Valvular heart disease Flashcards
Name the types of aortic stenosis
Supravalvular, subvalvular, valvular
What happens to the valve in degenerative aortic stenosis?
Thickened valve with reduced orifice
Calcification restricts opening of valve
What is the pathophysiology of aortic stenosis?
Pressure gradient develops between LV and the aorta > LV function initially maintained by compensatory pressure hypertrophy > compensatory mechanisms exhausted > LV function declines
How does aortic stenosis present?
Syncope
Angina
Dyspnoea on exertion (due to HF)
Sudden death (
What are the physical signs of aortic stenosis?
Slow rising carotid pulse (pulsus tardus) and decreased pulse amplitude (pulsus parvus)
Heart sounds - soft or absent second heart sound, S4 gallop due to LVH
Ejection systolic murmur
What investigations would be carried out for aortic stenosis?
Echocardiography - assess severity
What management is used for aortic stenosis?
Fastidious dental hygiene/care
Consider IE prophylaxis in dental procedures
Surgical replacement - transcutaneous aortic valve implantation
What are the indications for surgery in aortic stenosis?
Any symptomatic patient with severe AS
Any patient with decreasing EF
Any patient undergoing CABG with moderate or severe AS
What is the definition of mitral regurgitation?
Back-flow of blood from LV to LA during systole
What are the aetiologies of mitral regurgitation?
Myxomatous degeneration
Ischaemic MR
Rheumatic heart disease
Infective endocarditis
What is the pathophysiology of mitral regurgitation?
Pure volume overload
Compensatory mechanisms > LA enlargement, LVH and increased contractility
What are the physical signs and symptoms of mitral regurgitation?
Auscultation - soft S1 and pan systolic murmur at apex radiating to axilla
Exertional dyspnoea
HF: may coincide with increased haemodynamic burden
What imaging studies would be carried out for mitral regurgitation and what would they show?
ECG - LA enlargement, AF, and LVH with severe MR
CXR - LA enlargement, central pulmonary artery enlargement
Echocardiography - estimation of LA, LV size and function
What medication management would be used for mitral regurgitation?
Vasodilator - ACE-I, hydralazine Rate control for AF with beta-blockers, CCB, digoxin Anticoagulation in AF and flutter Diuretics for fluid overload IE prophylaxis
What would be the indications for surgery?
Any symptoms at rest or exercise
Asymptomatic - if EF
What is the definition of aortic regurgitation?
Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps
What is the aetiology of aortic regurgitation?
Bicuspid aortic valve
Rheumatic
Infective endocarditis
What is the pathophysiology of aortic regurgitation?
Combined pressure and volume overload
Compensatory mechanisms > LV dilatation, LVH
Progressive dilation > HF
What would be the physical exam findings in aortic regurgitation?
Wide pule pressure
Hyperdynamic and displaced apical impulse
Auscultation - diastolic blowing murmur at left sternal border; austin flint murmur; systolic ejection murmur
What imaging would be done in aortic regurgitation and what would it show?
CXR - enlarged cardiac silhouette and aortic root enlargement
Echo - evaluation of AV and aortic root with measurements of LV dimensions and function
What are the progressive symptoms of aortic regurgitation?
Dyspnoea - exertional, orthopnoea, and paroxysmal nocturnal dyspnoea
Palpitations - due to increased force of contraction and ectopics
What management is used for aortic regurgitation?
IE prophylaxis
Medical - vasodilators
Serial echo to monitor progression
What are the indications for surgery in aortic regurgitation?
Any symptoms at rest or exercise
Asymptomatic treatment if EF drops below 50% or LV becomes dilated
What is the definition of mitral stenosis?
Obstruction of LV inflow that prevents proper filling during diastole
What is the predominant cause of mitral stenosis?
Rheumatic carditis
What are some other rarer causes of mitral stenosis?
Infective endocarditis
Mitral annular calcification
What is the pathophysiology of mitral stenosis?
LA dilation > pulmonary congestion (reduced emptying) > progressive dyspnoea (worse with exercise, fever, tachycardia and pregnancy)
Increased transmitral pressures > LA enlargement and AF
Haemoptysis due to rupture of bronchial vessels due to elevated pulmonary pressure
What causes mortality in mitral stenosis?
Progressive pulmonary congestion, infection and thromboembolism
What are the physical signs of mitral stenosis?
Prominent ‘A’ wave in jugular venous pulsations - due to pulmonary hypertension and RVH
Signs of right-sided HF in advanced disease
Redness on face
What heart sounds would be heart in mitral stenosis?
Diastolic murmur
Loud opening S1 snap
What evaluations are done in mitral stenosis and what would be seen?
ECG - AF and LA enlargement
CXR - LA enlargement and pulmonary congestion; occasionally calcified MV
Echo - gold standard for diagnosis; assess mitral valve mobility, gradient and mitral valve area
What medical management is used for mitral stenosis?
Beta-blockers, CCBs and digoxin prolong diastole for improved diastolic filling
Diuretics for fluid overload
IE prophylaxis
What surgical treatment can be carried out for mitral stenosis?
Percutaneous mitral balloon valvotomy
What are the indications for valve replacement in mitral stenosis?
Any symptomatic patient
Asymptomatic moderate or severe MS with pliable valve suitable for PMBV
