Valvular Heart Disease

Question 1

What are the main types of valvular heart disease?

Answer 1

Aortic Stenosis
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation

Question 2

What can cause mitral stenosis?

Answer 2

Rheumatic heart disease
Congenital mitral stenosis
Systemic conditions e.g. systemic lupus erythematous, rheumatoid arthrtitis

Question 3

What is the criteria for mitral stenosis? And what are the physiological repercussions?

Answer 3

Mitral valve orifice <2cm squared

AV pressure gradient increases
LA pressure increases
Pulmonary venous and capillary venous pressure increases
Pulmonary VR increases
Pulmonary artery pressure increases and pulmonary hypertension develops
RH dilatation with tricuspid and pulmonary regurgitation

Question 4

What are some clinical manifestation/symptoms of mitral stenosis?

Answer 4

SOB - mild exertional to pulmonary oedema
Haemoptysis due to rupture of thin-walled veins
Systemic embolisation - LA and LA appendage enlargement
Infective endocarditis
Chest pain
Hoarseness due to compression of L recurrent laryngeal nerve

Question 5

Clinical signs of mitral stenosis?

Answer 5

Mitral facies - rosy cheeks, bluish tinge due to cyanosis
Normal pulse
Prominent A wave in JVP
Tapping apex beat and diastolic thrill
RV heave
Noise bewteen S2 and S1

Question 6

What investigations might be done in suspected mitral stenosis?

Answer 6

ECG
Cardiac catheterisation
CXR for LA enlargement
Echo - showing thickening and scarring of valve leaflets, fusion of the commissures
Cardiac MRI

Question 7

What are the treatments in mitral stenosis?

Answer 7

Diuretics and restricted sodium intake
Ventricular rate control if AF
Valvotomy (balloon vs surgical)
Valve replacement

Question 8

What are some causes of mitral regurgitation?

Answer 8

Rheumatic heart disease
Mitral valve prolapse
Infective endocarditis
Degenerative
Functional mitral regurgitation due to LV and annular dilatation

Question 9

What is the pathophysiology of mitral regurgitation?

Answer 9

Effective regurgitant orifice not fixed

• preload
• afterload
• LV contractility

Leads to LV compensation

• acute - end-systolic pressure and ESV decreased, wall tension decreased
• chronic = EDV increased and ESV back to normal, eccentric LVH develops

LA compliance

• reduced - marked pressure rise, thickening of atrial myocardium
• increased - marked volume enlargement
• combination?

Question 10

Symptoms of mitral regurgitation?

Answer 10

Acute
- SOB from pulmonary oedema or cardiogenic shock

Chronic

• fatigue, exhaustion (low cardiac output), RHF
• SOB or palpitations due to AF

Question 11

Signs of mitral regurgitation?

Answer 11

Pulse normal or reduced if HF
JVP prominent if RHF present
Brisk and hyperdynamic apex beat
RV heave
Auscultation
- reduced S1, holosystolic, blowing, loud at apex, radiation to axilla

Question 12

Investigations done in suspected mitral regurgitation?

Answer 12

ECG for LA enlargement (P>0.12s, tall)
- RVH prominent R wave in precordial leads

Echo

• LV dimensions
• cause of MR (leaflet dysfunction, chordae/pap muscle, annular disease
• severity

Question 13

Treatment for mitral regurgitation?

Answer 13

Acute
- preload and afterload reduction may be lifesaving (sodium nitroprusside, dobutamine, intra-aortic balloon pump)

Chronic
- lack of evidence that any therapy beneficial

Mitral valve repair or replacement

Question 14

What are the causes of aortic stenosis?

Answer 14

Degenerative - Linked to atherosclerosis, resulting in thickening and calcification of cusps

Rheumatic - ahdesion, fusion of the commissures and retraction and stiffening of free cusp margins

Question 15

What are the physiological repercussions of aortic stenosis?

Answer 15

Increased LV systolic pressure
Severe concentric hypertrophy, and LV mass
Increased LV end-diastolic pressure
Increased myocardial O2 consumption
- myocardial ischaemia
LVF

Question 16

What are the symptoms of aortic stenosis?

Answer 16

Long asymptomatic phase
Cardinal symptoms
- Chest pain (angina)
- Syncope/dizziness
- SOB on exertion
- Heart failure

Question 17

What might you find on examination in aortic stenosis?

Answer 17

Small pulse volume, slowly rising
Prominent JVP if RHF present
Low BP
Vigorous and sustained apex beat
RV heave
Auscultation
- late peaking
- loud at base
- harsh
- radiates to carotids

Question 18

What investigations might be done in suspected aortic stenosis?

Answer 18

ECG
- LVH, ST/T changes (LV strain)

CXR - calcification of valve
Catheterisation (obsolete)

Echo - demonstrates mobility, LV function, hypertrophy
- doppler haemodynamic assessment of pressure gradient

Cardiac MRI

Question 19

What is the treatment for aortic stenosis?

Answer 19

Limited to those who develop heart failure

Aortic valve replacement/repair

Question 20

What might cause aortic regurgitation?

Answer 20

Aortic disroder

• Dilated aorta (Marfan’s, hypertension)
• Connective tissue disorders

Leaflet disorder

• bicuspid instead of tri
• rheumatic heart disease
• endocarditis
• myxomatous degeneration

LV accomodates both SV and regurgitant volume
> increased LV end-diastolic pressure and LV systolic pressure
> LVH and LV dilatation
> increased myocardial O2 demand
> ischaemia
> LVF

Question 21

Symptoms of aortic regurgitation?

Answer 21

Chronic

• long asymptomatic
• exertional SOB

Acute
- poorly tolerated as wall tension cannot acutely adapt

Question 22

What might be found on examination in aortic regurgitation?

Answer 22

ECG - ST/T changes (LV strain)
CXR - cardiomegaly (chronic)
Cardiac catheterisation (obsolete)

Echo - demonstrates cusp thickening, prolapse, number, vegetation

• LV function, dilatation and hypertrophy
• doppler haemodynamic assessment

Cardiac MRI

Question 23

What treatment might be given in aortic regurgitation?

Answer 23

Vasodilator therapy shown to delay the timing for surgical intervention

Aortic valve replacement/repair