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Cardiovascular System > Valvular Heart Disease - Pathophysiology, Presentation & Investigation > Flashcards

Valvular Heart Disease - Pathophysiology, Presentation & Investigation Flashcards

1
Q

What is the most anterior heart valve?

A

pulmonary valve

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2
Q

Which valve lies immediately posterior to the pulmonary valve?

A

aortic valve

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3
Q

How many cusps does the mitral valve have?

What are they called?

A

2

anterior and posterior cusps of mitral valve

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4
Q

What sort of conditions are the valves of the right side of the heart normally involved in?

A

congenital diseases/abnormalities

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5
Q

What are the three main causes of mitral stenosis?

A
  • rheumatic heart disease
  • congenital mitral stenosis
  • systemic conditions
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6
Q

Which systemic conditions could lead to mitral stenosis?

2

A
  • lupus

- rheumatoid arthritis

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7
Q

Explain how a streptococcal throat infection can cause mitral stenosis.

(3)

A
  • mitral valve shares same antigens as streptococcal bacteria causing throat infection.
  • systemic antibodies not only attack the bacteria, but also attack the mitral valve.
  • leads to scarring of the valve = mitral stenosis.
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8
Q

What is the normal size of the mitral valve and what does it decrease to in mitral stenosis?

A
  • normally 4-6cm squared.

- in stenosis, <2cm squared

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9
Q

What happens to the atrioventricular pressure gradient in mitral stenosis?

A

it increases

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10
Q

What happens to the left atrial pressure in mitral stenosis?

Explain this.

A

it increases

  • blood return via pulmonary veins is greater than the volume of blood being pumped into the LV (due to narrower valve oriface) therefore LA pressure rises.
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11
Q

What happens to the pulmonary venous and capillary pressures in mitral stenosis?

Explain this.

A

it increases

Instead of being pumped into the LV, blood in the LA is flowing back through the pulmonary veins due to the increased pressure in the LA.

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12
Q

What happens to pulmonary vascular resistance (PVR) in mitral stenosis?

A

it increases

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13
Q

What happens to pulmonary arterial pressure in mitral stenosis?

What does this lead to?

A

it increases

pulmonary hypertension

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14
Q

What happens to the right side of the heart with mitral stenosis?

(3)

A
  • pulmonary hypertension leads to pulmonary and tricuspid regurgitation - this causes right heart dilation
  • leads to right heart failure.
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15
Q

What does the severity of mitral stenosis depend on?

2

A
  • trans-valvular pressure gradient

- trans-valvular flow rate

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16
Q

What increases trans-valvular flow rate, increasing the severity of mitral stenosis?

(2)

A
  • increased HR

- increased CO

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17
Q

When might heart rate increase, causing the severity of mitral stenosis to increase?

A
  • pregnancy
  • exercise
  • acute illness
  • atrial fibrilation
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18
Q

What are the clinical manifestations of mitral stenosis?

A
  • dyspnoea
  • haemoptysis
  • systemic embolisation
  • infective endocartitis
  • chest pain
  • hoarseness
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19
Q

What will cause dyspnoea in mitral stenosis?

A

on mild exertion from pulmonary oedema

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20
Q

Why might mitral stenosis cause haemoptysis?

2

A
  • rupture of thin-walled veins in the lungs

- due to increased pressure

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21
Q

How can mitral stenosis cause systemic embolisation? and

What can this lead to?

A
  • LA and LA auricle enlarge due, pressure increases
  • blood stagnates, forms emboli
  • emboli can lodge in common carotid a. and cause stroke.
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22
Q

How can mitral stenosis cause hoarseness of voice?

A

Pressure on left recurrent laryngeal nerve which innervated the voice box.

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23
Q

What might be found on clinical examination which would suggest mitral stenosis?

(6)

A
  • Mitral facies
  • normal pulse
  • JVP: prominent a wave
  • Tapping apex beat and diastolic thrill
  • RV heave
  • auscultation: faint murmur after S2
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24
Q

What is mitral facies?

A

red, blushed cheeks with cyanosed tissue around them

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25
Q

Why might a right ventricular heave be palpable in mitral stenosis?

A
  • increased left atrial pressure
  • increased pulmonary pressure
  • right ventricular hypertrophy
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26
Q

What are the investigations carried out for mitral stenosis?

