Valvular heart disease

Question 1

where is the mitral valve in the heart

Answer 1

between the L atrium and L ventricle

Question 2

what can cause mitral stenosis?

Answer 2

rheumatic heart disease
congenital mitral stenosis
systemic conditions like rheumatoid arthritis and systemic lupus erythematous (SLE)

Question 3

what happens to LV pressures and systolic function in mitral stenosis?

Answer 3

they remain normal

Question 4

Clinical signs of mitral stenosis (6)

Answer 4

Dyspnoea: mild exertional to pulmonary oedema

Haemoptisis: rupture of thin-walled veins

Systemic embolisation: LA and LAA enlargement

IE - infective endocarditis

Chest pain

Hoarseness (compression of the L recurrent laryngeal nerve)

Question 5

what is mitral facies?

Answer 5

a distinctive facial appearance associated with mitral stenosis. Someone with mitral stenosis may present with rosy cheeks, whilst the rest of the face has a bluish tinge due to cyanosis

Question 6

what would you find upon examination of stomeone with mitral senosis

Answer 6

Mitral facies
Pulse – normal
JVP – prominent a wave
Tapping apex beat and diastolic thrill
RV heave

Question 7

what investigations can be done for mitral stenosis

Answer 7

ECG
Echo - TOE
CXR - large left atrium
Cardiac catheterisation - dye put through heart - seen on chest x ray and pressure is measured - not used much

Question 8

what imaging techniques are used for VHD

Answer 8

echocardiogram - see thickening and scarring of the leaflets (around valve)

cardiac magnetic resonance (MRI of the heart)

Question 9

what are the 2 interventional invasive treatment options for mitral stenosis

Answer 9

valvotomy - balloon or surgical (cuts into leaflets)

Mitral valve replacement

Question 10

what change in your diet can be implemented to treat mitral stenosis

Answer 10

low Na intake

Question 11

what treatment options are there for mitral stenosis?

Answer 11

diuretics - increase the amount of H20 and Na in urine so more removed from the body

anticoagulants for all with atrial fibrillation

Question 12

what does treatment for those with atrial fibrillation aim to do?

Answer 12

restore sinus rhythm or ventricular rate control

Question 13

when might you get mitral regurgitation (backward blood flow through MV when left ventricle contracts)

Answer 13

rheumatic heart disease
mitral valve prolapse (2 valves don’t close evenly)
Infective endocarditis
degenerative MR - primary
functional MR - secondary - due to LV and annular dilatation

Question 14

anticoagulation treatment is given to all patients with what condition?

Answer 14

atrial fibrillation

Question 15

what 2 interventional/invasive treatments are used for mitral heart disease

Answer 15

Valvotomy - balloon vs surgical - cutting into valve leaflets

MVR - mitral valve replacement

Question 16

what diseases can cause mitral valve regurgitation?

Answer 16

rheumatic heart disease
mitral valve prolapse
infective endocarditis

Question 17

degenerative MR is primary or secondary?

Answer 17

primary

Question 18

functional MR is primary or secondary

Answer 18

secondary - due to LV and annular dilatation. The mitral valve itself is normal in secondary however regurgitation occurs by either myocardial infarction or cardiomyopathy

Question 19

Define mitral regurgitation

Answer 19

abnormal reversal of blood flow from the L ventricle to the L atrium. The volume of both chambers increase

Question 20

How does the LV compensate for MR

Answer 20

MR exerts a vol overload on the LV which is then compensated by eccentric hypertrophy (dilatation) in chronic MR

Question 21

What happens to the EDV and regurgitation vol in chronic MR?

Answer 21

EDV increases and end- systolic volume

regurgitation volume increases

Question 22

why is systolic pressure lower than normal in MR

Answer 22

extra volume is delivered into the LA so there is a smaller end systolic volume - lower systolic pressure

Question 23

What happens to the LV with pattern of overload over time? and what does this allow?

Answer 23

LV remodels as a thin-walled enlarged chamber that permits supernormal diastolic function. This allows the LV to deliver an increased total SV and a normal forward SV

Question 24

How does the remodeling of the LV ultimately lead to heart failure?

