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Cardiovascular system 16/17 > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What are the most common types of valvular heart disease?

A

Acquired left sided valvular lesions

  • aortic stenosis
  • mitral stenosis
  • aortic regurgitation
  • mitral regurgitation
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2
Q

When can some murmurs be normal?

A

In times of hyperdynamic circulation e.g. pregnancy, anaemia, thyrotoxicosis (hyperthyroidism)

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3
Q

What are the characteristics of benign murmurs?

A

Short
Systolic
May vary with posture
Not associated with heart disease

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4
Q

How do you assess the severity of murmurs?

A

Doppler echocardiography

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5
Q

Where is the mitral valve found?

A

Between left atrium and left ventricle

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6
Q

Describe the leaflets of the mitral valve

A

Anterior leaflet - bigger

Posterior leaflet - thinner and more semilunar

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7
Q

What is the mitral annulus?

A

Fibrous saddle shaped discontinuous ring around valve, aids closure of the valve in systole.

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8
Q

What can lead to functional mitral regurgitation?

A

Mitral annular dilatation

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9
Q

What is the most common cause of mitral stenosis?

A

Rheumatic fever

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10
Q

What are the typical pathological features of rheumatic MS?

A

Thickening and calcification of leaflets
Fusion of commisures
Shortening of chordae tendinae

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11
Q

What are some rarer causes of MS?

A

Congenital stenosis
Calcification with age
Endocarditis
Systemic conditions e.g. SLE, RA

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12
Q

What are some clinical signs of MS?

A 
Pulmonary oedema
Dyspnoea
Other signs of CHF
Pulmonary hypertension
RVH
Atrial fibrillation
Thrombus in LA -> systemic emboli
Haemoptysis
Systemic embolism 
IE
Chest pain
Hoarseness (compression of left recurrent laryngeal nerve by dilated pulmonary artery or LA)
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13
Q

What is the normal CSA of the mitral valve?

A

4-6cm2

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14
Q

At what CSA of the mitral valve does it become significantly haemodynamically impaired?

A

<2cm2

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15
Q

How do people with MS present?

A

Dyspnoea
Reduced exercise capacity

In more severe cases:
Orthopnea
Paroxysmal nocturnal dyspnoea

In very severe:
Increased JVP 
Hepatomegaly
Ascites
Peripheral oedema
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16
Q

What conditions can increase HR and therefore exacerbate MS?

A 
Fever
Anaemia
Hyperthyroidism
Pregnancy
Arrhythmias
Exercise
Stress
Sex
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17
Q

What are some clinical signs of MS?

A

Mitral facies or malar flush (cyanotic or dusty pink)
Prominent A wave in JVP
Tapping apex beat and diastolic thrill

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18
Q

What valve disease causes a mid diastolic murmur?

A

Mitral stenosis

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19
Q

What investigations would be carried out for MS?

A

ECG-catheterisation
CXR
ECHO

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20
Q

What would be seen on an ECG that indicates MS?

A

AF

Bifid P wave (P mitrale)

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21
Q

What is P mitrale?

A

Bifid P wave seen in MS

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22
Q

What would CXR show you in MS?

A

Calcified valve
Enlarged left atrium
Pulmonary oedema in severe cases

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23
Q

What would ECHO show you in MS?

A

Thickening and scarring of valve, sometimes fusion

24
Q

When is mechanical relief indicated for MS?

A

Symptoms are severe

If pulmonary hypertension develops

25
Q

What can cause mitral regurgitation?

A 
Structural abnormalities of mitral annulus, valve leaflets, chordae tendinae or the papillary muscles 
Myxomatous degeneration of valve
IE
RF
Hypertrophic obstructive cardiomyopathy
Calcification with age
Primary rupture of chordae tendinae
IHD
LV enlargement 
Degeneration of chords with age
26
Q

What diseases did the weight loss drugs fenfluramine and phentermine cause?

A

Thick plaques on valves, causing:
MR
AR
Tricuspid valve disease

27
Q

What are the symptoms of MR?

A 
Pulmonary oedema
Cardiogenic shock
Weakness and fatigue
Dyspnoea
Paroxysmal nocturnal dyspnoea
Right heart failure if severe
IE
28
Q

What are the clinical signs of MR?

A

Normal or reduced pulse in HF
Prominent JVP if RHF present
Brisk hyperdynamic laterally placed apex beat
Right ventricular heave
Reduced S1, pan systolic murmur, can hear S3 due to rapid filling of LV

29
Q

What are the two diastolic murmurs?

