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Cardiovascular System > Valvular Heart Disease Pathophysiology, Presentation and Investigation > Flashcards

Valvular Heart Disease Pathophysiology, Presentation and Investigation Flashcards

1
Q

What are the common heart valve lesions?

A

Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation

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2
Q

What are some possible causes of mitral stenosis?

A

Rheumatic heart disease
Congenital
Systemic e.g. systemic lupus erythematosus

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3
Q

What are some possible causes of mitral regurgitation?

A 
Rheumatic heart disease 
Infective endocarditis
Degenerative
Mitral valve prolapse
Ventricular and annular dilatation (functional MR)
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4
Q

What are some possible causes of aortic stenosis?

A

Degenerative
Rheumatic heart disease
Bicuspid aortic valve

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5
Q

What are some possible causes of aortic regurgitation?

A

Marfan’s
Hypertension
Connective tissue disorders

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6
Q

What is mitral stenosis?

A

Where mitral valve orifice < 2cm^2

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7
Q

What is the physiological impact of mitral stenosis?

A

Atrium-ventricle pressure gradient increases
Left atrial pressure increases
Pulmonary venous and capillary pressures increase
Pulse volume recording increases
Pulmonary arterial pressure increases and pulmonary hypertension develops
Right heart dilatation occurs with tricuspid regurgitation

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8
Q

What effect does mitral stenosis have on left ventricular pressures and systolic function?

A

Left ventricular pressures and systolic function remain normal

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9
Q

What does mitral valve stenosis severity vary with?

A

Trans-valvular pressure gradient and flow rate
Cardiac output
Heart fate

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10
Q

What are the symptoms of mitral stenosis?

A

Dyspnoea - ranging from mild exertional to pulmonary oedema
Haemoptysis (due to rupture of thin-walled veins)
Chest pain
Hoarseness (compression of left recurrent laryngeal nerve)
Infective endocarditis

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11
Q

What are the signs of mitral stenosis?

A 
Systemic embolisation - left atrial and left atrial appendage enlargement 
Mitral facies
Prominent a-wave of JVP 
Tapping apex beat
Diastolic thrill
Right ventricular heave
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12
Q

What is the effect of mitral stenosis on the pulse?

A

Pulse is normal

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13
Q

What investigations might be done for mitral stenosis?

A 
ECG  
Cardiac catheterisation
CXR
Echocardiography 
Cardiac MRI
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14
Q

What would be seen on the ECG in mitral stenosis?

A

P wave > 0.12msec, right ventricular hypertrophy

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15
Q

What would be seen on the CXR in mitral stenosis?

A

Left atrial enlargement

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16
Q

What would be seen on echocardiography in mitral stenosis?

A

Thickening and scarring of the leaflets, fusion of the commissures

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17
Q

What are the physiological effects of mitral regurgitation?

A

Regurgitant volume increases with annular enlargement
Left ventricular compensation occurs
In acute LV compensation, end diastolic pressure and volume decreases and wall tension decreases
In chronic LV compensation, end diastolic pressure increases and end systolic volume returns to normal, and eccentric left ventricular hypertrophy develops

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18
Q

What are the changes in left atrial compliance seen in mitral regurgitation?

A

Reduced - marked pressure risk, thickening of atrial myocardium, increase in PVR and remodelling of the pulmonary vasculature with PHT

Increased - marked volume enlargement, lesser changes in pulmonary vasculature, but develop in atrial fibrillation

Combination of the two may occur

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19
Q

What does the effective regurgitant orifice depend on?

A

Preload
Afterload
Left ventricular contractility

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20
Q

What are the symptoms and signs of acute mitral regurgitation?

A

Pulmonary oedema
Cardiogenic shock
Dyspnoea
(due to valve/chordal/papillary muscle perforation)

21
Q

What are the symptoms and signs of chronic mitral regurgitation?

A 
Fatigue
Exhaustion (due to low CO) 
Right heart failure 
Dyspnoea
Palpitations due to atrial fibrillation
22
Q

What might be seen on clinical examination of a patient with mitral regurgitation?

A

Normal pulse, or reduced in heart failure
Prominent JVP if right heart failure present
Brisk and hyperdynamic apex beat
Right ventricular heave
Auscultation - reduced S1, split S2, early A2, loud P2
Holosytolic murmur - blowing, loud at apex, radiation to axilla, no relationship between intensity and severity

23
Q

What investigations might be done for mitral regurgitation?

A 
ECG
CXR
Cardiac catheterisation
Echocardiography 
Cardiac MRI
24
Q

What might be seen on ECG in mitral regurgitation?

