Valvular heart disease Flashcards
where is the mitral valve in the heart
between the L atrium and L ventricle
what can cause mitral stenosis?
rheumatic heart disease
congenital mitral stenosis
systemic conditions like rheumatoid arthritis and systemic lupus erythematous (SLE)
what happens to LV pressures and systolic function in mitral stenosis?
they remain normal
Clinical signs of mitral stenosis (6)
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)
what is mitral facies?
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
what would you find upon examination of stomeone with mitral senosis
Mitral facies Pulse – normal JVP – prominent a wave Tapping apex beat and diastolic thrill RV heave
what investigations can be done for mitral stenosis
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
what imaging techniques are used for VHD
echocardiogram - see thickening and scarring of the leaflets (around valve)
cardiac magnetic resonance (MRI of the heart)
what are the 2 interventional invasive treatment options for mitral stenosis
valvotomy - balloon or surgical (cuts into leaflets)
Mitral valve replacement
what change in your diet can be implemented to treat mitral stenosis
low Na intake
what treatment options are there for mitral stenosis?
diuretics - increase the amount of H20 and Na in urine so more removed from the body
anticoagulants for all with atrial fibrillation
what does treatment for those with atrial fibrillation aim to do?
restore sinus rhythm or ventricular rate control
when might you get mitral regurgitation (backward blood flow through MV when left ventricle contracts)
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
anticoagulation treatment is given to all patients with what condition?
atrial fibrillation
what 2 interventional/invasive treatments are used for mitral heart disease
Valvotomy - balloon vs surgical - cutting into valve leaflets
MVR - mitral valve replacement
what diseases can cause mitral valve regurgitation?
rheumatic heart disease
mitral valve prolapse
infective endocarditis
degenerative MR is primary or secondary?
primary
functional MR is primary or secondary
secondary - due to LV and annular dilatation. The mitral valve itself is normal in secondary however regurgitation occurs by either myocardial infarction or cardiomyopathy
Define mitral regurgitation
abnormal reversal of blood flow from the L ventricle to the L atrium. The volume of both chambers increase
How does the LV compensate for MR
MR exerts a vol overload on the LV which is then compensated by eccentric hypertrophy (dilatation) in chronic MR
What happens to the EDV and regurgitation vol in chronic MR?
EDV increases and end- systolic volume
regurgitation volume increases
why is systolic pressure lower than normal in MR
extra volume is delivered into the LA so there is a smaller end systolic volume - lower systolic pressure
What happens to the LV with pattern of overload over time? and what does this allow?
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
How does the remodeling of the LV ultimately lead to heart failure?
eventually the overload damages the LV
what clinical signs are associated with acute and chronic MR?
acute - SOB - pulmonary oedema, cardiogenic shock
chronic - fatigue, exhaustion (low cardiac output), right heart failure
dyspnoea or palpitations due to atrial fibrillation
What would you find on clinical examination of someone with MR?
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
Lab investigations
ECG
CXR
Cardiac catheterisation - LV angiography, obsolete
Imaging for MR
echocardiography
helps see severity of MR
Treatment for acute and chronic MR
Acute preload and afterload reduction may be life-saving
sodium nitroprusside
chronic - lack of evidence that therapy works for haemodynamic improvement
MVR
how wide is a normal aortic valve
3-4 cm2
3 causes of aortic stenosis
degenerative
rheumatic
bicuspid - if valve is bicuspid and not tricuspid it may cause the aortic valve to narrow
Describe what happens to the aortic valve in rheumatic aortic stenosis
- 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
Describe what happens to the aortic valve in degenerative aortic stenosis
linked to atherosclerosis, a slow inflammatory process in thickening and calcification of the cusps from base to free margins
Describe pathophysiology of aortic stenosis
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
define concentric hypertrophy
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.
Symptoms of aortic stenosis
long asymptomatic phase chest pain (angina) syncope/dizziness (exertional pre-syncope) breathlessness on exertion heart failure
what would you find on clinical examination of patient with aortic stenosis
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)
investigations for aortic stenosis and regurgitation?
ECG
CXR
cardiac catheterisation
Imaging for Aortic stenosis
echocardiography
CMR - MRI
Causes for aortic regurgitation in relation to aorta (2)
dilated due to Marfan’s (an abnormality in connective tissue) or hypertension
Causes for aortic regurgitation in relation to leaflets (4)
Bicuspid aortic valve
rheumatic heart disease
endocarditis
myxomatous degeneration - Connective tissue disorder
pathophysiology of aortic regurgitation
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
Symptoms of chronic aortic regurgitation
long asymptomatic phase
exertional breathlessness
Symptoms of acute aortic regurgitation
poorly tolerated as LV wall tension cannot acutely adapt
What would you find on examination of patient with aortic regurgitation
pulse - large volume and collapsing
wide pulse pressure
hyperdynamic, displaced apex beat
normal S1 and S2 sounds, soft murmur, early diastolic
treatment for aortic regurgitation (2)
vasodilator therapy shown to delay the timing for surgical intervention
AVR
