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CVS Pathology > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

What valve is between the right atrium and the right ventricle?

A

Tricuspid valve

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2
Q

What valve is between the right ventricle and the lungs?

A

Pulmonary oedema

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3
Q

What valve is between the left atrium and the left ventricle?

A

Mitral valve

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4
Q

What valve is between the left ventricle and the aorta?

A

Aortic valve

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5
Q

What are the parts of the mitral valve?

A

Anterior mitral valve leaflet (AMVL)

Posterior mitral valve leaflet (PMVL)

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6
Q

Size of a normal aortic valve

A

3 - 4cm2

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7
Q

How many leaflets does the aortic valve have?

A

3

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8
Q

What are the common heart valve lesions?

A

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

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9
Q

Definition of mitral stenosis

A

Narrowing of the mitral valve

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10
Q

What is a normal mitral valve orifice?

A

Between 4 - 6cm2

Good dynamic range

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11
Q

What size of mitral valve orifice is stenosed?

A

<2cm2

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12
Q

Pathology of mitral stenosis

A 
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

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13
Q

What is mitral regurgitation?

A

Leaking or incompetent mitral valve

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14
Q

Causes of MVP

A

Rheumatic heart disease
Infective endocarditis
Degenerative
Functional

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15
Q

What is functional mitral valve regurg?

A

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

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16
Q

Pathology of mitral valve regurg

A

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

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17
Q

Types of aortic stenosis

A

Degenerative
Rheumatic
Bicuspid

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18
Q

Pathology of Degenerative AS

A

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

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19
Q

Pathology of rheumatic AS

A

Adhesion, fusion of the commissures and retraction and stiffening of the free cusp margins

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20
Q

Pathology of bicuspid AS

A

Two leaflet aortic valve

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21
Q

What is the commonest congenital condition that survives in adulthood?

A

Bicuspid aortic valve

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22
Q

What can happen to a bicuspid aortic valve?

A

Stenosis
Regurgitant
Both
Some no effects at all

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23
Q

Pathology of AS

A

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

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24
Q

Causes of aortic regurgitation

A 
Dilated aorta (marfans, HTN)
Connective tissue disorders 
Bicuspid aortic valve
Rheumatic heart disease
IE
Myxomatous degeneration
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25
Q

Pathology of aortic regurg

A 
LV accommodates both SV and reg volume 
Increased LVEDV and LV systolic pressure 
LV hypertrophy and LV dilatation 
Increased MVO2
Myocardial ischaemia 
LV failure
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26
Q

Presentation of MS

A 
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
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27
Q

Why can you get haemoptysis in MS?

A

Rupture of thin walled veins

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28
Q

What is mitral facies?

A

Decolourisation of nose and cheeks

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29
Q

What murmur is heard in MS? What other heart signs?

A

Tapping apex beat
DIASTOLIC THRILL (discrete)
- a blow in diastole
RV heave

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30
Q

Why does MS give the murmur it does?

A

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

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31
Q

Causes of acute MR

A

Valve perforation

Chordal/papillary muscle rupture

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32
Q

Presentation of acute MR

A

SOB (pulmonary oedema, cardiogenic shock)

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33
Q

Which valve injury is an emergency?

A

Acute MR

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34
Q

Presentation of chronic MR

A

Fatigue
Exhaustion (Low CO)
Right heart failure
SOB or palpitations due to AF

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35
Q

Signs of MR

A

Normal or reduced in HF
JVP (prominent if RH failure present)
Brisk and dynamic apex beat
RV heave

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36
Q

What heart signs are seen in MR?

A

Brisk and hyperdynamic apex beat
RV heave
REDUCED S1 and SPLIT S2

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37
Q

Pathology of murmur in MR

A 
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
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38
Q

Where is MR best heard?

A

Apex

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39
Q

Presentation of AS

A 
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
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40
Q

Heart signs with AS

A 
Vigorous and sustained apex beat
RV heave
NORMAL S1, S2 LESS AUDIBLE 
LATE PEAKING, HARSH 
Loud at base 
RADIATING TO CARTOIDS
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41
Q

Where does AS murmur radiate to?

A

Carotids

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42
Q

Where does MR murmur radiate to?

A

Axilla

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43
Q

What is the issue with acute AR?

