Valvular Heart Disease Flashcards
What is the name given to the assessment tool used to predict Infective Endocarditis?
Duke’s Criteria
What are the Major and Minor criteria for Duke’s to diagnose Infective Endocarditis?
Major criteria:
- 2 positive blood cultures for infectious agents causing Infective Endocarditis
- Echocardiographic evidence of endocardial involvement
Minor criteria:
- Predisposition i.e. heart conditions, IVDU
- Fever >38 degrees
- Vascular phenomena i.e. Janeway lesions
- Immunological phenoma i.e. Roth spots, Osler nodes, Glomerulonephritis
- Positive culture not meeting Major criteria
What criteria for Dukes must be satisfied for a Definite Diagnosis of Infective Endocarditis?
- 2 major criteria
- 1 major + 3 minor
- 5 minor
What criteria for Dukes must be satisfied for a Possible Diagnosis of Infective Endocarditis?
- 1 major + 1 minor
- 3 minor
What antibiotic prophylaxis is given to dental patients at risk of developing Infective Endocarditis?
None is recommended by NICE, unless they already have an existing infection
INFECTIVE ENDOCARDITIS
- What valve is most commonly affected?
- What valve is affected in IVDUs?
- What is the most common cause of IE?
- What is the most common cause in the developing world?
- Which organism is from indwelling lines?
- Which organism is found in the oral cavity?
- Which organism is associated with colorectal cancer?
- Which organism is associated with animals?
- Mitral valve
- Tricuspid valve
- Staph aureus (Gram positive)
- Strep viridian
- Staph epidermidis
- Strep viridians
- Strep bovis
- Coxiella burnetti
What might be seen in urinalysis in patients with Infective Endocarditis?
Septic emboli i.e. RBC / WBC casts
Discuss the significance of Staph aureus with respect to Infective Endocarditis. Where is it found? What is it associated with?
Staph aureus is the most common cause of Infective Endocarditis in the developed world. Is found on skin flora and is associated with IVDU. Commonly involves the tricuspid valve / right side of the heart
Discuss the significance of Viridians Streptococci with respect to Infective Endocarditis. Where is it found?
Viridians Streptoccoci commonly causes Infective Endocarditis in the developing world. Is found in the mouth and is associated with poor dental hygiene
Discuss the significance of Staph Epidermidis with respect to Infective Endocarditis
Commonly associated with patients who have prosthetic valves
Discuss the significance of Coxiella Burnetii with respect to Infective Endocarditis
Commonly obtained from infected animals
What are the HACEK organisms which can cause Infective Endocarditis?
- Haemophilus
- Actinobacilli
- Cardiobacterium
- Eikenella
- Kingella
Where are Janeway lesions and Osler’s nodes found? Which are painful?
Janeway: Palms / soles of hands / feet (Painless)
Osler’s: Distal fingers (Painful)
What is the name given to non-infectious endocarditis? What condition is it associated with?
Libman-Sacks Endocarditis
Associated with SLE
What is the most common type of Valvular heart disease? What is the second most common?
Aortic stenosis (most common) Mitral regurgitation (2nd most common)
What are the two valves on the left hand side of the heart?
Aortic valve
Mitral valve
What are the positions to auscultate the Aortic, Pulmonary, Tricuspid and Mitral valves?
Aortic - R 2nd intercostal, parasternal
Pulmonary - L 2nd intercostal, parasternal
Tricuspid - L 4th intercostal, parasternal
Mitral - L 5th intercostal, mid-clavicular
Which of the heart valves are trileafleted and bileafleted?
Aortic, Pulmonary, Tricuspid - trileafleted
Mitral - bileafleted
State four examples of mid-systolic murmurs
Aortic stenosis
Pulmonic stenosis
HOCM
ASD
State three examples of pan-systolic murmurs
Mitral regurgitation
Tricuspid regurgitation
VSD
State one example of late-systolic murmurs
Mitral valve prolapse
State three examples of early diastolic murmurs
Aortic regurgitation
Pulmonic regutation
Austin flint
State two examples of mid/late-diastolic murmurs
Mitral stenosis
Tricuspid stenosis
What sort of murmur does a Patent Ductus Arteriosis (PDA) give?