Answer 24

eventually the overload damages the LV

Question 25

what clinical signs are associated with acute and chronic MR?

Answer 25

acute - SOB - pulmonary oedema, cardiogenic shock chronic - fatigue, exhaustion (low cardiac output), right heart failure dyspnoea or palpitations due to atrial fibrillation

Question 26

What would you find on clinical examination of someone with MR?

Answer 26

``` Normal pulse or reduced in heart failure JVP prominent if RH failure Brisk or hyperdynamic apex beat - radiates to axilla RV heave Reduced S1 sound split S2 ```

Question 27

Lab investigations

Answer 27

ECG CXR Cardiac catheterisation - LV angiography, obsolete

Question 28

Imaging for MR

Answer 28

echocardiography | helps see severity of MR

Question 29

Treatment for acute and chronic MR

Answer 29

Acute preload and afterload reduction may be life-saving sodium nitroprusside chronic - lack of evidence that therapy works for haemodynamic improvement MVR

Question 30

how wide is a normal aortic valve

Answer 30

3-4 cm2

Question 31

3 causes of aortic stenosis

Answer 31

degenerative rheumatic bicuspid - if valve is bicuspid and not tricuspid it may cause the aortic valve to narrow

Question 32

Describe what happens to the aortic valve in rheumatic aortic stenosis

Answer 32

- adhesion, fusion of the commissures (location at which 2 valve leaflets touch at the edges) and retraction and stiffening of the free cusp margins so basically can get fusion of commissures like as if someone has sown the valve leaflets together so they open up less or calcification of the valve - stiffer - can't open much

Question 33

Describe what happens to the aortic valve in degenerative aortic stenosis

Answer 33

linked to atherosclerosis, a slow inflammatory process in thickening and calcification of the cusps from base to free margins

Question 34

Describe pathophysiology of aortic stenosis

Answer 34

increase in LV systolic pressure severe concentric hypertrophy and LV mass increased LV EDP LA pressure increases and you get pulmonary hypertension increased myocardial O2 consumption myocardial ischaemia (can't meet demand) LV failure

Question 35

define concentric hypertrophy

Answer 35

hypertrophic growth of a hollow organ without overall enlargement, in which the walls of the organ are thickened and its capacity or volume is diminished.

Question 36

Symptoms of aortic stenosis

Answer 36

``` long asymptomatic phase chest pain (angina) syncope/dizziness (exertional pre-syncope) breathlessness on exertion heart failure ```

Question 37

what would you find on clinical examination of patient with aortic stenosis

Answer 37

small pulse volume slowly rising JVP - prominent if RH failure present, low BP vigorous and sustained apex beat RV heave normal S1 sound S2 : less audible A2 (closure of aortic valve)

Question 38

investigations for aortic stenosis and regurgitation?

Answer 38

ECG CXR cardiac catheterisation

Question 39

Imaging for Aortic stenosis

Answer 39

echocardiography | CMR - MRI

Question 40

Causes for aortic regurgitation in relation to aorta (2)

Answer 40

dilated due to Marfan's (an abnormality in connective tissue) or hypertension

Question 41

Causes for aortic regurgitation in relation to leaflets (4)

Answer 41

Bicuspid aortic valve rheumatic heart disease endocarditis myxomatous degeneration - Connective tissue disorder

Question 42

pathophysiology of aortic regurgitation

Answer 42

LV accommodates both SV and regurgitant volume increased LVEDV and LV systolic pressure LV hypertrophy and LV dilatation increased MVO2 (myocardial O2 consumption) Myocardial ischaemia LV failure

Question 43

Symptoms of chronic aortic regurgitation

Answer 43

long asymptomatic phase | exertional breathlessness

Question 44

Symptoms of acute aortic regurgitation

Answer 44

poorly tolerated as LV wall tension cannot acutely adapt

Question 45

What would you find on examination of patient with aortic regurgitation

Answer 45

pulse - large volume and collapsing wide pulse pressure hyperdynamic, displaced apex beat normal S1 and S2 sounds, soft murmur, early diastolic

Question 46

treatment for aortic regurgitation (2)

Answer 46

vasodilator therapy shown to delay the timing for surgical intervention AVR