Valvular heart disease

Question 1

Everyone has a degree of valvular dysfunction.

Our valves stop growing when we’re 14 years old, they lose their blood supply and become fibrous flaps that have to last us for the rest of our lives.

Definition of ‘valve’?

Answer 1

Valve = device for controlling passage of fluid through a pipe/duct, typically one direction only.

Question 2

Majority of adult valvular heart disease takes place in ___ side of heart (
_____ valve + ____ valve affected most).

This is because _______ circulation pressure is higher.

Answer 2

Majority of adult valvular heart disease takes place in left side of heart ( mitral valve +aortic valve affected most).

This is because systemic circulation pressure is higher.

Question 3

Aortic valve: pretty simple,

• it is a tricuspid valve in the _____ ___, which is a fibrous tube
• Aortic root is a fixed structure and the leaflets are ___-_______ (independent, in the sense it doesn’t need other apparatus to support it)

Mitral valve: pretty complex,

• _ leaflets, _ scallops (one of a continuous series of circle segments or angular projections forming a border, pics in folder)
• held within mitral valve ______ (fibrous ring around valve, doesn’t cover anterior though) this moves with cardiac cycle
• not self-contained (not independent) due to pressure in LV, so held up by apparatus: papillary muscles and tendinae chordae

Answer 3

Aortic valve: pretty simple,

• it is a tricuspid valve in the aortic root, which is a fibrous tube
• Aortic root is a fixed structure and the leaflets are self-contained (independent, in the sense it doesn’t need other apparatus to support it)

Mitral valve: pretty complex,

• 2 leaflets, 6 scallops (one of a continuous series of circle segments or angular projections forming a border, pics in folder)
• held within mitral valve annulus (fibrous ring around valve, doesn’t cover anterior though) this moves with cardiac cycle
• not self-contained (not independent) due to pressure in LV, so held up by apparatus: papillary muscles and tendinae chordae

Question 4

What can go wrong?

Valve Leaflets:

• c________
• t________
• d_________
• i______ (endocarditis)
• p______

Apparatus/annulus:

• annular ________ (for instance in MI, LV may dilate and stretch annular ring)
• -> annular _______ is mostly in mitral be can be aortic root too
• annular _________
• apparatus _________ or rupture
• regional wall motion abnormality

Answer 4

What can go wrong?

Valve Leaflets:

• calcification
• thickening
• degeneration
• infection (endocarditis)
• prolapse

Apparatus/annulus

• annular dilatation (for instance in MI, LV may dilate and stretch annular ring)
• -> annular dilatation is mostly in mitral be can be aortic root too
• annular calcification
• apparatus thickening or rupture
• regional wall motion abnormality

Question 5

Stenosis:
leads to –> ______ overload

• left ventricular _________ response
• atria don’t tend to _________ so in mitral stenosis can get left atrial _______

Regurgitation:
leads to –> _____ overload

• causes chamber _______
• marker of aortic regurgitation is ___ ____ dilatation
• marker of mitral regurgitation is ___ ____ dilatation

Answer 5

Stenosis:
leads to –> pressure overload

• left ventricular hypertrophy response
• atria don’t tend to hypertrophy so in mitral stenosis can get left atrial dilatation

Regurgitation:
leads to –> volume overload

• causes chamber dilatation
• marker of aortic regurgitation is LV dilatation
• marker of mitral regurgitation is Left atrial dilatation

Question 6

Rheumatic valve disease

• rheumatic fever is an antibody cross-reactivity issue as a response to a _________ _____ infection
• acute rheumatic fever symptoms: painful ____, fever, r___
• on decline in population due to _______
• likely cause of valvular problems in ______ patients.

Answer 6

Rheumatic valve disease

• rheumatic fever is an antibody cross-reactivity issue as a response to a stretococcal throat infection
• acute rheumatic fever symptoms: painful joints, fever, rash
• on decline in population due to antibiotics
• likely cause of valvular problems in younger patients, eg. 20s, 30s.

Question 7

Aortic valve

• _ cusps –> __-leaflet
• _ cusps are ___, ___ and __-______

Answer 7

Aortic valve

• 3 cusps –> tri-leaflet
• 3 cusps are right, left and non-coronary

Question 8

Aortic stenosis

• commonest cause is just ______
• valve damaged by: t_________, c________, r_______ valve disease, c________
• valve narrows and murmur can be heard, narrower the valve the ______ the murmur
• however if you develop LV failure below a narrow valve the murmur becomes ______ (this is called low flow, low gradient stenosis)
• _________, thickening + calcification will always ______
• increased LV ______
• pressure overload causes LV ________
• symptoms: ________, syncope, chest pain, reduced exercise capacity

Answer 8

Aortic stenosis

• commonest cause is just ageing
• thickening, calcification, rheumatic valve disease, congenital
• valve narrows and murmur can be heard, narrower the valve the louder the murmur
• however if you develop LV failure below a narrow valve the murmur becomes quieter (this is called low flow, low gradient stenosis)
• progressive, thickening + calcification will always progress
• increased LV pressure
• pressure overload causes LV hypertrophy
• symptoms: breathless, syncope, chest pain, reduced exercise capacity

Question 9

Aortic regurgitation

• due to __________ mostly, however in aortic root dilatation, valve can be normal but stretched
• causes: r______ valve disease, e_______, systemic cause (M_____, Ehlers Danlos syndrome, a______ s______, lupus)
• ______ overload, blood runs back into LV from aorta during ______ as valve is incompetent
• this, as well as blood coming into LV from atrium, causes LV ______
• symptoms: _______, reduced exercise capacity

Answer 9

Aortic regurgitation

• degeneration mostly, however in aortic root dilatation valve can be normal but stretched
• causes: rheumatic valve disease, endocarditis, systemic cause (Marfan’s, Ehlers Danlos syndrome, ankylosing spondylitis, lupus)
• volume overload, blood runs back into LV from aorta during diastole as valve is incompetent
• this, as well as blood coming into LV from atrium, causes LV dilatation
• symptoms: breathless, reduced exercise capacity

Question 10

______ _____ valve

• ______ valves for ____ (in 1-2% of population)
• prone to premature dysfunction
• can be associated with ____ _______

Answer 10

Bicuspid aortic valve

• bicuspid valves for aorta (in 1-2% of population)
• prone to premature dysfunction
• can be associated with aortic dilatation

Question 11

Mitral valve

• has _____ and _______ leaflet
• ______ is smaller at __ position than _______ (pic in folder)

Answer 11

Mitral valve

• has anterior and posterior leaflet
• posterior is smaller at P2 position than anterior (pic in folder)

Question 12

Mitral stenosis

• rare now
• usually causes by rheumatic valve disease, rarely degenerative
• left atrium dilates (due to pressure overload)
• pulmonary hypertension and secondary right heart dilatation result (makes sense)
• can develop atrial fibrillation
• symptoms: breathless, palpitations, haemoptysis (coughing up blood from somewhere below the glottis)

Answer 12

.