Systolic murmur
What are some causes of Aortic Stenosis? 5 examples
- Age related degenerative stenosis (6th/7th decade)
- Congenital bicuspid valve (5th decade)
- Rheumatic aortic valve disease
- William’s syndrome (Supravalvular stenosis)
- Rare: Paget’s disease, SLE, hyperparathyroidism
In rheumatic aortic valve disease causing aortic stenosis, what other finding might be present?
The mitral valve almost always has stenosis as well
On examination what findings might be present in patients with Aortic Stenosis, for example:
On auscultation?
On carotid pulse?
Heaves / thrills?
On auscultation: A right-sided, second intercostal space ejection (crescendo-decrescendo) systolic murmur, with radiation to the carotids, louder on expiration. A soft S2 sound may be heard as well as S4
On carotid pulses: Slow rising with low volume, with narrow pulse pressure
Left ventricular heave and a thrill may be present
What are the three main symptoms in patients with Aortic Stenosis?
- Exertional angina
- Exertional syncope / dizziness
- Exertional dyspnoea
For asymptomatic patients with Aortic Stenosis, what is the treatment?
Observe the patient as a general rule, unless they have a valvular gradient > 40mmHg then consider surgery
For symptomatic patients with Aortic Stenosis, what is the treatment?
Surgery i.e. Mechanical / Biological valves or if not fit for surgery then a Balloon Valvuloplasty
What are the anticoagulant requirements for Mechanical and Biological valves for valve replacement?
Mechanical - lifelong anti-coagulation
Biological - anti-coagulation for first 3 months
Explain the RILE mnemonic
Right sided murmurs are Louder on Inspiration (Pulmonary / Tricuspid)
Left sided murmurs are Louder on Expiration (Aortic / Mitral)
The Austin Flint murmur is a diastolic murmur associated with?
Severe aortic regurgitation
What are some causes of Aortic Regurgitation?
- Disease of Aortic Root: Aneurysm / Dissection
- Connective tissue Disease: Marfan’s, Ehlers-Danlos, Osteogenesis Imperfecta
- Inflammatory Disease: Rheumatoid Arthritis, Ankylosing Spondylitis, Infective Endocarditis, Rheumatic Fever
On examination what findings might be present in patients with Aortic Regurgitation, for example:
On auscultation?
On carotid pulse?
Heaves / thrills?
On auscultation: A right-sided, second intercostal space decrescendo diasystolic murmur. A soft S2 sound may be heard
On carotid pulses: Collapsing, with wide pulse pressure
Heaves and a thrill may be present
Aortic Stenosis / Regurgitation sounds louder on…?
Expiration
What is the collapsing pulse in Aortic Regurgitation called?
Corrigan’s Pulse
What is De Musset’s sign? What condition is it associated with?
Head bobbing with pulse, associated with Aortic Regurgitation
What is Corrigan’s pulse? What condition is it associated with?
Collapsing pulse, associated with Aortic Regurgitation
What is Quincke’s sign? What condition is it associated with?
Pulsating nail bed capillaries, associated with Aortic Regurgitation
What is Muller’s sign? What condition is it associated with?
Pulsating Uvulva, associated with Aortic Regurgitation
What is the size of a normal Aortic valve orifice? How stenosed must it be, to become symptomatic?
3-4cm sq initially
<1.5cm sq - symptomatic
What is the size of a normal Mitral valve orifice? How stenosed must it be, to become symptomatic?
4-5cm sq initially
<2cm sq - symptomatic
What are some risk factors to Mitral stenosis?