5

A
  • CXR
  • ECG
  • cardiac catheterisation

Imaging:

  • echocardiogram (best investigation)
  • cardiac MRI
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27
Q

What will be seen on a CXR with mitral stenosis?

A
  • LA atrial enlargement

i. e. enlarged heart borders

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28
Q

What will be seen on an ECG of mitral stenosis?

2

A
  • may show higher R wave (RVH)

- P>0.12sec

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29
Q

What will be seen in an echocardiogram of mitral stenosis?

2

A
  • thickening and scarring of leaflets

- fusion of the commissures (where leaflets meet)

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30
Q

What can be seen on cardiac MRI of mitral stenosis?

A
  • left atrial dilatation

- LA>LV (very unusual)

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31
Q

What is the treatment of mitral stenosis?

6

A
  • diuretics
  • reduced Na intake
  • atrial fibrillation and sinus rhythm restoration or ventricular rate control
  • anti-coagulation

Surgical:

  • valvotomy
  • mitral valve replacement
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32
Q

Why might atrial fibrilation occur in mitral stenosis?

A

atrial dilatation causes abnormal electrical activity

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33
Q

What are the causes of mitral regurgitation?

A
  • Rheumatic Heart Disease
  • Mitral valve prolapse (MVP)
  • Infective endocarditis
  • degenerative
  • functional mitral regurgitation due to LV and annular dilatation.
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34
Q

What causes mitral valve prolapse?

A
  • may be genetic predisposition

- degenerative, over 50s, men

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35
Q

What factors increase the annular dilatation (orifice) and therefore the volume regurgitated through the mitral valve?

(3)

A
  • preload
  • afterload
  • LV contractility
36
Q

How does the left ventricle of the heart adapt to increased volume entering it from regurgitation in chronic mitral regurgitation?

(3)

A
  • EDV increases
  • ESV normal
  • LVH
37
Q

How does the left ventricle of the heart adapt to increased volume entering it from regurgitation in acute mitral regurgitation?

(2)

A
  • ESP/ESV decrease

- wall tension decrease

38
Q

What happens to the left atrium in chronic mitral regurgitation if it adapts/complys?

(3)

A
  • enlargement of LA
  • less changes in pulmonary vasculature
  • may develop AF
39
Q

What happens to the left atrium in chronic mitral regurgitation if it does not adapt/comply?

(3)

A
  • LA pressure rise
  • atrial myocardium thickens
  • PVR increases
  • develops pulmonary hypertension
  • remodelling of pulmonary vasculature
40
Q

What are the acute causes of mitral valve regurgitation?

A

Valve, chordae tendinae or papillary muscle perforation.

41
Q

What are the symptoms/clinical manifestations of acute mitral valve regurgitation?

(2)

A
  • breathlessness (as a result of pulm. oedema)

- cardiogenic shock

42
Q

What is cardiogenic shock?

A

heart suddenly can’t pump enough blood to meet your body’s needs

43
Q

Why is acute mitral regurgitation a clinical emergency?

A
  • blood floods back into an atrium which is unadapted to the increased volume and pressure.
44
Q

What are the clinical presentations of chronic mitral regurgitation?

(5)

A
  • fatigue
  • exhaustion
  • right heart failure
  • dyspnoea
  • palpitations
45
Q

What causes fatigue and exhaustion in chronic mitral regurgitation?

A

Low CO

46
Q

What cause dyspnoea and palpitations in mitral regurgitation?

A

atrial fibrillation

47
Q

What are the signs of mitral regurgitation?

5

A
  • normal pulse (low in HF)
  • JVP: prominent with R hypertrophic failure)
  • hyperdynamic apex beat
  • right ventricular heave
  • murmur during systole
48
Q

What will be heard on auscultation in mitral regurgitation?

A
  • reduced S1 (leaflets not in close contact)
49
Q

Which investigations are used to diagnose mitral regurgitation?

(4)

A
  • ECG
  • CXR
  • Echocardiogram
  • cardiac MRI
50
Q

What does mitral regurgitation show up as on ECG?

2

A
  • P wave >0.12 sec/tall = LA enlargement

- prominent R wave in R precordial leads = RVH

51
Q

What will be seen in a CXR in mitral regurgitation?

