Valvular Heart Disease Flashcards
What valve is between the right atrium and the right ventricle?
Tricuspid valve
What valve is between the right ventricle and the lungs?
Pulmonary oedema
What valve is between the left atrium and the left ventricle?
Mitral valve
What valve is between the left ventricle and the aorta?
Aortic valve
What are the parts of the mitral valve?
Anterior mitral valve leaflet (AMVL)
Posterior mitral valve leaflet (PMVL)
Size of a normal aortic valve
3 - 4cm2
How many leaflets does the aortic valve have?
3
What are the common heart valve lesions?
Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
Definition of mitral stenosis
Narrowing of the mitral valve
What is a normal mitral valve orifice?
Between 4 - 6cm2
Good dynamic range
What size of mitral valve orifice is stenosed?
<2cm2
Pathology of mitral stenosis
A-V pressure gradient increases LA pressure increases Pulmonary venous and capillary pressures increase PVR increases PaP increases and PHTN develops RH dilatation with TR and PReg
SO when valve becomes narrower, the pressure gradient between atrium and ventricles increases which backtracks through pulmonary circulation to the right side of the heart - called pulmonary HTN
LV pressures and systolic function is normal
LA suffers upstream of the valve
Downstream of the valve there is nothing wrong so left ventricle functions fine
Causes tachycardia
What is mitral regurgitation?
Leaking or incompetent mitral valve
Causes of MVP
Rheumatic heart disease
Infective endocarditis
Degenerative
Functional
What is functional mitral valve regurg?
Due to left ventricular and annular dilatation
Ventricle enlarges and then the annulus of the mitral valve when it is anchored will enlarge as well, and the posterior and anterior bits of the valve wont meet in the middle to shut and therefore the valve becomes incompetent
Pathology of mitral valve regurg
Mitral valve leaky
LV compensation; ventricle doesn’t have time to adapt and has to do something
Acute
- ESP and ESV decrease, wall tension decreases, so the ventricle contracts much more forcefully and then the end systolic volume is much less - dilates much more slowly to compensate for blood
Chronic
- EDV increases and ESV returns to normal, eccentric LVH develops
LA compliance
- reduced; marked pressure rise, thickening of atrial myocardium, increase in PVR and remodelling of pulmonary vasculature with PHT
- increased; marked volume enlargement, lesser changes in pulmonary vasculature, but develop AF
Types of aortic stenosis
Degenerative
Rheumatic
Bicuspid
Pathology of Degenerative AS
Aortic valve tends to degenerate because it is subject to high velocities and pressures of blood. With time it wears and tears aortic valve.
Linked to atherosclerosis, a slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins
Pathology of rheumatic AS
Adhesion, fusion of the commissures and retraction and stiffening of the free cusp margins
Pathology of bicuspid AS
Two leaflet aortic valve
What is the commonest congenital condition that survives in adulthood?
Bicuspid aortic valve
What can happen to a bicuspid aortic valve?
Stenosis
Regurgitant
Both
Some no effects at all
Pathology of AS
Pressure in ventricle increases (increase in LV systolic pressure)
Ventricle hypertrophy to increase muscle mass (LVM) - increased pressure in left atrium and it goes back into the pulmonary circulation and to the right side of the heart. (causing pulmonary HTN)
The myocytes want to take more oxygen into the hypertrophic ventricle and so it is more common here to develop ischaemia - myocardial ischaemia
Left ventricular failure
Causes of aortic regurgitation
Dilated aorta (marfans, HTN) Connective tissue disorders Bicuspid aortic valve Rheumatic heart disease IE Myxomatous degeneration
Pathology of aortic regurg
LV accommodates both SV and reg volume Increased LVEDV and LV systolic pressure LV hypertrophy and LV dilatation Increased MVO2 Myocardial ischaemia LV failure
Presentation of MS
SOB (pulmonary oedema) Haemoptysis Systemic embolization (LA and LAA enlargement) IE Chest pain Hoarseness (compression of L recurrent laryngeal nerve) Stroke Mitral facies Normal pulse JVP prominent a wave Tapping apex beat
Why can you get haemoptysis in MS?
Rupture of thin walled veins
What is mitral facies?
Decolourisation of nose and cheeks
What murmur is heard in MS? What other heart signs?
Tapping apex beat
DIASTOLIC THRILL (discrete)
- a blow in diastole
RV heave
Why does MS give the murmur it does?
Diastolic thrill
Takes a while for the mitral valve to open as it is stenosed (more the stenosis, the longer it takes) - so there is a 3rd heart sound which is the MV snap when it opens under pressure
Systole is unaffected
Causes of acute MR
Valve perforation
Chordal/papillary muscle rupture
Presentation of acute MR
SOB (pulmonary oedema, cardiogenic shock)
Which valve injury is an emergency?
