early diastolic murmur, best heard in the tricuspid area, with the patient sitting forwards and breath held in expiration collpasing pulse (waterhammer) - increased stroke volume and rapid run of blood back into ventricle wide pulse pressure downward and laterally displaced apex beat which is thrusting in nature Mussets - head bobbing with each beat) Corrigan (prominent pulsation in neck) quincke sign (visible capullary pulsation in the nail bed) mid-diastolic austin-flint murmur in severe AR due to partial closure of the anterior mitravl valve cusps caused by regurgitation streams

acute AR sudden, severe shortness of breath, rapidly deveoping heart failure, chest pain chronic AR long asymptomatic period, palpitations, shortness of rbeath, chest pain, sudden cardiac death

ECO: AV structure, morphology, regurgitation jet with colour doppler CXR: acute (minimal cardiac enlargement, normal aortic root/arch, pulmonary venous pattern increases, chronic (marked cardiac enlargement, prominent aortic root.arch, normal pulmonary venous pattern) ECG: LVH, LAD, LV conduction defects

Valvular Heart disease Flashcards by Taryn Miller

Anatomy of the valves

tricuspid valve - Located between the right atrium and the right ventrile
Pulmonary valve- Located between the right ventrcile and the pulmonary artery
Mitral valve- Located bettwen teh LA and LV
Aortic valve - Located between the LV and the aorta

Atrioventricular (AV) valves - Mitral (biscuspid) and tricuspid calve

Semi-lunar valves - aortic valve and pulmonary valve

Mitral and aortic- left heart

Pulmonary and tricuspid are in the right heart

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Aortic stenosis definition

Narrowing of the aortic valve producing turbulent blood flow. Obstruction of blood flow across the aortic valve.

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Classfication of aortic stenosis

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Aortic stenosis Clinical features

Patients often asymptomatic
elderly patient with chest pain
SAD
- Syncope
- Angina - increased myocardial work
- Dyspnoea

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Pathophysiology of aortic stenosis

LV outflow obstruction
results in Increased LV pressure
LV hypertrophy and more vigorous and prolonged contraction to overcome obstruction and maintain cardiac output
myocardial oxygen demand is increased
As systole is prolonged, diastole is shortened and therefore myocardial blood suuply from the coronary arteries is reduced

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Causes of aortic stenosis

congenital e.g Bicuspid aortic valve (most common in younger patients), Williams sundrome (supravalvular aortic stenosis)
degenerative calcification (most common in older patients)
post rhuematic disease
subvalvular HOCM

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Features of Aortic stenosis

Low pitched ejection systolic murum best heard in aortic area that radiates to the carotids
thrills (palpable murmur)
Narrow pulse pressure
anacrotic - slow rising pulse
Heaving non displaced apex beat

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Investigations of aortic stenosis

ECG:
- LVH,
- LBBB
- Poor wave progression
Echocardiography: valve area <1.5cm
- diagnostic
- colour doppler signals show high velocity
CXR:
- LVH
- Aortic valve calcification,
cathetherism: accurate measure of aortic stenosis

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Management of aortic stenosis

is asymptomatic then observe patient as a rule
if symptomatic then surgery (AVR) or TAVI
is asymptomatic but valvular gradient >50 mmHg and with features such as LV systolic dysfunction then consider surgery
balloon valvuloplasty is limited to patientd with critical aortic stenosis who are not fit for valve replacement
medical management is only symptomatic

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Aortic regurgitation definition

Aortic regurgitaition is the diastolic flow of blood from the aorta into the left ventricle

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Pathophysiology of aortic regurgitation

regurgitation of blood back into the LV after each systole
results in an increased end-diastolic volume and increased SV
LV works harder and become hypertrophied
If AR worsens the LV may not be able to compensate and LVF will result
situation worses resulting in congestion
backpressure from the LV may also cause pulmonary hypertension and RVF

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Causes of Aortic regurgitation

valvular
- rhuematic
- infective endocarditis
- connective tissue disease e.g RA/S:E
- bicuspid aortic valve
aortic
- aortic dissection
- sponyli-arthropathies
- hypertension
- sphyllis
- marfans

