Valvular heart disease - booklet

Question 1

Aortic stenosis symptoms

Answer 1

• Angina
• HF symptoms
• Syncope
• Initial symptom is decreased exercise tolerance or dyspnoea on exertion

Question 2

Causes of aortic stenosis

Answer 2

• Age related
• Congenital bicuspid valve
• CKD
• Previous rheumatic fever

Question 3

Murmur of aortic stenosis

Answer 3

• Aortic area
• Ejection systolic
• Radiating to carotid/neck

Question 4

Assessment of AS

Answer 4

• Echocardiogram
• Quantify severity of aortic stenosis

Question 5

Indications for surgery for AS

Answer 5

• 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

Question 6

When to consider TAVI?

Answer 6

• Older patients
• Significant co-morbidities
• Go via femoral artery

Question 7

Aortic regurge symptoms

Answer 7

• 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

Question 8

Causes of AR

Answer 8

• Idiopathic dilatation of aorta - pulls valve leaflets apart
• Congenital abnormalites of aortic valve (biscuspic)
• Calcific degeneration
• Rheumatic disease
• IE
• Marfans

Question 9

Murmur for AR

Answer 9

• Left sternal edge
• Early diastolid
• Associated with collapsing pulse
• De Mussets sign (head bobbing)

Question 10

Therapy for AR

Answer 10

ACEi - reduces afterload

Question 11

Assessment of AR

Answer 11

Echocardiogram

Question 12

Indications for surgery for AR

Answer 12

• 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)

Question 13

Mitral regurge presentation

Answer 13

• Asymptomatic ofor many years - 16yrs average

Question 14

Cause mitral regurge

Answer 14

• MV prolapse - more common in Marfans and Pectus Excavatum
• Rheumatic heart disease
• IHD
• IE
• Drugs
• Collagen vascular disease

Question 15

When can MR be acute and severe?

Answer 15

• Ruptured chordae
• Ruptured papillary muscle
• IE

Question 16

Murmur for MR

Answer 16

• Pansystolic
• Best heard mitral area
• Radiates to axilla

Question 17

Indications for surgery for MR

Answer 17

• Symptomatic patients
• Asymptomatic with mild-moderate LV dysfunction

Question 18

Medical therapy for MR

Answer 18

• Diuretics
• In ischaemic MR ACEi beneficial

Question 19

Predisposing cardiac conditions for IE

Answer 19

• MV prolapse
• Prosthetic material - valves, patches but NOT stents)
• Rheumatic heart disease
• Degenerative and bicuspid aortic valve disease
• Congenital heart disease

Question 20

Native valve IE organisms

Answer 20

Viridans streptococci
Staphylococcus aureus

Question 21

IE organisms IV drug users

Answer 21

Staphylococcus aureus

Question 22

IE early after prosthetic heart valve organsism (within 1yr)

Answer 22

Periop contamination
Staphylococci coagulase -ve eg staphylococcus epidermidis

BUT returns to normal list (eg SA being most common) after 2 months following surgery

Question 23

Late prosthetic valve IE causes

Answer 23

• Viridans streptococci
• Staphylococcus aureus
• Coagulase -ve staphylococci

Question 24

What does enterococci IE suggest?

Answer 24

Disease of GU or GI tract

Question 25

When are fungi such as aspergillus and candida a cause for IE?

Answer 25

* Immunosupression * IV drug use * Cardiac surgery * Prolonged exposure to antimicrobial drugs * IV feeding

Question 26

Why are blood cultures sometimes -ve in IE?

Answer 26

* Recent antimicrobials * Infection with slow growing organisms - HACEK, streptococci, coxiella burnetti, brucella

Question 27

Cause mortiality in IE

Answer 27

* HF * CNS emboli * Uncontrolled infection

Question 28

Investigations for IE

Answer 28

* FBC * ESR and CRP * U&Es * LFTs * Urine dip and MSU * CXR * ECG

Question 29

KEY investigations for IE

Answer 29

* BLOOD CULTURES - at least 3 sets at different sites over several hrs * ECHOCARDIOGRAM - TTE or TOE if needed

Question 30

Duke criteria for IE to make diagnosis

Answer 30

* One major and three minor * Five minor criteria

Question 31

Major Duke Criteria for IE

Answer 31

* Blood cultures positive for endocarditis - persistant * Positive findings on echocardiogram

Question 32

Minor Duke Criteria

Answer 32

* 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

Question 33

Treatment streptococci caused IE

Answer 33

* Benzylpenicillin IV (or Vancomycin if allergic) + low dose gentamicin

Question 34

Endocarditis caused by enterococci treatment

Answer 34

* Amoxicillin (or vancomycin if allergic) + low dose gentamicin

Question 35

Endocarditis caused by staphylococci abx

Answer 35

* Flucloxacillin (or benzylpenicillin if penicillin sensitive, vancomycin if allergic or MRSA) + gentamicin

Question 36

How to check for response to therapy in IE?

Answer 36

* 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

Question 37

When is surgery considered in IE?

Answer 37

* 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