Acute MR
Presentation of chronic MR
Fatigue
Exhaustion (Low CO)
Right heart failure
SOB or palpitations due to AF
Signs of MR
Normal or reduced in HF
JVP (prominent if RH failure present)
Brisk and dynamic apex beat
RV heave
What heart signs are seen in MR?
Brisk and hyperdynamic apex beat
RV heave
REDUCED S1 and SPLIT S2
Pathology of murmur in MR
Reduced SI, SPLIT S2 SPLIT S2 - early A2 and loud P2 Holosystolic, blowing Loud at apex, radiating to axilla Systolic murmur so loud it will obscure other heart sounds
Where is MR best heard?
Apex
Presentation of AS
Long asymptomatic phase (incidental finding) Chest pain (angina) Syncope/dizziness (exertional pre-syncope) SOB on exertion HF Small pulse and slowly rising Low BP JVP prominent if RH failure present Vigorous and sustained apex beat RV heave
Heart signs with AS
Vigorous and sustained apex beat RV heave NORMAL S1, S2 LESS AUDIBLE LATE PEAKING, HARSH Loud at base RADIATING TO CARTOIDS
Where does AS murmur radiate to?
Carotids
Where does MR murmur radiate to?
Axilla
What is the issue with acute AR?
EMERGENCY
Regurg makes a sudden whoosh of blood back into the ventricle which it is not expecting, so heart cannot cope. Tension cannot acutely adapt
Presentation of chronic AR
Long asymptomatic phase (incidental finding)
Exertional SOB
HF
Angina
Large hearts - dilates ventricles chronically to cope with increased volume
Signs of AR
Large volume and collapsing pulse (Corrigan sign)
Wide pulse pressure
Hyperdynamic as a volume overloaded heart, displaced apex beat
Heart signs of AR
Displaced apex beat
NORMAL S1 , NORMAL S2, EARLY DIASTOLIC MURMUR
Pathology of murmur of AR
Normal S1 - systole completely clear
Normal S2
Early diastolic, decrescendo, soft murmur
How to listen for murmur of AR?
Patients sitting forward holding out breath
Investigations of MS
ECG; - LA enlargement - larger P wave (>0.12 sec) - Prominent R wave - RVH Cardiac catheterisation CXR - LA enlargement / pulmonary oedema ECHO - thickening and scarring of leaflets - fusion of commissures Cardiac MRI
Investigations of MR
ECG - LA enlargement - P tall and > 0.12sec - RVH (prominent R wave in R Precordial leads) CXR - cardiomegaly - LA enlargement - calcification of mitral annulus Cardiac catheterisation - LV angiography ECHO
Investigations of AS
ECG - LVH voltage criteria - ST/T changes (LV strain) CXR - calcification of AV Cardiac catheterisation - Peak LV peak aortic gradient ECHO - AV cusp motility - LV function and hypertrophy CMR
Investigations of AR
ECG - ST/T changes (LV strain) - LAD CXR - cardiomegaly in chronic AR Cardiac catheterisation ECHO - AV cusp anatomy - LV function, dilation and hypertrophy CMR
Treatment for MS
Diuretics Restriction of Na intake If AF - sinus rhythm restoration or ventricular rate control Anticoagulation Watchful waiting Invertational treatment - valvotomy (balloon vs surgical) - mitral valve replacement
Treatment for acute MR
Preload and afterload reduction - Diuretics - Sodium nitroprusside - Dobutamine - IABP Invertational treatment - mitral valve apparatus repair - mitral valve replacement
Treatment for chronic MR
Interventional treatment
- mitral valve apparatus repair
- mitral valve replacement
Treatment for AS
Aortic valve replacement or repair
Treatment for AR
Vasodilator therapy
Aortic valve replacement or repair
Who is treatment for AS saved for?
Those who develop HF
Causes of cardiac ischaemia
Atherosclerosis Embolism Coronary thrombosis Aortic dissection Arteritides Congenital
What are Arteritides?
Inflammatory cells infiltrate into the walls of the artery and cause inflammation
Presentation of ischaemic heart disease
Angina MI Arrhythmias Chronic heart failure Sudden death
What are the dangerous heart conditions (2)?
Left main stem stenosis
3 vessel coronary artery disease
Causes of valvular heart disease in adult
Degenerative Congenital Infection Inflammatory LV or RV dilatation Trauma Neoplastic Paraneoplastic
What is rheumatic fever related to?
Streptococcal infections
Where is rheumatic fever common in?
Africa / developing countries
What is the hallmark pathology in rheumatic fever?
Pancarditis (effects myocardium, pericardium and epicardium)
What manifestations are also common in rheumatic fever?
Skin
- cellulite on legs
- migratory erythema (blotchy red swelling of skin)
Joint
Pathology of chronic rheumatic fever
Gradually progressive MVDx +/- AVDx
What is the most worldwide cause of death in pregnancy?
Chronic rheumatic fever
What sugical technique can be used to treat IHD?
CABG
Indications for CABG
Symptomatic (any CAD pattern)
Prognostic (LMSS, 3VDx)
What does CABG stand for?