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Features of AR

early diastolic murmur, best heard in the tricuspid area, with the patient sitting forwards and breath held in expiration
collpasing pulse (waterhammer) - increased stroke volume and rapid run of blood back into ventricle
wide pulse pressure
downward and laterally displaced apex beat which is thrusting in nature
Mussets - head bobbing with each beat)
Corrigan (prominent pulsation in neck)
quincke sign (visible capullary pulsation in the nail bed)
mid-diastolic austin-flint murmur in severe AR due to partial closure of the anterior mitravl valve cusps caused by regurgitation streams

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Presentation of AR

acute AR
- sudden, severe shortness of breath, rapidly deveoping heart failure, chest pain
chronic AR
- long asymptomatic period, palpitations, shortness of rbeath, chest pain, sudden cardiac death

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Investigations of AR

ECO: AV structure, morphology, regurgitation jet with colour doppler
CXR:
- acute (minimal cardiac enlargement, normal aortic root/arch, pulmonary venous pattern increases,
- chronic (marked cardiac enlargement, prominent aortic root.arch, normal pulmonary venous pattern)
ECG: LVH, LAD, LV conduction defects

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Management of AR

severe acute AR
- surgical intervention
chronic
- medical tx: ACE i, ARBs, diuretics
- Surgical tx: valve repair or valve replacement
indications for surgery
- symptoms
- no symtpms but EF <55%
- no symptoms but LVSD>55mm

Mitral stenosis definition

obstruction to left ventricular inflow at the level of mitral valve due to structural abnormaltiy of the mitral valve apparatus

Clinical features of mitral stenosis

dyspnoea- due to pulmonary hypetenion
haemoptysis -pulmonary vein rupture
palpitations- AF
systemic emboli
Left atrial enlargement
- hoarsness
- dysphagia
- left lung collapse

Causes of MS

RHUEMATIC fever, rhuematic fever

Features of MS

opening snap after the second heart sound followed by a low rumbling mid-diastlic murmur, best heard at the apex with the patient on his or her left side
prominent a waves in jugular venous pressure
loud S1, opening snap
tapping apex beat that is not displaced
diastolic thrill at apex
Left parasternal heave
atrial firbillation
malar flush

Presentation of MS

symptoms during 3rd and 4th decade
initially asymptomatic at rest
dyspnoea with exertion
palpitations
15% have embolic episodes due to AF (stroke, renal failure, MI)
hoarsness, persistent cough (due to compression from LA)

Investigations of AS

Echo - see table
ecg: AF or LAE
CXR: LAE

Management of MS

reduce recurrence of rhuematic fever
prophylaxis for infective endocarditis
reduces symptoms of pulmonary congestion
rate control and anticoagulation in AF
percutaneous balloon valvuloplasty
valve replacement

Mitral regurg definition

abnormal reversal of blood flow from the left ventricle to the left atrium caused by disrruption in any part of teh mitral valve apparatus

Causes of MR

* leaflets * rhuematic * endocartisi * chordae * rupture * papillary muscle * ischaemia or infarction * left ventricle * any cause of enlargement

Features of MR

* apical pansystolic murmur that radiates to axilla * lung creptitations

features of MR

* apical pansystolic murmur that radiates to the axilla * lung crepitations

Investigations

* CXR: pulmonary congestion or LAE * ECG: lae, LVH * echo: identifies structural abnormalities of valve

Presentation of MR

* acute * dyspnoea * fatigue * orthopnoea * chronic * asynptatic for years * dyspnoea on exertion * fatigue * palpitaitons

Management of MR

* Medical * diuretics * ACE I * digoxin * warfarin * surgical * valve replacement * valve repair

Cause of slow rising or plateu pulse

aortic stenosis

Causes of collapsing puse

Aortic regurg

Bifid pulse causes

mixed aortic stenonsis and regurg

Causes of a narrow pulse pressure

Pulse pressure (PP) is defined as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) Narrow pulse pressure in aortic stenosis

Causes pf wide pulse pressure

Aortic regurg

Precordium findings (apex beat)

* **Displaced =** Mitral regurg * **Double apical pulse-** HCM * **Tapping apex beat -** Mitral stenosis * **Heaving apex beat -** Aortic stenosis * **Thrusting apex beat -** Aortic or mitral regurg

How to extenuate murmurs

* **Roll patient to left lateral position-** listen to axilla with bell for mitral stenosis * **Sit the patient forward -** Listen with diaphragm over left sternal edge while the patient is holding their breath in full expiration - aortic regurg Radiation * **Aortic stenosis -** Carotids * **Mitral regurg -** Axilla