A

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

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44
Q

Presentation of chronic AR

A

Long asymptomatic phase (incidental finding)
Exertional SOB
HF
Angina
Large hearts - dilates ventricles chronically to cope with increased volume

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45
Q

Signs of AR

A

Large volume and collapsing pulse (Corrigan sign)
Wide pulse pressure
Hyperdynamic as a volume overloaded heart, displaced apex beat

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46
Q

Heart signs of AR

A

Displaced apex beat

NORMAL S1 , NORMAL S2, EARLY DIASTOLIC MURMUR

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47
Q

Pathology of murmur of AR

A

Normal S1 - systole completely clear
Normal S2
Early diastolic, decrescendo, soft murmur

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48
Q

How to listen for murmur of AR?

A

Patients sitting forward holding out breath

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49
Q

Investigations of MS

A 
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
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50
Q

Investigations of MR

A 
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
51
Q

Investigations of AS

A 
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
52
Q

Investigations of AR

A 
ECG
- ST/T changes (LV strain)
- LAD
CXR
- cardiomegaly in chronic AR
Cardiac catheterisation 
ECHO
- AV cusp anatomy 
- LV function, dilation and hypertrophy 
CMR
53
Q

Treatment for MS

A 
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
54
Q

Treatment for acute MR

A 
Preload and afterload reduction 
- Diuretics
- Sodium nitroprusside 
- Dobutamine
- IABP 
Invertational treatment 
- mitral valve apparatus repair
- mitral valve replacement
55
Q

Treatment for chronic MR

A

Interventional treatment

  • mitral valve apparatus repair
  • mitral valve replacement
56
Q

Treatment for AS

A

Aortic valve replacement or repair

57
Q

Treatment for AR

A

Vasodilator therapy

Aortic valve replacement or repair

58
Q

Who is treatment for AS saved for?

A

Those who develop HF

59
Q

Causes of cardiac ischaemia

A 
Atherosclerosis 
Embolism 
Coronary thrombosis
Aortic dissection 
Arteritides 
Congenital
60
Q

What are Arteritides?

A

Inflammatory cells infiltrate into the walls of the artery and cause inflammation

61
Q

Presentation of ischaemic heart disease

A 
Angina
MI
Arrhythmias 
Chronic heart failure
Sudden death
62
Q

What are the dangerous heart conditions (2)?

A

Left main stem stenosis

3 vessel coronary artery disease

63
Q

Causes of valvular heart disease in adult

A 
Degenerative
Congenital 
Infection 
Inflammatory 
LV or RV dilatation 
Trauma
Neoplastic 
Paraneoplastic
64
Q

What is rheumatic fever related to?

A

Streptococcal infections

65
Q

Where is rheumatic fever common in?

A

Africa / developing countries

66
Q

What is the hallmark pathology in rheumatic fever?

A

Pancarditis (effects myocardium, pericardium and epicardium)

67
Q

What manifestations are also common in rheumatic fever?

A

Skin
- cellulite on legs
- migratory erythema (blotchy red swelling of skin)
Joint

68
Q

Pathology of chronic rheumatic fever

A

Gradually progressive MVDx +/- AVDx

69
Q

What is the most worldwide cause of death in pregnancy?

A

Chronic rheumatic fever

70
Q

What sugical technique can be used to treat IHD?

A

CABG

71
Q

Indications for CABG

A

Symptomatic (any CAD pattern)

Prognostic (LMSS, 3VDx)

72
Q

What does CABG stand for?

A

Coronary artery bypass grafting

73
Q

Selection of patients for CABG must have…

A 
Adequate 
- lung function 
- mental function 
- hepatic function 
Ascending aorta OK
Distal coronary artery targets OK
LVEG >20%
74
Q

Conduits for CABG

A

Reversed saphenous vein
Internal mammary arteries
Radial arteries

75
Q

Sternotomy problems

A

Wire infection
Pain
Sternal dehiscence
Sternal malunion

76
Q

Post op complications of cardiac surgery

A

Cardiac tamponade
Death
Stroke

77
Q

Risk of death with CABG

A

2%

78
Q

What is cardiac tamponade?

A

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

79
Q

Presentation of cardiac tamponade

A 
Primary 
- raised CVP
- Raised HR
- Low BP
Secondary 
- oliguria
- increased O2 requirements 
- metabolic acidosis
80
Q

What % of patients may need a repeat CABG?

A

5%

81
Q

Treatment of cardiac tamponade following cardiac surgery

A

Chest re-opening

82
Q

Which valves are most frequently operated on in adult cardiac surgery?