A

Left atrial enlargement - P > 0.12 msec, tall

RVH - prominent R wave in right precordial leads

25
Q

What might be seen on CXR in mitral regurgitation?

A

Cardiomegaly
Left atrial enlargement
Calcification of mitral annulus

26
Q

What might be seen on echocardiography in mitral regurgitation?

A

LV dimensions
Leaflet dysfunction
Chordae tendinae, papillary or annular disease

27
Q

What are the physical effects of rheumatic aortic stenosis?

A

Adhesion

Fusion of the commissures and retraction and stiffening of the free cusp margins

28
Q

What are the physical effects of degenerative aortic stenosis?

A

Slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins

29
Q

What are the physiological effects of aortic stenosis?

A 
Increased LV systolic pressure
Severe concentric hypertrophy and LVM 
Increased LVEDP 
Increased MV O2
Myocardial ischaemia 
LV failure
30
Q

What are the symptoms and signs of aortic stenosis?

A 
Long asymptomatic phase
Chest pain
Syncope/dizziness
Dyspnoea on exertion
Heart failure
31
Q

What might be seen on clinical examination of a patient with aortic stenosis?

A

Small volume and slow rising pulse
Prominent JVP if right heart failure present
Vigorous and sustained apex beat
RV heave
Ausculation - normal S1 but less audible A2
Late peaking harsh sounds radiating to the carotids and loud at the base

32
Q

What investigations might be done for aortic stenosis?

A 
ECG 
CXR
Cardiac catheterisation
Echocardiography 
Cardiac MRI
33
Q

What might be seen on ECG in aortic stenosis?

A

LVH voltage criteria

ST/T changes

34
Q

What might be seen on CXR in aortic stenosis?

A

Calcification of AV

35
Q

What can echocardiography demonstrate which is useful in diagnosing aortic stenosis?

A

AV cusp mobility
LV function and hypertrophy
Doppler haemodynamic assessment of pressure gradient and AVA

36
Q

What is the aetiology of aortic regurgitation?

A

Dilated aorta in Marfans/connective tissue disorders

Leaflets

  • bicuspid aortic valve
  • rheumatic heart disease
  • endocarditis
  • myxomatous degeneration
37
Q

What are the physiological effects of aortic regurgitation?

A

Left ventricle accommodates both SV and regional volume
Increased LVEDV and LV systolic pressure
LV hypertrophy and dilatation
Increased MV O2
Myocardial ischaemia
LV failure

38
Q

What are the symptoms and signs of chronic aortic regurgitation?

A

Long asymptomatic phase

Exertional breathlessness

39
Q

What are the symptoms and signs of acute aortic regurgitation?

A

Poorly tolerated - wall tension cannot acutely adapt

40
Q

What might be seen on clinical examination of a patient with aortic regurgitation?

A

Large volume collapsing pulse
Wide pulse pressure
Hyperdynamic displaced apex beat
Auscultation- normal S1 and S2, early diastolic, soft murmu

41
Q

What investigations might be done for aortic regurgitation?

A 
ECG
CXR
Cardiac catheterisation
Echocardiography 
Cardiac MRI
42
Q

What might be seen on ECG in aortic regurgitation?

A

ST/T changes

43
Q

What might be seen on CXR in aortic regurgitation?

A

Cardiomegaly in chronic AR

44
Q

What might be demonstrated in echocardiography that could be useful in the diagnosis of aortic regurgitation?

A

AV cusp anatomy - thickening, prolapsing, number of cusps, any vegetations
LV function, dilatation and hypertrophy
Doppler haemodynamic assessment of regurgitant flow

45
Q

What are the treatment options for mitral stenosis?

A

Diuretics and restriction of sodium intake
SR restoration or ventricular rate control for a-fib
Anticoagulation for all patients with a-fib
Valvotomy
MVR
Only treated medically in late/severe stages due to possibility of haemodynamic disturbance

46
Q

When is intervention indicated in mitral stenosis?

A

When patients become restricted by their symptoms

47
Q

What are the treatment options for mitral regurgitation?

A

Acute
- preload and afterload reduction e.g. sodium nitroprusside, dobutamine

Chronic

  • lack of evidence that any therapy is beneficial for haemodynamic improvement
  • LV function preservation

Mitral valve apparatus repair or replacement

48
Q

What are the treatment options for aortic stenosis?

A

Medical treatment limited to those who develop heart failure
Aortic valve replacement or repair

49
Q

What are the treatment options for aortic regurgitation?

A

Vasodilator therapy shown to delay timing for surgical intervention
Aortic valve replacement or repair

Cardiovascular System (40 decks)

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