Rheumatic fever, congenital valve defects, mitral valve calcification, infective endocarditis
What is the facial symptom experienced in patients with Mitral Stenosis?
Malar flush
What condition is also concurrent in patients with Mitral Stenosis?
Atrial fibrillation
What does a Mitral Stenosis murmur sound like on auscultation?
A mid-diastolic murmur, heard loudest in the 5th intercostal space mid-clavicular line on expiration. No radiation. A loud opening snap (S1) may also be heard
What ECG findings may be present in patients with Mitral Stenosis / Regurgitation?
P wave Mitrale (Upright p waves in Lead 1, and bifid M-shaped P waves in Lead 2)
Atrial fibrillation
Why is Mitral Stenosis quite rare in developed countries?
Due to it commonly being caused by rheumatic fever, which is rare in developed countries
Mitral Regurgitation has both primary and secondary causes. What are they?
Primary: Disease affecting mitral valve / chordae tendinae / papillary muscles i.e. Rheumatic fever, IE, Mitral valve prolapse
Secondary:
1) Due to LV dilatation stretching the mitral valve / chordae tendinae / papillary muscles
2) Due to myocardial ischaemia causing papillary muscle dysfunction
What does a Mitral Regurgitation murmur sound like on auscultation?
Pansystolic murmur, sounding loudest in the 5th intercostal space mid-clavicular line, with radiation to the axilla. Heard loudest on expiration, and has a soft first heart sound (S1). There is also a laterally displaced apex beat
What does an Echocardiogram show in patients with Mitral Stenosis / Regurgitation?
Left atrial dilatation for Stenosis / Regurg
In Stenosis also: Reduced mitral valve orifice
Malar flush is associated with which murmur?
Mitral stenosis
PROSTHETIC VALVES
- Patients who have had a valve replacement may have what scars?
- What are the two broad types of valves?
- What is the lifespan of each?
- What valve requires anticoagulation?
- What are the different types of mechanical valves?
- Of the mechanical valves, which has the highest and lowest risk of thrombus formation?
- What are 3 complications of mechanical valves?
- A “click” in S1 and S2 corresponds to what type of heart valve?
- When is a TAVI indicated?
- Outline the procedure of a TAVI
- What is the pros and cons of a TAVI
- Midline sternotomy (aortic or mitral valve replacement), or a right-sided mini thoracotomy (mitral valve)
- Bioprosthetic vs. Mechanical
- Bioprosthetic = 10 years, Mechanical = 20 years
- Mechanical valves
- Starr-Edwards, Tilting disc, St. Judes
- Starr-Edwards = highest, St. Judes = lowest
- Thrombus formation, Infective endocarditis, Haemolysis
- S1 = mitral valve replacement, S2= aortic valve replacement
- For patients with severe aortic stenosis who will not survive open surgery
- Catheter into femoral artery, fed by a guide wire under X-ray guidance, followed by balloon inflation to stretch the stenosed aortic valve and bioprosthetic valve insertion
- Pros = no anticoagulation required. Cons = Long term outcomes still unclear
MURMURS
- What does S1 represent?
- What does S2 represent?
- What does S3 represent? Is it normal?
- What does S4 represent? Is it normal?
- What valves are on the LHS?
- What valves are on the RHS?
- What are the grades of murmurs?
- S1 is the closure of the atrioventricular valves (Tricuspid and Mitral)
- S2 is the closure of the semilunar valves (Pulmonary and Aortic)
- S3 represents rapid ventricular filling. It is normal in young adults, abnormal in older people ?heart failure
- S4 represents a stiff hypertrophic ventricle. ALWAYS abnormal
- LHS = Aortic and Mitral
- RHS = Tricuspid and Pulmonary
- Grade 1: Difficult to hear
Grade 2: Quiet
Grade 3: Easy to hear
Grade 4: Easy to hear with a palpable thrill
Grade 5: Can hear with stethoscope barely touching chest
Grade 6: Can hear with stethoscope off the chest
