Valvular heart disease - booklet Flashcards
Aortic stenosis symptoms
- Angina
- HF symptoms
- Syncope
- Initial symptom is decreased exercise tolerance or dyspnoea on exertion
Causes of aortic stenosis
- Age related
- Congenital bicuspid valve
- CKD
- Previous rheumatic fever
Murmur of aortic stenosis
- Aortic area
- Ejection systolic
- Radiating to carotid/neck
Assessment of AS
- Echocardiogram
- Quantify severity of aortic stenosis
Indications for surgery for AS
- Symptoms
- Asymptomatic severe AS with LVSD
- Asymptomatic severe AS with abnormal exercise test (symptoms, drop in BP, ST changes)
- Asymptomatic severe AS at the time of other cardiac surgery
When to consider TAVI?
- Older patients
- Significant co-morbidities
- Go via femoral artery
Aortic regurge symptoms
- Asymptomatic for many years despite significant regurge
- Increased volume load on LV leads to LV dilatation and eventually HF
- Initial symptom = exertional dyspnoea or reduced exercise tolerance
Causes of AR
- Idiopathic dilatation of aorta - pulls valve leaflets apart
- Congenital abnormalites of aortic valve (biscuspic)
- Calcific degeneration
- Rheumatic disease
- IE
- Marfans
Murmur for AR
- Left sternal edge
- Early diastolid
- Associated with collapsing pulse
- De Mussets sign (head bobbing)
Therapy for AR
ACEi - reduces afterload
Assessment of AR
Echocardiogram
Indications for surgery for AR
- Symptomatic severe
- Asymptomatic severe with evidence of early LVSD
- Asymptomatic AR of any severity with aortic root dilatation more than 5,5cm (4.5 in marfan and bicuspid)
Mitral regurge presentation
- Asymptomatic ofor many years - 16yrs average
Cause mitral regurge
- MV prolapse - more common in Marfans and Pectus Excavatum
- Rheumatic heart disease
- IHD
- IE
- Drugs
- Collagen vascular disease
When can MR be acute and severe?
- Ruptured chordae
- Ruptured papillary muscle
- IE
Murmur for MR
- Pansystolic
- Best heard mitral area
- Radiates to axilla
Indications for surgery for MR
- Symptomatic patients
- Asymptomatic with mild-moderate LV dysfunction
Medical therapy for MR
- Diuretics
- In ischaemic MR ACEi beneficial
Predisposing cardiac conditions for IE
- MV prolapse
- Prosthetic material - valves, patches but NOT stents)
- Rheumatic heart disease
- Degenerative and bicuspid aortic valve disease
- Congenital heart disease
Native valve IE organisms
Viridans streptococci
Staphylococcus aureus
IE organisms IV drug users
Staphylococcus aureus
IE early after prosthetic heart valve organsism (within 1yr)
Periop contamination
Staphylococci coagulase -ve eg staphylococcus epidermidis
BUT returns to normal list (eg SA being most common) after 2 months following surgery
Late prosthetic valve IE causes
- Viridans streptococci
- Staphylococcus aureus
- Coagulase -ve staphylococci
What does enterococci IE suggest?
Disease of GU or GI tract
When are fungi such as aspergillus and candida a cause for IE?
- Immunosupression
- IV drug use
- Cardiac surgery
- Prolonged exposure to antimicrobial drugs
- IV feeding
Why are blood cultures sometimes -ve in IE?
- Recent antimicrobials
- Infection with slow growing organisms - HACEK, streptococci, coxiella burnetti, brucella
Cause mortiality in IE
- HF
- CNS emboli
- Uncontrolled infection
Investigations for IE
- FBC
- ESR and CRP
- U&Es
- LFTs
- Urine dip and MSU
- CXR
- ECG
KEY investigations for IE
- BLOOD CULTURES - at least 3 sets at different sites over several hrs
- ECHOCARDIOGRAM - TTE or TOE if needed
Duke criteria for IE to make diagnosis
- One major and three minor
- Five minor criteria
Major Duke Criteria for IE
- Blood cultures positive for endocarditis - persistant
- Positive findings on echocardiogram
Minor Duke Criteria
- Predisposition (eg IV drug user, valvular abnormality)
- Fever above 38
- Vascular phenomena - splenic infarct, janeway lesions, ICH
- Immunological phenomena - oslers nodes, roth spots, GN
- Microbiological - positive cultures not quantifying major criteria
Treatment streptococci caused IE
- Benzylpenicillin IV (or Vancomycin if allergic) + low dose gentamicin
Endocarditis caused by enterococci treatment
- Amoxicillin (or vancomycin if allergic) + low dose gentamicin
Endocarditis caused by staphylococci abx
- Flucloxacillin (or benzylpenicillin if penicillin sensitive, vancomycin if allergic or MRSA) + gentamicin
How to check for response to therapy in IE?
- Echocardiogram - weekly
- ECG - twice per week check for aortic root abscess
- Blood tests twice weekly - ESR, CRP, FBC, U&Es
- Patients often need 6weeks or mroe of abx
When is surgery considered in IE?
- Moderate to severe cardiac failure
- Valve dehiscience
- Uncontrolled infection despite adequate abx
- Relapse after medical therapy
- Threatened or actual systemic emboli
- Coxiella burnetii and fungal infection
- Paravalvar infection eg aortic root abscess
- Sinus of valsalva aneurysm
- Valve obstruction