A

Mitral stenosis

Aortic regurgitation

30
Q

What are the two systolic murmurs?

A

Aortic stenosis

Mitral regurgitation

31
Q

What murmur is associated with mitral regurgitation?

A

High pitched pan-systolic murmur that extends to the left axilla

32
Q

What investigations are used for MR?

A

CXR - cardiomegaly, LA enlargement, calcification of annulus

ECG - atrial enlargement, LV enlargement, RV hypertrophy

Cardiac catheterisation

ECHO - can establish aetiology of MR, and haemodynamic consequences, LV dimensions

Doppler ultrasonography - measure severity of MR

33
Q

Why might ECG and CXR be normal with MR?

A

Signs don’t appear until late stage disease

34
Q

Where is the aortic valve found?

A

Between left ventricle and aorta

35
Q

What % of the population is found to have a congenitally acquired bicuspid aortic valve (meant to have 3 leaflets)?

A

1-2%

36
Q

What are the 3 leaflets of the aortic valve?

A

Left
Right
Posterior

37
Q

Normal CSA of aortic valve =

A

3-4cm2

38
Q

What are the 3 main causes of aortic stenosis?

A

Degeneration and calcification with age
Calcification of congenital bicuspid valve
Rheumatic heart disease

39
Q

What is more likely to cause AS in younger patients?

A

Calcification of congenital bicuspid valve

40
Q

What is more likely to cause AS in older patients?

A

Degeneration and calcification with age

41
Q

At what CSA is AS diagnosed?

A

1.5-2cm2

42
Q

Describe the pathphysiology of AS

A

Causes increased LV pressure, leading to concentric hypertrophy of the left ventricle, reducing the compliance of the LV. Eventually leads to MI and angina, arrhythmias and LVF

43
Q

What are the 3 major manifestations of AS?

A

Angina
Exertional syncope
Congestive heart failure

44
Q

How is the severity of AS decided?

A 
Mild = <2cm2
Moderate = 1-1.5cm2
Severe = <1cm2
45
Q

What are the symptoms of AS?

A 
Chest pain/angina
Syncope on exertion
Breathlessness on exertion 
Symptoms of HF
Ventricular arrhythmias (may cause sudden death)
46
Q

What are the clinical signs of AS?

A 
Slowly rising carotid pulse
Prominent JVP in RH failure
Thrusting apex beat
RV heave
Harsh high pitched systolic murmur, which radiates to the carotids, nay be preceded by ejection click
Normal S1, diminished S2 by murmur
47
Q

What investigations are carried out for AS?

A 
ECG - LVH
CXR - calcification, post stenotic dilation of aorta
Cardiac catheterisation - Excludes CAD
ECHO - LVH thickness, AV motility
Doppler - assesses pressure gradient
48
Q

What is used to monitor progression of AS every 1-2 years following diagnosis?

A

ECHO

49
Q

What causes aortic regurgitation?

A

Dilation of aortic root or valve ring
Disease of the valve leaflets
Rheumatic fever
Infective endocarditis

50
Q

What can cause dilation of the aortic root or valve ring?

A 
Dilated aorta - Marfans, aneurysms, high BP
Connective tissue disorders
Aortic dissection 
Syphilis
Annuloaortic ectasia
51
Q

What diseases of the aortic valve leaflets can cause AR?

A

Congenital bicuspid aortic valve
Rheumatic heart disease
Endocarditis
Myxomatous degeneration

52
Q

When is blood regurgitated back into the LV from the aorta in AR?

A

Diastole

53
Q

What factors affect the severity of AR?

A

Size of regurgitant orifice
Pressure gradient across AV during systole
Duration of systole

54
Q

What are the symptoms of AR?

A 
Dyspnoea 
Pulmonary oedema
Symptoms of LV HF in late disease
Exertional breathlessness
Orthopnoea
Fatigue
55
Q

What murmur causes a collapsing pulse?

A

Aortic regurgitation

Also called water hammer or Corrigans sign

56
Q

What are the clinical signs for AR?

A

Collapsing pulse/water hammer/Corrigans
Laterally displaced apex beat, thrusting
Normal S1 and S2
Diastolic murmur, descrescendro, soft

57
Q

What investigations are used for AR?

A

ECG - ST/Tchanges shows evidence of LVH

CXR - cardiomegaly, dilation of aorta

Cardiac catheterisation - could assess severity

ECHO + doppler - examines severity and AV cusp anatomy, LV function, dilation, hypertrophy

Cardiovascular system 16/17 (40 decks)

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