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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
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 ```
26
What diseases did the weight loss drugs fenfluramine and phentermine cause?
Thick plaques on valves, causing: MR AR Tricuspid valve disease
27
What are the symptoms of MR?
``` Pulmonary oedema Cardiogenic shock Weakness and fatigue Dyspnoea Paroxysmal nocturnal dyspnoea Right heart failure if severe IE ```
28
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
29
What are the two diastolic murmurs?
Mitral stenosis | Aortic regurgitation
30
What are the two systolic murmurs?
Aortic stenosis | Mitral regurgitation
31
What murmur is associated with mitral regurgitation?
High pitched pan-systolic murmur that extends to the left axilla
32
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
33
Why might ECG and CXR be normal with MR?
Signs don't appear until late stage disease
34
Where is the aortic valve found?
Between left ventricle and aorta
35
What % of the population is found to have a congenitally acquired bicuspid aortic valve (meant to have 3 leaflets)?
1-2%
36
What are the 3 leaflets of the aortic valve?
Left Right Posterior
37
Normal CSA of aortic valve =
3-4cm2
38
What are the 3 main causes of aortic stenosis?
Degeneration and calcification with age Calcification of congenital bicuspid valve Rheumatic heart disease
39
What is more likely to cause AS in younger patients?
Calcification of congenital bicuspid valve
40
What is more likely to cause AS in older patients?
Degeneration and calcification with age
41
At what CSA is AS diagnosed?
1.5-2cm2
42
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
43
What are the 3 major manifestations of AS?
Angina Exertional syncope Congestive heart failure
44
How is the severity of AS decided?
``` Mild = <2cm2 Moderate = 1-1.5cm2 Severe = <1cm2 ```
45
What are the symptoms of AS?
``` Chest pain/angina Syncope on exertion Breathlessness on exertion Symptoms of HF Ventricular arrhythmias (may cause sudden death) ```
46
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 ```
47
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 ```
48
What is used to monitor progression of AS every 1-2 years following diagnosis?
ECHO
49
What causes aortic regurgitation?
Dilation of aortic root or valve ring Disease of the valve leaflets Rheumatic fever Infective endocarditis
50
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 ```
51
What diseases of the aortic valve leaflets can cause AR?
Congenital bicuspid aortic valve Rheumatic heart disease Endocarditis Myxomatous degeneration
52
When is blood regurgitated back into the LV from the aorta in AR?
Diastole
53
What factors affect the severity of AR?
Size of regurgitant orifice Pressure gradient across AV during systole Duration of systole
54
What are the symptoms of AR?
``` Dyspnoea Pulmonary oedema Symptoms of LV HF in late disease Exertional breathlessness Orthopnoea Fatigue ```
55
What murmur causes a collapsing pulse?
Aortic regurgitation Also called water hammer or Corrigans sign
56
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
57
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

Cardiovascular system 16/17 (40 decks)

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