Valvular Heart Disease

Question 1

Common heart valve lesions

Answer 1

Mitral stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation

Question 2

Symptoms of mitral stenosis

Answer 2

Dyspnoea
Haemoptysis
Systemic embolization
Infective endocarditis
Chest pain
Hoarseness
Stroke

Question 3

Signs of mitral stenosis

Answer 3

Mitral facies
Normal pulse
JVP = prominent a wave
Tapping apex beat and diastolic thrill
RV heave
Auscultation: discreet murmur (blow) in diastole. Systole unaffected

Question 4

Symptoms of mitral regurgitation

Answer 4

Acute MR:
- Dyspnoea; Pulmonary oedema, cardiogenic shock
- Emergency
Chronic MR:
- Fatigue/exhaustion (low CO)
- Right heart failure
- Dyspnoea or palpitations due to AF

Question 5

Signs of mitral regurgitation

Answer 5

Pulse: normal or REDUCED in HF
JVP: Prominent if RH failure present
Brisk and hyperdynamic apex beat
RV heave
Auscultation: reduced S1. Split S2. Loud at apex and radiating to the axilla. Systolic murmur so loud. Best heard at the apex

Question 6

Symptoms of aortic stenosis

Answer 6

Long asymptomatic phase
Chest pain (angina)
Syncope/dizziness (exertional pre-syncope)
Breathlessness on exertion
Heart failure

Question 7

Signs of aortic stenosis

Answer 7

Pulse: small volume and slow rising
JVP: prominent if RH failure present
Low BP
Vigorous and sustained apex beat
RV heave
Auscultation: normal S1, S2 less audible. Late peaking, harsh, loud at base, radiating to carotids

Question 8

Symptoms of aortic regurgitation

Answer 8

Acute AR:
- medical emergency: rush to surgery
Chronic AR:
- Long asymptomatic phase
- Exertional breathlessness

Question 9

Signs of aortic regurgitation

Answer 9

Pulse: large volume and collapsing
Wide pulse pressure
Hyperdynamic as volume overloaded heart, displaced apex beat
Auscultation: normal S1 (systole completely clear), Normal S2. Early diastolic, decrescendo, soft murmur. Patients have to be sat up and slightly leaning forward to hear it, in perfect silence

Question 10

Mitral valve stenosis investigations

Answer 10

ECG (LA enlargement = larger P wave)
Cardiac catheterisation
CXR (for LA enlargement/ PO)
ECHO (fusion of commissures/thickening/scarring of leaflets)
Cardiac MRI

Question 11

Aortic stenosis investigations

Answer 11

ECG (LVH voltage criteria - ST/T changes (LV strain))
CXR: calcification of AV
Cardiac catheterisation: obsolete
ECHO: demonstrates AV cusp mobility. LV function and hypertrophy
CMRI

Question 12

Mitral regurgitation investigations

Answer 12

ECG (LA enlargement = tall P wave, RVH (prominent R wave)
CXR: cardiomegaly, LA enlargement, calcification of mitral annulus
Cardiac catheterisation; obsolete
ECHO

Question 13

Aortic Regurgitation investigations

Answer 13

ECG: ST/T changes (LV strain), LAD
CXR: cardiomegaly in chronic AR
Cardiac catheterisation: obsolete 
ECHO: demonstrates AV cusp anatomy. LV function, dilation and hypertrophy. Doppler haemodynamic assessment of regurgitant flow
CMRI

Question 14

Treatment for mitral stenosis

Answer 14

Diuretics and restriction of Na intake
If in AF; sinus rhythm restoration or ventricular rate control
Anticoagulation
Watchful waiting
Pressure tissue for as long as possible without compromising well-being
Invertational treatment is valvotomy (balloon vs. surgical). Mitral valve replacement

Question 15

Treatment for mitral regurgitation

Answer 15

Acute MR:
- preload and afterload reduction. May be life saving. Diuretics, sodium nitroprusside, dobutamine, IABP)
Chronic MR:
- No therapy benefit for haemodynamic improvement, LV function and preservation
Interventional treatment:
- Mitral valve apparatus repair
- Mitral valve replacement

Question 16

Treatment for aortic stenosis

Answer 16

Limited to those who develop heart failure

Interventional treatment: aortic valve replacement or repair

Question 17

Treatment for aortic regurgitation

Answer 17

Vasodilator therapy: shown to delay time for surgical intervention
Interventional treatment: aortic valve replacement/repair