valvular heart disease

Question 1

cardiac breathlessness

Answer 1

> related to activity (usually)
often associated with ankle swelling
orthopnoea
paroxysmal nocturnal dyspnoea (PND)

Question 2

NYHA

Answer 2

class 1 - can do whatever 
class 4 - severe limitations of minimal activity or at rest

Question 3

clinical cardiology exam

Answer 3

general appearance
arterial pulse (radial, carotid)
venous pulse (JVP)
palpation (apex, parasternal heave)
auscultation (heart sounds and murmurs)

Question 4

the signs of right HF

Answer 4

raised JVP
pitting oedema
hepatic congestion

Question 5

Apex beat

Answer 5

• normal 5th intercostal space/mid clavicle line
• tapping apex in mitral stenosis
• displaced and diffuse in left ventricular dilation (volume overload)
• displaced and heaving in LVH (pressure overload)

Question 6

what is a cardiac murmur?

Answer 6

the hearing of turbulent blood flow

Question 7

how can you describe a murmur?

Answer 7

systole or diastole?
what type of murmur?
where is it the loudest?
where does it radiate to?
what grade of murmur?
(is it influenced by respiration?)

Question 8

what is the 1st heart sound

Answer 8

the mitral and tricuspid valve closing

indicating the start of systole

Question 9

what is the 2nd heart sound

Answer 9

the aortic and pulmonary valves closing indicating the start of diastole

Question 10

what type of systolic murmurs

Answer 10

they can either be pansystolic or ejection systolic

Question 11

what type of diastolic murmur

Answer 11

can be early diastolic or mid diastolic

Question 12

where can murmurs radiate?

Answer 12

> if it radiates to carotid sinus its indicative of aortic stenosis
if it radiates to axilla then it’s indicative of mitral regurgitation

Question 13

how to grade a murmur

Answer 13

1 = very quiet 
6 = loud and audible without a stethoscope

Question 14

what is a thrill

Answer 14

ie a thrill on palpation, a vibratory sensation felt on the sky over lying an area of turbulence

Question 15

right side vs left side murmur

Answer 15

right sided murmurs typically louder with inspiration

Question 16

innocent murmur

Answer 16

soft ie less than 3/6 severity
position dependent
often early systolic (diastolic murmurs are always pathological)

Question 17

aortic stenosis murmur

Answer 17

a lot louder than an innocent one and tend to be late peaking (systolic murmur)

Question 18

murmurs

Answer 18

can either be stenotic or regurgitative or a mixture of the two

Question 19

valve stenosis

Answer 19

valves that do not open properly

Question 20

valve regurgitation

Answer 20

valves that do not close properly

Question 21

mixed valve disease

Answer 21

valves which neither open properly nor close properly

Question 22

clinical diagnosis

Answer 22

history = restriction and functional capacity
physical examination = murmurs and signs of heart failure
investigations = non-invasive - echo
invasive - cardiac catheterisation

Question 23

aortic stenosis

Answer 23

a common lesion

• degenerative (age related)
• congenital (bicuspid valve)
• rheumatic

Question 24

aortic stenosis symptoms

Answer 24

breathlessness, chest pain, dizziness/syncope

Question 25

aortic stenosis signs

Answer 25

low volume pulse, forceful displaced apex, ejection systolic murmur that can radiate to the carotids

Question 26

aortic stenosis treatment

Answer 26

• conventional valve replacement
• trans catheter aortic valve replacement (TAVI)
• balloon aortic valvotomy (BAV)

Question 27

prosthetic heart valves

Answer 27

mechanical - longevity, warfarin, younger patients

bio-prosthetic - don’t need coagulation - no warfarin, 10 years, older patients

Question 28

TAVI

Answer 28

trans catheter aortic valve implantation
deploy through the groin and deploy the valve on a balloon mounted system
>co morbidity
>previous sternotomy

Question 29

AVR

Answer 29

still preferred
long term outcomes
no contra-indications
CABG as well

Question 30

mitral regurgitation

Answer 30

different cause of mitral regurgitation 
primary = 
leaflets - prolapse
rheumatic 
myxomatous 
endocarditis 
chordae rupture = prolapse / flail leaflet  
papillary muscles rupture = ischaemic 
annular dilatin = functional

Question 31

myxomatous valves

Answer 31

are thick and billowing mitral valves

Question 32

mitral regurgitation symptoms

Answer 32

breathlessness on exertion
peripheral oedema
fatigue

Question 33

mitral regurgitation signs

Answer 33

displaced apex

pan systolic murmur (axilla)

Question 34

treatment of MR

Answer 34

medication = diuretics and ACE inhibitors
surgical = repair - prolapse
replacement - degenerative
percutaneous = clips in infancy - encouraging results

Question 35

mitral stenosis

Answer 35

rheumatic heart disease (ongoing immunological response leads to thickening of the mitral valve) is the main cause - this is where you get rheumatic fever
congenital - rare

Question 36

MS symptoms

Answer 36

breathlessness
fatigue
palpitations (AF)

Question 37

MS signs

Answer 37

malar flush
tapping apex beat
mid diastolic rumbling diastolic murmur localised to apex

Question 38

MS treatment

Answer 38

medication = diuretics and treat AF
surgery = valve replacement
balloon valvuloplasty

Question 39

aortic regurgitation

Answer 39

causes = 
endocarditis 
connective tissue disease
rheumatic 
marfans 
aortic dissection

Question 40

aortic regurgitation symptoms

Answer 40

breathlessness

Question 41

aortic regurgitation signs

Answer 41

collapsing pulse
displaced apex
early diastolic murmur left sternal edge