Valvular heart disease Flashcards
What are the most common types of valvular heart disease?
Acquired left sided valvular lesions
- aortic stenosis
- mitral stenosis
- aortic regurgitation
- mitral regurgitation
When can some murmurs be normal?
In times of hyperdynamic circulation e.g. pregnancy, anaemia, thyrotoxicosis (hyperthyroidism)
What are the characteristics of benign murmurs?
Short
Systolic
May vary with posture
Not associated with heart disease
How do you assess the severity of murmurs?
Doppler echocardiography
Where is the mitral valve found?
Between left atrium and left ventricle
Describe the leaflets of the mitral valve
Anterior leaflet - bigger
Posterior leaflet - thinner and more semilunar
What is the mitral annulus?
Fibrous saddle shaped discontinuous ring around valve, aids closure of the valve in systole.
What can lead to functional mitral regurgitation?
Mitral annular dilatation
What is the most common cause of mitral stenosis?
Rheumatic fever
What are the typical pathological features of rheumatic MS?
Thickening and calcification of leaflets
Fusion of commisures
Shortening of chordae tendinae
What are some rarer causes of MS?
Congenital stenosis
Calcification with age
Endocarditis
Systemic conditions e.g. SLE, RA
What are some clinical signs of MS?
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)
What is the normal CSA of the mitral valve?
4-6cm2
At what CSA of the mitral valve does it become significantly haemodynamically impaired?
<2cm2
How do people with MS present?
Dyspnoea
Reduced exercise capacity
In more severe cases:
Orthopnea
Paroxysmal nocturnal dyspnoea
In very severe: Increased JVP Hepatomegaly Ascites Peripheral oedema
What conditions can increase HR and therefore exacerbate MS?
Fever Anaemia Hyperthyroidism Pregnancy Arrhythmias Exercise Stress Sex
What are some clinical signs of MS?
Mitral facies or malar flush (cyanotic or dusty pink)
Prominent A wave in JVP
Tapping apex beat and diastolic thrill
What valve disease causes a mid diastolic murmur?
Mitral stenosis
What investigations would be carried out for MS?
ECG-catheterisation
CXR
ECHO
What would be seen on an ECG that indicates MS?
AF
Bifid P wave (P mitrale)
What is P mitrale?
Bifid P wave seen in MS
What would CXR show you in MS?
Calcified valve
Enlarged left atrium
Pulmonary oedema in severe cases
What would ECHO show you in MS?
Thickening and scarring of valve, sometimes fusion
When is mechanical relief indicated for MS?
Symptoms are severe
If pulmonary hypertension develops
What can cause mitral regurgitation?
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
What diseases did the weight loss drugs fenfluramine and phentermine cause?
Thick plaques on valves, causing:
MR
AR
Tricuspid valve disease
What are the symptoms of MR?
Pulmonary oedema Cardiogenic shock Weakness and fatigue Dyspnoea Paroxysmal nocturnal dyspnoea Right heart failure if severe IE
What are the clinical signs of MR?
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
What are the two diastolic murmurs?
Mitral stenosis
Aortic regurgitation
What are the two systolic murmurs?
Aortic stenosis
Mitral regurgitation
What murmur is associated with mitral regurgitation?
High pitched pan-systolic murmur that extends to the left axilla
What investigations are used for MR?
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
Why might ECG and CXR be normal with MR?
Signs don’t appear until late stage disease
Where is the aortic valve found?
Between left ventricle and aorta
What % of the population is found to have a congenitally acquired bicuspid aortic valve (meant to have 3 leaflets)?
1-2%
What are the 3 leaflets of the aortic valve?
Left
Right
Posterior
Normal CSA of aortic valve =
3-4cm2
What are the 3 main causes of aortic stenosis?
Degeneration and calcification with age
Calcification of congenital bicuspid valve
Rheumatic heart disease
What is more likely to cause AS in younger patients?
Calcification of congenital bicuspid valve
What is more likely to cause AS in older patients?
Degeneration and calcification with age
At what CSA is AS diagnosed?
1.5-2cm2
Describe the pathphysiology of AS
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
What are the 3 major manifestations of AS?
Angina
Exertional syncope
Congestive heart failure
How is the severity of AS decided?
Mild = <2cm2 Moderate = 1-1.5cm2 Severe = <1cm2
What are the symptoms of AS?
Chest pain/angina Syncope on exertion Breathlessness on exertion Symptoms of HF Ventricular arrhythmias (may cause sudden death)
What are the clinical signs of AS?
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
What investigations are carried out for AS?
ECG - LVH CXR - calcification, post stenotic dilation of aorta Cardiac catheterisation - Excludes CAD ECHO - LVH thickness, AV motility Doppler - assesses pressure gradient
What is used to monitor progression of AS every 1-2 years following diagnosis?
ECHO
What causes aortic regurgitation?
Dilation of aortic root or valve ring
Disease of the valve leaflets
Rheumatic fever
Infective endocarditis
What can cause dilation of the aortic root or valve ring?
Dilated aorta - Marfans, aneurysms, high BP Connective tissue disorders Aortic dissection Syphilis Annuloaortic ectasia
What diseases of the aortic valve leaflets can cause AR?
Congenital bicuspid aortic valve
Rheumatic heart disease
Endocarditis
Myxomatous degeneration
When is blood regurgitated back into the LV from the aorta in AR?
Diastole
What factors affect the severity of AR?
Size of regurgitant orifice
Pressure gradient across AV during systole
Duration of systole
What are the symptoms of AR?
Dyspnoea Pulmonary oedema Symptoms of LV HF in late disease Exertional breathlessness Orthopnoea Fatigue
What murmur causes a collapsing pulse?
Aortic regurgitation
Also called water hammer or Corrigans sign
What are the clinical signs for AR?
Collapsing pulse/water hammer/Corrigans
Laterally displaced apex beat, thrusting
Normal S1 and S2
Diastolic murmur, descrescendro, soft
What investigations are used for AR?
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
