Valvular Heart Disease

Question 1

Normal size of opening of mitral valve

Answer 1

4-6cm

Question 2

Aetiology of mitral stenosis

Answer 2

Rheumatic heart disease
Congenital MS
Systemic conditions

Question 3

Classification of mitral stenosis and pathophysiology

Answer 3

MV orifice<2cm

A-V pressure gradient increases
LA pressure increases
Pulmonary venous and capillary pressures increase
PVR increases
Pulmonary hypertension develops
RH dilatation
Left heart will be normal

Question 4

Symptoms of mitral stenosis

Answer 4

Dyspnoea which could include pulmonary oedema
Haemoptysis due to rupture of capillaries
Systemic embolization due to enlargements of left atrium
IE
Chest pain
Hoarseness due to compression of left recurrent laryngeal nerve

Question 5

Clinical examination for mitral stenosis

Answer 5

Red cheeks
Normal pulse
Prominent A wave in JVP
Tapping apex beat with diastolic thrill
RV heave
Sound between S2 and S1

Question 6

Investigations for mitral stenosis

Answer 6

ECG (not great but if P>0.12s)
CXR (LA enlargement)
Echocardiography (can see the narrowing)
Cardiac magnetic resonance

Question 7

Treatment for mitral stenosis

Answer 7

Diuretics and restricted Na intake

If AF then SR restoration or ventricular rate control and anticoagulation

Question 8

Aetiology of mitral regurgitation

Answer 8

Rheumatic heart disease
Mitral valve prolapse (more common)
IE
Degenerative
Functional due to LV and annular dilatation (the left ventricular is hypertrophic and pulls apart it's valve)

Question 9

Pathophysiology of MR

Answer 9

Not a fixed ERO (effective regurgitant orifice) as depends on preload, afterload and LV contractility
LV will compensate

Question 10

LV compensation in acute MR

Answer 10

ESP and ESV drop and wall tension drops

Question 11

LV compensation in chronic MR

Answer 11

EDV increases so ESV returns to normal but eccentric LVH develops

Question 12

LA compliance in MR

Answer 12

Can be increased, reduced or a combination

Reduced because of the pressure rise, a thickening of the atrial myocardium, increase in PVR and remodeling with PHT

Increased because of the volume enlargement but AF

Question 13

Acute MR clinical signs

Answer 13

Breathlessness, pulmonary oedema, cardiogenic shock

Question 14

Chronic MR signs

Answer 14

Fatigue, exhaustion (low CO), right heart failure, dyspnoea or palpitations due to AFib

Question 15

Clinical examination signs of MR

Answer 15

Normal or reduced pulse in heart failure
JVP prominent if RH failure present
Brisk and hyperdynamic apex beat
RV heave
On auscultation, reduced S1 and split s2

Question 16

Laboratory investigations for MR

Answer 16

ECG: LA enlargement so p>0.12s and RVH (prominent R wave in R precordial leads)

CXR: cardiomegaly, LA enlargement, calcification of mitral annulus

Question 17

Treatment for mitral regurgitation

Answer 17

For acute, preload and afterload reduction (sodium nitroprusside, dobutamine)

For chronic, maybe LV function preservation

Question 18

Normal size of aortic valve

Answer 18

3-4cm

Question 19

Aetiology of aortic valve stenosis

Answer 19

Degenerative
Rheumatic
Could be bicuspid instead of tricuspid

Question 20

Size of stenosis aortic valve

Answer 20

<1.5-2cm2

Question 20

Size of stenosis aortic valve

Answer 20

<1.5-2cm2

Question 21

Rheumatic aortic stenosis

Answer 21

Adhesion, fusion and retraction

Question 22

Degenerative aortic stenosis

Answer 22

Linked to arthrosclerosis, a slow inflammatory process resulting in thickening and calcification of the cusps from bases to free margins

Question 23

Effects of AS on the heart

Answer 23

Increased LV systolic pressure
Hypertrophy
Increased LVEDP
PHT
Increased MVO2
Myocardial ischemia
LV failure

Question 24

Symptoms of AS

Answer 24

Has a long asymptomatic phase | Chest pain, syncope/dizziness, breathlessness, heart failure

Question 25

Clinical examination for AS

Answer 25

``` Small pulse volume that's slowly rising Prominent JVP if right heart failure Low BP Vigourous and sustained apex beat RV heave Late peaking on auscultation which is loud at base and radiates to carotids ```

Question 26

Laboratory examination for AS

Answer 26

ECG: LV strain CXR calcification Echocardiography shows LV function and hypertrophy

Question 27

Medical treatment for AS

Answer 27

Only for heart failure

Question 28

Aetiology of AR at aorta

Answer 28

Dilated aorta | Connective tissue disorders

Question 29

Aetiology of AR

Answer 29

Bicuspid aortic valve Rheumatic heart disease Endocarditis Myxomatous degeneration

Question 30

Cause of LV failure in AR

Answer 30

``` LV accommodates SV and regVol Increased pressure Hypertrophy and dilatation Increased MVO2 Myocardial ischemia ```

