Valvular heart disease

Question 1

What are the core symptoms of aortic stenosis?

Answer 1

Angina

Syncope

Heart failure

Question 2

What symptom usually presents first in aortic stenosis?

Answer 2

Decreased exercise tolerance

Dyspnoea on exertion

Question 3

What are the most common causes of aortic stenosis?

Answer 3

Age related calcification

Second most common cause is congenital bicuspid valve.

Rheumatic fever

Chronic kidney disease

Question 4

How would you describe an aortic stenosis murmur?

Answer 4

Ejection systolic murmur that radiates to the carotids.

Presents as a crescendo-decrescendo murmur.

Question 5

How would you diagnose aortic stenosis?

Answer 5

Echocardiography

Question 6

When is surgery indicated for aortic stenosis?

Answer 6

If a patient is symptomatic

Asymptomatic severe AS with left ventricular systolic dysfunction

Asymptomatic severe AS with abnormal exercise test

Asymptomatic severe AS at the time of other cardiac surgery (eg. CABG)

Question 7

What procedure should be considered in patients who have significant co-morbidities who require surgical intervention for aortic stenosis?

Answer 7

TAVI - Transcatheter aortic valve implantation

Question 8

What pathological changes occur in a patient with chronic aortic regurgitation?

Answer 8

Left ventricular dilatation and resultedly heart failure.

Question 9

What is the most common initial symptom in aortic regurgitation?

Answer 9

Exertional dyspnoea/reduced exercise tolerance.

Question 10

What are the most common causes of aortic regurgitation?

Answer 10

Idiopathic

Degeneration of the valve - age related calcification

Rheumatic disease

Infective endocarditis

Marfans syndrome

Question 11

How would you describe an aortic regurgitation murmur?

Answer 11

An early diastolic blowing murmur that is associated with a collapsing pulse and De Musset’s sign (head bobbing)

Question 12

What is the management for patients with aortic regurgitation?

Answer 12

ACE inhibitor to reduce the after load

Surgery indicated in patients with:

• Symptomatic severe AR
• Asymptomatic severe AR with evidence of early LV dysfunction
• Asymptomatic AR with aortic root dilatation

Question 13

What is the prognosis for mitral regurgitation?

Answer 13

Patients can have had it for years without ever knowing and often intervention is not required throughout life.

Question 14

When is surgery indicated in patients with mitral regurgitation?

Answer 14

Symptomatic patients

Asymptomatic patients with mild-moderate LV dysfunction.

Question 15

What pharmacological management can be used in patients with mitral regurgitation?

Answer 15

Diuretics

ACE inhibitors and beta blockers have been shown to be beneficial in patients with ischaemic disease.

Question 16

What conditions can predispose a patient to suffering with infective endocarditis?

Answer 16

Mitral valve prolapse

Prosthetic valves

Rheumatic heart disease

Degenerative and bicuspid aortic valve disease

Question 17

What are the most common causative organisms for infective endocarditis?

Answer 17

Staphylococcus aureus in the UK (due to IVDU)

Streptococcus viridans

Question 18

If someone presents with infective endocarditis less than 1 year after having a prosthetic valve placed, what bacteria is this likely to be due to?

Answer 18

Coagulase negative Staphylococci

Question 19

What are ‘late’ prosthetic valve infections commonly due to?

Answer 19

Streptococcus viridans

Staphylococcus aureus

Coagulase negative Staphylococci

Question 20

When should you suspect infective endocarditis in a cardiac patient?

Answer 20

When a patient presents with an unexplained fever, bacteraemia or systemic illness and/or with a new murmur or other features of the illness.

Question 21

What routine investigations should be carried out for patients with suspected infective endocarditis?

Answer 21

U+E
LFT
FBC 
Blood culture 
Urine dipstick analysis and MSU MC
ESR
CRP
CXR
ECG

Question 22

What are the key diagnostic investigations for infective endocarditis?

Answer 22

Blood cultures and an transthoracic echocardiogram initially. However transoesophageal echocardiogram is more sensitive.

Question 23

What are the requirements for diagnosis of infective endocarditis using blood cultures?

Answer 23

At least 3 sets of cultures should be taken from different sites over several hours. Antibiotics should be withheld if possible whilst these cultures are being taken.

Question 24

What are the major criteria for diagnosis of infective endocarditis?

Answer 24

New valvular regurgitation

Blood cultures positive

Signs of endocardial involvement on the echocardiogram

Positive echo findings - eg. vegetations/abscess

Dehiscence of the prosthesis

Question 25

What are the minor criteria for diagnosis of infective endocarditis?

Answer 25

Predisposing valvular or cardiac abnormality

IV drug user

Pyrexial >38oC

Embolic/vasculitis phenomenon

Blood cultures suggestive of atypical organism

Suggestive echo findings but not meeting the major criteria

Question 26

How many major/minor criteria are required for a diagnosis?

Answer 26

2 major or one major and three minor or five minor criteria.

Question 27

What is the management of a patient with infective endocarditis caused by the following

1) Streptococcus viridans
2) Staphylococcus aureus
3) Enterococcus faecalis

Answer 27

1) Viridans streptococci - benzylpenicillin IV plus low dose gentamicin. Vancomycin and gentamicin if the px is penicillin allergic
2) Flucloxacillin plus gentamicin
3) Amoxicillin IV plus low dose gentamicin

Question 28

How should you monitor a patient with infective endocarditis?

Answer 28

Weekly echo’s

ECG twice weekly

Blood tests twice weekly