea
  • Decreased CO

Signs

  • ​Variable murmur
  • S3
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12
Q

Clinical presentation of chronic MR

A

Symptoms

  • ​Variable

Signs

  • PSM (pre-systolic murmur)
  • LV enlargement
  • PHT (pressure half-time)
  • S3
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13
Q

Mitral regurgitation medical treatment

A

Diuretics

  • Decrease LV filling pressures
  • Decrease peripheral oedema

Vasodilators

  • Reduce LV afterload
  • Increase forward aortic flow
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14
Q

Mitral regurgitation surgical treatment

A
  • Mitral valve repair
  • Mitral valve replacement
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15
Q

Aortic stenosis aetiology

A

Congenital

  • 1st-3rd decade

Rheumatic

  • 4th decade

Senile calcific degeneration

  • 7-8th decade
  • 2% incidence

Bicuspid

  • 5-6th decade
  • 1% incidence
  • Males > females
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16
Q

Aortic stenosis pathophysiology

A
  • 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.
17
Q

Aortic stenosis symptoms and signs

A

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
18
Q

Aortic stenosis treatment

A

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
19
Q

Aortic regurgitation aetiology

A

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
20
Q

Acute aortic regurgitation clinical features

A
  • 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
21
Q

Chronic AR clinical features

A
  • 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
22
Q

De Musset sign

A

Head bobs with each heart beat.

SIgn of aortic regurgitation.

23
Q

Corrigan pulse

A

Sign of AR.

Collapsing pulse.

24
Q

Traube sign

A

Sign of AR.

Pistol shot sound over femoral artery.

25
Q

Quincke sign

A

Patient’s fingertips pulsating

26
Q

Chronic AR treatment

A

Medical (to decrease afterload)

  • Vasodilators

Surgery

  • AVR prior to irreversible LV dysfunction

CAM201 Clinical Skills (14 decks)

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