Question 31

Symptoms of AR

Answer 31

Chronic - long asymptomatic then exertional breathlessness Acute- poorly tolerated as wall tension can't adapt

Question 32

Clinical examination of AR

Answer 32

Large volume and collapsing pulse Wide pulse pressure Hyperdynamic, displaced apex beat Early diastolic with decrescendo but normal S1 and S2

Question 33

Lab investigations of AR

Answer 33

ECG: ST change as LV strain CXR: cardiomegaly in chronic Echocardiography: thickening,prolapse, vegetations, number of cusps, LV function, dilatation and hypertrophy Doppler assessment of regurgitation flow

Question 34

Medical treatment of AR

Answer 34

Vasodilators delay timing for surgery

Question 34

Medical treatment of AR

Answer 34

Vasodilators delay timing for surgery

Question 35

Causes of cardiac ischaemia

Answer 35

``` Arthrosclerosis Embolism Coronary thrombosis Aortic dissection Arteritides(inflammation) Congenital ```

Question 36

Manifestations (results) of IHDx

Answer 36

``` Angina MI Arrythmias Chronic heart failure Sudden death ```

Question 37

2 most dangerous types of coronary artery disease

Answer 37

Left main stem stenosis or 3 vessel artery disease

Question 38

When would coronary artery bypass grafting surgery be done

Answer 38

If any CAD is symptomatic | Or if it's LMSS or 3VDx

Question 39

Patient criteria for CABG

Answer 39

Adequate Lung, mental, hepatic function Ascending aorta and distal coronary artery targets OK LV EF>20%

Question 40

What vessels can be used in CABG

Answer 40

Reversed saphenous vein (back of leg) Internal mammary arteries Radial arteries

Question 41

Problems from sternotomy

Answer 41

Wire infection Painful wires Sternal dehiscence Sternal malunion

Question 42

Post operative problems in cardiac surgery

Answer 42

Cardiac tamponade (large pericardial effusion) Death Stroke

Question 43

Cardiac tamponade after surgery

Answer 43

Fluid around the heart. Primary features are raised CVP, tachycardia, low BP Secondary features are oliguria, needing more oxygen and metabolic acidosis Treated by chest reopening

Question 44

Long-term outcomes of CABG

Answer 44

50% have no further cardiac problems 10 years later Majority of problems are minor and can be controlled with medication 5% need a repeat CABG

Question 45

Main types of surgery for ages

Answer 45

Adult- aortic and mitral valves | Paediatrics- all four with roughly equal frequency

Question 46

Three most common valve problems needing surgery in Aberdeen

Answer 46

Senile tricuspid AS Bicuspid AS Degenerative MR

Question 47

Rheumatic fever

Answer 47

A relapsing illness related to streptococcal infections. Causes pancarditis (whole heart inflammation) with skin and joint manifestations and Sydenham's chorea/st Vitus dance Treated with aspirin and bed rest

Question 48

Chronic rheumatic heart disease

Answer 48

Gradually progressive MVDx and AVDx , worldwide most common heart problem Causes death in pregnancy and sometimes means cardiac surgery is performed during pregnancy

Question 49

Organisms that causes endocarditis

Answer 49

Strep viridans - subacute | Then staph. Aureus - acute

Question 50

Chances of cures with different valves for endocarditis

Answer 50

NVE- 90% chance with ABx PVE- 50% chance with ABx Chances cute higher for viridans too

Question 51

Indications for endocarditis surgery

Answer 51

Severe valvular regurgitation Large vegetations Persistent pyrexia Progressive renal failure Give IV ABx 6 weeks after surgery

Question 52

Aortic stenosis

Answer 52

HF, angina, syncope, incidental Easily heard murmur and loss of aortic S2 LVH, AV gradient of over 59mmHg AVR for severe

Question 53

Aortic regurgitation

Answer 53

HF, angina or incidental Difficult murmur AVR for severe especially with LV regurgitation In severe, LV is filled with contrast after one diastolic interval during aortography

Question 54

Mitral stenosis

Answer 54

Difficult murmur unless severe or exercised May have presystolic accentuation Surgery if MVA on echo is <1.5cm

Question 55

Mitral regurgitation

Answer 55

Easy murmur Associated with LV and LA dilatation and AF and pulmonary hypertension if severe MVR if severe On echo, systolic blood flow reversal in pulmonary veins (severe)

Question 56

Cardiopulmonary bypass

Answer 56

Blood drained from RA and returned to AA CFB machine operated by perfusionists takes over heart and lung Systemic anticoagulation used and induced hypothermia There will be non-pulsatile flow and max time is 12 hours. Maximum cardiac ischaemic time is 6. Air embolism is more common in open cardiac surgery eg valve replacement than CABG

Question 57

Choice of heart valve prosthesis

Answer 57

Biological don't need warfarin but wear out after 15 years Mechanical do but wear out after 40 Mitral valve repair can be possible in degenerative MR instead of replacement

Question 58

Choice of heart valve prosthesis

Answer 58

Biological don't need warfarin but wear out after 15 years Mechanical do but wear out after 40 Mitral valve repair can be possible in degenerative MR instead of replacement