Valvular heart disease

Question 1

Mitral Stenosis

Describe the murmur - sound and quality

What signs other than murmur?

What causes?

How appear on CXR?

How lead to RHF?

Answer 1

Mitral Stenosis

1. Mid-diastolic, with loud S1 (opening snap) low flow, low pressure.
2. Malar flush, AF, ? left parasternal heave (hypertrophied RV due to PulHTN); tapping, non-displaced apex
3. Rheumatic heart disease, SLE
4. Prominent LA
5. Increased filling pressure of LV, increases back pressure on LA, increasing pulmonary circulation pressure. This leads to RV hypertrophy, trciuspid regurgitation and eventual RHF.

Question 2

Mitral Regurgitation

Describe the murmur - sound and quality

What signs other than murmur?

What causes?

Answer 2

Mitral Regurg

Pan-systolic murmur, with blurring into S2. Volume overload, leading to ventricular dilatation. Much louder at apex, with radiation into axilla

APex displacement, cardiomegaly

Primary - MI, IHD, IE, Papillary muscle rupture, CTD

Secondary - e.g. MArfan’s or LV dilatation (i.e. functioning but due to dilatation of area, becomes incompetent)

Question 3

Aortic Regurgitation

Describe the murmur - sound and quality

What signs other than murmur?

What causes?

Answer 3

Aortic Regurgitation

Diastolic - after S2

COllapsing pulse (Corrigan’s), collapsing pulse in neck (Corrigan’s sign); Volume overload therfore displaced apex

Rheumatic HD, IE, Degenerative (totally calcified, won’t be able to close at all), Marfan’s (aortic root), Syphillis

Question 4

Aortic Stenosis

Describe murmur

Signs

What suggests poor prognosis?

Causes?

How differs from aortic sclerosis?

Answer 4

Aortic Stenosis

1. Harsh ejection systolic with radiation into carotids
2. Slow-rising pulse, more palpable apex because pressure overload
3. Syncope, Chest pain (IHD), Breahtlessness (worst)
4. Degenerative calcificaition over time, bicuspid valve, RHD
5. Sclerosis is thickening of valve leaflets, with no carotid radiation and no pressure overload therefore no LVH

Question 5

Causes of Pressure overload?

Causes of volume overload?

Answer 5

HTN, AS, LVOTO (i.e. HOCM), Coarctation

AR, MR, ? myopathy

Question 6

What treatment options are available in valvular disease

Answer 6

NB - will need bypass during operation, so quite serious; repair concurrent IHD as needed as well

Medical - bblocker, diuretics (reduce preload); treat underlying condition. repair is needed before symptomatic

Repair - mainly in mitral valve disease

Balloon valvuloplasty

Replacement - bio or mechanical prosthesis - mainly aortic

TAVI - trnascatheter aortic valve implantation - closed repair, much safer if operative risk

Question 7

What mechanical valves are available?

What are benefits and issues with bio/mechacnical valve replacment?

Complications of valve replacement?

Answer 7

Ball and cage or bi/tri-leaflet

Mechanical - durable, noisy, lifelong anticoagulation (INR 3-4)

Bioprosthesis - no anticoag (unless underlying arrhythm), use for elderly or child-bearing age women (i.e. bleed or teratogen risk). If fail, acute severe LVF. Ltd lifspan - 10-15y

TE, Failure, Leak (paravalvular), allergic rct, SBE, obstruction due to invading pannus, haemolytic jaundice

Question 8

What are the Major and minor criteria for Rheumatic fever?

JoNES CrITERIA

Answer 8

Diagnosis = 2 major or one major and 2 minor with evidence of streptococcal infection (e.g. high/rising ASO or DNAse titre)

Major:

• Joint arthritis
• Nodules (rheumatoid)
• Erythema marginatum
• Sydenham Chorea
• panCarditis

Minor

• Inflammatory cells (raised WCC)
• Temperature
• ESR/CRP raised
• Raised (prolonged) PR interval
• Itself (previous history RF)
• Arthralgia