Valvular heart disease (brief)

Question 1

How common is it?

Answer 1

Mitral Regurgitation: Commonest valvular lesion. 2% prevalence

Mitral Stenosis: Prevalence <1% in west, commoner in Asia and Africa

Aortic Stenosis: Prevalence 1-2% in over 65s

Aortic regurgitation (AR): <1% prevalence

Question 2

What causes it?

Answer 2

Mitral Regurgitation: MV prolapse (congenital or rupture of chordae/papillary muscles), rheumatic disease, endocarditis, connective tissue disorder

Mitral Stenosis: Rheumatic heart disease

Aortic Stenosis: Calcific degeneration, bicuspid valve, rheumatic disease

Aortic regurgitation (AR): Rheumatoid, endocarditis, aortic dissection, Marfan’s and other connective tissue disorders, calcific degeneration, trauma.

Question 3

Signs on examination?

Answer 3

Mitral Regurgitation: Acute MR presents with signs of CCR (congestive cardiac failure). Chronic MR causes exertional dyspnoea, orthopnea. Displaced apex beat, soft S1, pansystolic murmur loudest at apex radiating to axilla. AF in 80%.

Mitral Stenosis: Dyspnoea, bronchitis, haemoptysis, AF, left parasternal heave, tapping apex beat, loud S1, rumbling mid-diastolic murmur at apex.

Aortic Stenosis: Triad of angina, syncope, dyspnoea. Sudden death. Slow rising, low volume pulse, heaving apex beat, reversed splitting S2, ejection systolic murmur loudest in the aortic area radiating to carotids.

Aortic regurgitation (AR): Acute AR (endocarditis) presents with signs of LVF. Chronic AR often asymptomatic. Later orthopnoea, fatigue, dyspnoea. Signs of wide pulse pressure, collapsing water hammer pulse, Quinke’s sign (nail bed pulsitation), corrigans sign (visible neck pulsitation), De Musset’s sign (head nodding), Duroziers sign (femoral diastolic murmur), hyperdynamic misplaced apex beat, early diastolic murmur, Austin Flint mid-diastolic murmur due to regurgitant stream hitting anterior MV cusp.

Question 4

Signs on examination?

Answer 4

Mitral Regurgitation: Acute MR presents with signs of CCR (congestive cardiac failure). Chronic MR causes exertional dyspnoea, orthopnea. Displaced apex beat, soft S1, pansystolic murmur loudest at apex radiating to axilla. AF in 80%.

Mitral Stenosis: Dyspnoea, bronchitis, haemoptysis, AF, left parasternal heave, tapping apex beat, loud S1, rumbling mid-diastolic murmur at apex.

Aortic Stenosis: Triad of angina, syncope, dyspnoea. Sudden death. Slow rising, low volume pulse, heaving apex beat, reversed splitting S2, ejection systolic murmur loudest in the aortic area radiating to carotids.

Aortic regurgitation (AR): Acute AR (endocarditis) presents with signs of LVF. Chronic AR often asymptomatic. Later orthopnoea, fatigue, dyspnoea. Signs of wide pulse pressure, collapsing water hammer pulse, Quinke’s sign (nail bed pulsitation), corrigans sign (visible neck pulsitation), De Musset’s sign (head nodding), Duroziers sign (femoral diastolic murmur), hyperdynamic misplaced apex beat, early diastolic murmur, Austin Flint mid-diastolic murmur due to regurgitant stream hitting anterior MV cusp.

Question 5

Investigations

Answer 5

Mitral Regurgitation: CXR shows cardiomegaly. Transthoracic ECHO diagnostic.

Mitral Stenosis: CXR shows splaying of carina (enlarged LA). Echo diagnostic.

Aortic Stenosis: ECG shows LV hypertrophy, transthoracic echo diagnostic.

Aortic regurgitation (AR): CXR shows cardiomegaly. Transthoracic echo diagnostic.

Question 6

Treatment

Answer 6

Mitral Regurgitation: Surgery if acute or severe chronic

Mitral Stenosis: Surgery if MC area <1cm2 (normal valve 3-4cm2)

Aortic Stenosis: Surgery if symptomatic

Aortic regurgitation (AR): Acute AR is a surgical emergency. Chronic AR is operated on before ejection fraction <55%, or LV dilates >5.5.cm