Coronary artery bypass grafting
Selection of patients for CABG must have…
Adequate - lung function - mental function - hepatic function Ascending aorta OK Distal coronary artery targets OK LVEG >20%
Conduits for CABG
Reversed saphenous vein
Internal mammary arteries
Radial arteries
Sternotomy problems
Wire infection
Pain
Sternal dehiscence
Sternal malunion
Post op complications of cardiac surgery
Cardiac tamponade
Death
Stroke
Risk of death with CABG
2%
What is cardiac tamponade?
Collection of blood in the pericardial sac which is under pressure, so doesn’t allow the atrium to fill in diastole so have a fast HR and low BP
Presentation of cardiac tamponade
Primary - raised CVP - Raised HR - Low BP Secondary - oliguria - increased O2 requirements - metabolic acidosis
What % of patients may need a repeat CABG?
5%
Treatment of cardiac tamponade following cardiac surgery
Chest re-opening
Which valves are most frequently operated on in adult cardiac surgery?
Aortic
Mitral
What differentiates aortic stenosis from aortic sclerosis?
Loss of A2
Is AS an easy murmur to hear?
Yes
What is on an ECG/ECHO of AS?
LVH
Is the murmur of AR easy to hear?
No
Is murmur of MS easy to hear? What may have to be done to hear it?
No - if easily hear then stenosis is severe
May need to exercise the patient to hear it
Is the murmur of MR easy to hear?
Yes
If loud - severe
What is severe MR usually associated with?
LV and LA dilatation
Onset of AF
Pulmonary HTN
What is severe MR on ECHO characterised by?
Systolic blood flow reversal into the pulmonary veins
What does a cardiopulmonary bypass do?
Blood is drained from right atrium and is returned to the ascending aorta
Heart and lung function taken over by the CPB machine
Induced hypothermia
What is required with CPB?
Systemic anticoagulation
What is the max time limit with CPB?
12 hours
What is the max cardiac ischaemic time in CPB?
6 hours
What is a common problem in CPB?
Coagulopathy
Types of heart valve prosthesis
Biological valve
Mechanical valve
Features of biological valve
No warfarin required
Wears out after 15 years
Features of mechanical valve
Warfarin required for life
Valve lasts for > 40 years
What is better for the mitral valve, repair or replacement?
Repair
Who would get biological valve replacements?
Patients who are elderly as wont live that long
What is the most common organism causing IE? What does it give rise to?
Strep viridans
Subacute bacterial endocarditis
What is the second most common organism causing IE? What does it give rise to?
Staph aureus
Acute bacterial endocarditis
Indications for surgery in IE
Severe valvular regurgitation
Large vegetations
Persistent pyrexia (fever)
Progressive renal failure
In surgery for IE, what is given post op and for how long?
Ax IV for 6 weeks post op
What valvular problem is associated with polycystic kidney disease?
Mitral valve prolapse
What drugs are contraindicated in aortic stenosis?
Nitrates
Criteria for aortic stenosis management
Symptoms
Aortic valve gradient of 40mmHg
What is a clinical sign of AR?
De musset sign (Head bobbing)
How can functional tricuspid regurgitation occur?
Secondary to pulmonary HTN as a result of chronic lung disease
What murmurs cause an ejection systolic murmur?
AS
Pulmonary stenosis, HOCM
ASD
Teratology of fallot
What murmurs cause a holosystolic (Pansystolic) murmur?
MR / TR (high pitched and blowing in character)
VSD (harsh in character)
What murmurs cause a late systolic murmur?
MVP
Coarctation of aorta
What murmurs cause a early diastolic murmur?
AR (high pitched, blowing in character)
Graham steel murmur (pulmonary regurg, high pitched and blowing in character)
What murmurs cause a mid-late diastolic murmur?
MS (rumbling in character)
Austin-Flint murmur (severe AR, again rumbling)
What causes a continuous machine like murmur?
PDA
What is an atrial myxoma?
Commonest benign tumour most commonly occurring in the left atrium (75%) attached to the fossa ovalis
Presentation of atrial myxoma
Mitral valve obstruction Systemic embolization Constitutional symptoms - SOB - weight loss - fever - clubbing
Which gender gets atrial myxoma more commonly?
Females
Heart signs of atrial myxoma
Mid diastolic murmur - ‘tumour plop’
ECHO
- pedunculated heterogenous mass typically attached to the fossa ovalis region of the interatrial septum
What type of pulse is shown in aortic stenosis?
Slow rising pulse
What type of pulse is shown in HOCM?
Jerky pulse
What heart sound does pulmonary HTN cause?
A loud second heart sound
Murmurs are often described using what scale?
Levine scale
Describe the levine scale
Grade 1 - very faint murmur
Grade 2 - Slight murmur
Grade 3 - Moderate murmur WITHOUT palpable thrill
Grade 4 - Loud murmur WITH palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