A

Aortic

Mitral

83
Q

What differentiates aortic stenosis from aortic sclerosis?

A

Loss of A2

84
Q

Is AS an easy murmur to hear?

A

Yes

85
Q

What is on an ECG/ECHO of AS?

A

LVH

86
Q

Is the murmur of AR easy to hear?

A

No

87
Q

Is murmur of MS easy to hear? What may have to be done to hear it?

A

No - if easily hear then stenosis is severe

May need to exercise the patient to hear it

88
Q

Is the murmur of MR easy to hear?

A

Yes

If loud - severe

89
Q

What is severe MR usually associated with?

A

LV and LA dilatation
Onset of AF
Pulmonary HTN

90
Q

What is severe MR on ECHO characterised by?

A

Systolic blood flow reversal into the pulmonary veins

91
Q

What does a cardiopulmonary bypass do?

A

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

92
Q

What is required with CPB?

A

Systemic anticoagulation

93
Q

What is the max time limit with CPB?

A

12 hours

94
Q

What is the max cardiac ischaemic time in CPB?

A

6 hours

95
Q

What is a common problem in CPB?

A

Coagulopathy

96
Q

Types of heart valve prosthesis

A

Biological valve

Mechanical valve

97
Q

Features of biological valve

A

No warfarin required

Wears out after 15 years

98
Q

Features of mechanical valve

A

Warfarin required for life

Valve lasts for > 40 years

99
Q

What is better for the mitral valve, repair or replacement?

A

Repair

100
Q

Who would get biological valve replacements?

A

Patients who are elderly as wont live that long

101
Q

What is the most common organism causing IE? What does it give rise to?

A

Strep viridans

Subacute bacterial endocarditis

102
Q

What is the second most common organism causing IE? What does it give rise to?

A

Staph aureus

Acute bacterial endocarditis

103
Q

Indications for surgery in IE

A

Severe valvular regurgitation
Large vegetations
Persistent pyrexia (fever)
Progressive renal failure

104
Q

In surgery for IE, what is given post op and for how long?

A

Ax IV for 6 weeks post op

105
Q

What valvular problem is associated with polycystic kidney disease?

A

Mitral valve prolapse

106
Q

What drugs are contraindicated in aortic stenosis?

A

Nitrates

107
Q

Criteria for aortic stenosis management

A

Symptoms

Aortic valve gradient of 40mmHg

108
Q

What is a clinical sign of AR?

A

De musset sign (Head bobbing)

109
Q

How can functional tricuspid regurgitation occur?

A

Secondary to pulmonary HTN as a result of chronic lung disease

110
Q

What murmurs cause an ejection systolic murmur?

A

AS
Pulmonary stenosis, HOCM
ASD
Teratology of fallot

111
Q

What murmurs cause a holosystolic (Pansystolic) murmur?

A

MR / TR (high pitched and blowing in character)

VSD (harsh in character)

112
Q

What murmurs cause a late systolic murmur?

A

MVP

Coarctation of aorta

113
Q

What murmurs cause a early diastolic murmur?

A

AR (high pitched, blowing in character)

Graham steel murmur (pulmonary regurg, high pitched and blowing in character)

114
Q

What murmurs cause a mid-late diastolic murmur?

A

MS (rumbling in character)

Austin-Flint murmur (severe AR, again rumbling)

115
Q

What causes a continuous machine like murmur?

A

PDA

116
Q

What is an atrial myxoma?

A

Commonest benign tumour most commonly occurring in the left atrium (75%) attached to the fossa ovalis

117
Q

Presentation of atrial myxoma

A 
Mitral valve obstruction 
Systemic embolization 
Constitutional symptoms
- SOB
- weight loss
- fever 
- clubbing
118
Q

Which gender gets atrial myxoma more commonly?

A

Females

119
Q

Heart signs of atrial myxoma

A

Mid diastolic murmur - ‘tumour plop’
ECHO
- pedunculated heterogenous mass typically attached to the fossa ovalis region of the interatrial septum

120
Q

What type of pulse is shown in aortic stenosis?

A

Slow rising pulse

121
Q

What type of pulse is shown in HOCM?

A

Jerky pulse

122
Q

What heart sound does pulmonary HTN cause?

A

A loud second heart sound

123
Q

Murmurs are often described using what scale?

A

Levine scale

124
Q

Describe the levine scale

A

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

CVS Pathology (19 decks)

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