Valvular Heart Disease Flashcards
What are three common aetiologies of mitral stenosis?
RHEUMATIC FEVER, RHEUMATIC FEVER, RHEUMATIC FEVER
Rarer causes - mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
What are the features of mitral stenosis?
Mid-late diastolic murmur (best heard in expiration) Loud S1, opening snap Low volume pulse Malar flush AF
What are features of severe MS?
Length of murmur increases
Opening snap becomes closer to S2
What might you see on CXR in MS?
Left atrial enlargement
What is mitral regurgitation?
When blood leaks back through the mitral valve on systole
What is the most common valve disease?
Aortic stenosis
What is the second most common valve disease?
Mitral regurg
Where is the mitral valve located?
Between the L atrium and ventricle
What can MR lead to?
Less efficient heart as less blood is pumped through the body with each contraction
NOTE: it is common in otherwise healthy patients to a trivial degree and does not req. treatment
As the degree of regurg in MR becomes more severe what happens?
Bodys O2 demands may exceed what the heart can supply –> myocardium thickens
Can lead to patient becoming fatigued as thicker myometrium is less efficient and –> irreversible heart failure
What are RFs for mitral regurgitation?
Female sex Low BMI Age Renal dysfunction Prior MI Prior mitral stenosis or valve prolpase Collagen disorders, e.g. Marfans, EDS
How can rheumatic fever cause mitral regurg?
Causes inflammation of the valves
How can MR occur post-CAD/MI?
If papillary muscles/chordae tendinae are affected by cardiac insult, mitral valve disease may ensue
What is mitral valve prolapse?
Leaflets of mitral valve are deformed so valve doesn’t close properly and allows for backflow
How can IE lead to mitral regurg?
Vegetations colonising the valve prevent it closing properly
What are causes of mitral regurg?
CAD/MI Mitral valve prolapse IE Rheumatic fever Congenital
What are symptoms of MR?
Usually asymptomatic
May have symptoms due to failure of left ventricle, arrhythmias, pulmonary hypertension (SoB, fatigue, oedema)
What are signs of MR?
Pansystolic blowing murmur
Heard best at apex and radiates to axila
S1 quiet (due to incomplete closure of valve)
Severe MR may cause widely split S2
What might you see on ECG with MR?
Broad P wave (indicative of atrial enlargement)
What might you see on CXR in MR?
Cardiomegaly (with enlarged left atrium and ventricle)
What investigation is crucial to the diagnosis of MR?
Echocardiography
How is MR managed?
Medical mx in acute cases - nitrates, diuretics, positive inotropes, intra-aortic balloon pump
If in HF - ACEi + beta blockers + spironolactone
Acute, severe regurg –> surgery (repair > replacement in degenerative regurg)
If cannot repair - mechanical/pig valve
What things is mitral valve prolapse associated with?
PDA, ASD Cardiomyopathy Turner's Marfan's, Fragile X Osteogenesis imperfecta Pseudoxanthoma elasticum Wolf-Parkinson White syndrome Long QT syndrome EDS PCKD
What are features of mitral valve prolapse?
Atypical chest pain/palpitations
Mid-systolic click (occurs later if patient squatting)
Late systolic murmur (longer if pt standing)
What are complications of mitral valve prolapse?
MR
Arrhythmias (incl. long QT)
Emboli
Sudden death
What is responsible for the first heart sound?
Closure of the mitral and tricuspid valves
What is responsible for the second heart sound?
Closure of aortic and pulmonary valves
What does splitting of S2 during inspiration indicate?
This is normal
When might you get a soft S1?
MR
When might you get a loud S1?
MS
When might you get a soft S1?
Aortic stenosis
What causes a third heart sound?
Diastolic filling of the ventricle
Considered normal up to 30y (up to 50y in women)
Heart in LV failure, pericarditis, MR
When might a fourth heart sound be heard?
AS, HOCM, HTN
What causes a fourth heart sound?
Atrial contraction against a stiff ventricle
What does a fourth heart sound coincide with on ECG?
The P wave
Where should you auscultate to hear the pulmonary valve?
L 2nd intercostal space, upper border of sternum
Where should you auscultate to hear the aortic valve?
R 2nd intercostal space, upper border of sternum
Where should you auscultate to hear the mitral valve?
Left fifth intercostal space, medial to midclav line
Where should you auscultate to hear the tricuspid valve?
Left 4th intercostal space, lower left sternal border
What part of the stethoscope is best at picking up high pitched noises?
Diaphragm
What part of the stethoscope is best at picking up low pitched noises?
Bell
What clinical features may be present in aortic stenosis?
Chest pain
SoB
Syncope
What murmur is classically seen in aortic stenosis?
Ejection systolic murmur
What decreases the murmur in aortic stenosis?
Valsalva manoeuvre
What are features of severe aortic stenosis?
Narrow pulse pressure Slow rising pulse Delayed ESM Soft/absent S2 S4 Thrill LV hypertrophy/failure
What are causes of aortic stenosis?
Degenerative calcification (most common in pts >65)
Bicuspid aortic valve (most common in <65)
William’s syndrome (supravalvular aortic stenosis)
Post-rheumatic disease
Subvalvular - HOCM
How do you manage asymptomatic aortic stenosis?
Observe pt
Unless valvular gradient >40mmHg + features like LV systolic dysfunction
How do you manage symptomatic aortic stenosis?
Valve replacement
What treatment may be given to those with critical aortic stenosis who are not fit for valve replacement?
Balloon valvuloplasty
What is the murmur of AR like?
Early diastolic
What increases the intensity of the AR murmur?
Handgrip manoeuvre
What are other features of AR?
Collapsing pulse Wide pulse pressure Quincke sign (nailbed pulsation) De Musset's sign (head bobbing) Mid-diastolic Austin-Flint murmur in severe AR
What causes an Austin flint murmur?
Partial closure of the anterior mitral valve cusps caused by the regurg streams
What are causes of AR?
Valve dx: Rheumatic fever IE Connective tissue dx, e.g. RA/SLE Bicuspid aortic valve
Aortic root dx: Aortic dissection Spondyloarthopathies, e.g. AS Syphillis Marfans, EDS
What are signs of tricuspid regurg?
Pansystolic murmur
Promiment/giant V waves on JVP
Pulsatile hepatomegaly
Left parasternal heave
What are causes of TR?
R ventricular infarction (damage to papillary muscles)
Pulmonary HTN (e.g. COPD)
Rheumatic heart disease
IE
Ebstein’s anomaly (leaflets in ventricle)
Carcinoid syndrome
How does pulmonary hypertension cause tricuspid regurg?
It causes increased right ventricular pressure which dilates the tricuspid valve
What most commonly causes tricsupid valve stenosis?
Rheumatic fever (inflammation –> valve fuses)
What murmur do you get with tricuspid stenosis?
Mid-diastolic
What conditions cause an ejection systolic murmur?
Aortic stenosis
Pulmonary stenosis
ASD, ToF
What conditions cause a holosystolic murmur?
Mitral/tricuspid regurg (high pitched and blowing)
VSD (harsh in nature)
What conditions cause a late systolic murmur?
Mitral valve prolapse
Coarcation of aorta
What conditions cause an early diastolic murmur?
AR (high pitched, blowing)
Graham-Steel (pulmonary regurg, high pitched and blowing)
What conditions cause a mid-late diastolic murmur?
MS (rumbling)
Austin-Flint (severe AR, rumbling)
What condition causes a continuous machine like murmur?
PDA
