valvular heart disease Flashcards
why is rheumatic fever less common?
- Environmental factors
- Decreased virulence of group A h’lytic strep
- Penicillin
- Surgical treatment saving more lives
name common valve lesions from most to least common
- Mitral valve prolapse
- Aortic stenosis / regurgitation
- Mitral regurgitation
- Mitral stenosis
- Right sided valve lesions
define mitral valve prolapse
≥2mm systolic prolapse of 1 or both valve leaflets beyond long-axis annular plane during 2DE
what is the prevalence of mitral valve prolapse?
2-3% affecting men and women equally
what is the pathology of mitral valve prolapse
o histologically normal valves
o myxomatous degeneration
o Marfan, Ehlers danlos
what is the physiology of mitral valve prolapse?
valve leaflet(s) prolapses back into LA during systole, sometimes producing MR (variable severity - usually trivial)
what are the symptoms of mitral valve prolapse?
usually asymptomatic, questionable association with chest pain and atrial arrhythmias
what are the signs of mitral valve prolapse?
ejection click ± late systolic murmur
what is the treatment for mitral valve prolapse?
usually none necessary
what are the causes of aortic stenosis?
- Calcific disease
- Congenital bicuspid valve
- Rheumatic disease
what are the symptoms of aortic stenosis and what causes them?
- Dyspnoea - diastolic pressure in stiff non-compliant LV
- Angina - O2 demand of hypertrophied LV
- Syncope - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion
- LVF - contractile failure as ventricle dilates
- Sudden death - ventricular arrhythmias
what are the signs of aortic stenosis?
- Slow rising carotid pulse
- S4 ± ejection click
- Ejection systolic murmur
what do the pressure signals look like in aortic stenosis?
- Severe pressure gradient across aortic valve
* Prominent ‘a’ wave (arrowed)
what are indications for surgery in aortic stenosis?
- Any symptoms of AS
- Echocardiographic evidence of worsening LV dilatation
- Peak systolic pressure gradient >50 mmHg
what do you do for aortic stenosis patients too sick for heart surgery?
• TAVI for patients too sick for heart surgery
what are the 2 main causes of aortic regurgitation?
aortic valve leaflet disease
aortic root dilating disease
what are the causes of aortic valve leaflet disease?
o Calcific disease
o Congenital bicuspid valve
o Rheumatic disease
o Infective endocarditis
what are the causes of aortic root dilating disease?
o Ankylosing spondylitis
o Marfan syndrome
o Aortic dissection
what are the symptoms of aortic regurgitation and what causes them?
often none
o Dyspnoea - contractile failure as ventricle dilates
o Angina - O2 demand of dilated hypertrophied LV
what are the signs of aortic regurgitation?
o Rapidly rising carotid pulse - vigorous ejection of volume loaded LV
o Early diastolic murmur - aortic backflow (left sternal edge)
o Ejection murmur - turbulent ejection from volume loaded LV (left sternal edge)
what investigations do you do for aortic regurgitation?
aortic root angiogram and 2D Echo-Doppler
what are the indications for surgery in aortic regurg?
any symptoms of AR, echocardiographic evidence of worsening LV dilation
what are the causes of mitral stenosis?
rheumatic fever
what are the symptoms of mitral stenosis and what causes them?
- Dyspnoea, orthopnoea - left atrial pressure
- RV failure - passive consequence of left atrial pressure and reactive pulmonary vasoconstriction
- Palpitations - atrial fibrillation
- Systemic emboli - static blood within dilated fibrillating left atrium predisposes to thrombosis
what are signs of mitral stenosis?
- Pulse – AF
- Ascultation (heart) – loud S1, opening snap mid-diastolic rumble + pre-systolic murmur (SR only)
- Volume overload - JVP, basal creps, ankle oedema
what investigations are needed for mitral stenosis?
just need an echo
how is mitral stenosis treated?
valvuloplasty
what are the requirements for valvuloplasty?
Noncalcified valve, no mitral regurgitation, no LA thrombus
what are the 3 main causes of mitral regurg?
mitral valve leaflet disease
subvalvular disease
functional MR
what causes mitral valve leaflet disease?
Mitral valve prolapse
• Rheumatic disease
• Infective endocarditis
what causes subvalvular disease?
Chordal rupture
• Papillary muscle dysfunction (usually ischaemic)
• Papillary muscle rupture
what causes functional MR?
LV dilation
what are the symptoms of mitral regurg and what causes them?
- Dyspnoea, orthopnoea - left atrial pressure
- Palpitations - atrial fibrillation
- Systemic emboli - static blood within dilated fibrillating left atrium predisposes to thrombosis
what are the signs of mitral regurg?
- Pulse - SR/AF
- Auscultation (heart) - Pansystolic murmur - S3
- Volume overload - JVP, basal creps, ankle oedema
what investigations are done to detect mitral regurg?
- M-mode echo/phono/Doppler
* LV angiogram
what are indications for surgery in patients with mitral regurg?
• Symptoms that fail to respond to medical treatment
• Worsening cardiovascular complications
o pulmonary hypertension (MS)
o LV dilatation (MR)
• Percutaneous MitraClip for patients too sick for heart surgery
what is the medical treatment for valvular heart disease?
- Fluid retention - diuretics
- Low forward output due to regurgitant valve lesions (AR, MR) - vasodilators
- AF (MS, MR) - digoxin, beta-blockers, verapamil
- Anticoagulants to protect against systemic embolisation (AF)
how do you treat fluid retention?
diuretics
how do you treat Low forward output due to regurgitant valve lesions (AR, MR)?
vasodilators
how do you treat AF?
digoxin, beta-blockers, verapamil
how do you protect against systemic embolisation?
anticoagulants