3

A
  • cardiomegaly
  • LA enlargement
  • calcification of mitral annulus
52
Q

What can an echocardiogram be used to assess in mitral regurgitation?

(2)

A
  • leaflet, chordae or papillary dysfunction, annular disease

- severity of MR and pulmonary artery pressure.

53
Q

What can a cardiac MRI be used to assess in mitral regurgitation?

(2)

A
  • accurate cardiac volumes (EDV)

- volumetric analysis of regurgitation volume

54
Q

What are the non-surgical treatments for acute mitral regurgitation?

(3)

A

Reduce preload/afterload

  • nitroprusside (NO = vasodilator)
  • doputamine (B1-agonist, increases contractility but not HR)
  • IABP (intra-aortic balloon pump, decreases afterload)
55
Q

What are the non-surgical treatment for chronic mitral valve regurgitation?

A

there isn’t much

56
Q

What are the surgical interventions for mitral valve regurgitation?

(2)

A
  • MV apparatus repair

- MVR

57
Q

What are the causes of aortic valve stenosis?

3

A
  • degeneration
  • rheumatic heart disease
  • congenital bicuspid aortic valve
58
Q

What does bicuspid aortic valve cause?

A

aortic stenosis or regurgitation

59
Q

How dies rheumatic heart disease affect the aortic valve to cause stenosis?

A
  • adhesion and fusion of the commissures

- retraction and stiffening of the free cusp margins

60
Q

What are the degenerative changes in the aortic valve that cause stenosis?

(3)

A
  • inflammatory process

- thickening and calcification of the cusps.

61
Q

What is degeneration of the aortic valve associated with?

A

atherosclerosis

62
Q

Describe the pathophysiology of aortic stenosis?

A
  • ventricular systolic P increase
  • increased LVH/mass
  • increased left ESP
  • increased LA pressure
  • pulmonary hypertension
  • increased O2 use
  • leads to ischaemia
  • LV failure
63
Q

When do symptoms of aortic stenosis commonly occur?

A

after a long asymptomatic phase of about 50-60 years

64
Q

What are the cardinal symptoms of aortic stenosis?

4

A
  • angina
  • syncope
  • Breathlessness on exertion
  • Heart failure
65
Q

what are the clinical manifestations of aortic stenosis?

5

A
  • slow/rising pulse
  • JVP: present in RHF, low BP
  • vigorous apex beat (because of LVH)
  • RV heave
  • systolic murmur with crescendo-decrescendo sound
66
Q

Where will a murmur form aortic stenosis radiate to?

A

the carotid arteries

67
Q

Where will a murmur from mitral regurgitation radiate to?

A

the axilla

68
Q

What are the investigations for aortic stenosis?

4

A
  • ECG
  • CXR
  • Echocardiogram
  • cardiac MRI
69
Q

What does an ECG of aortic stenosis look like?

2

A
  • signs of LVH

- ST/T changes (LV strain)

70
Q

What will a CXR show on a patient with aortic stenosis?

A

calcification of aortic valve, but not specific to

71
Q

What can an echocardiogram be used to assess in aortic stenosis?

(3)

A
  • aortic valve cusp motility
  • LV function and hypertrophy
  • Doppler haemodynamic assessment of pressure gradient and aortic valve area
72
Q

To who are the non-surgical treatment of aortic valve stenosis limited to?

A

Limited to those who develop heart failure

73
Q

What is the surgical treatment of aortic stenosis?

A

aortic valve replacement or repair

74
Q

What are the causes of aortic regurgitation?

6

A

Aorta:

  • aortic dilatation
  • connective tissue disorders

Leaflets:

  • bicuspid aortic valve
  • rheumatic heart disease
  • endocarditis
  • moxymatous degeneration (prolapse)
75
Q

Describe the pathology of aortic regurgitation.

7

A
  • LV accommodates both SV and regurgitated V
  • increased EDV
  • increased systolic pressure
  • LVH/dilation
  • increased O2 consumption
  • myocardial ischaemia
  • LV failure
76
Q

What are the symptoms of chronic aortic regurgitation?

2

A
  • Long asymptomatic phase

- Exertional breathlessness

77
Q

Why is acute aortic regurgitation a medical emergency?

3

A
  • sudden backflow of blood into an unadapted LV.
  • pressure back into LA
  • to PV
  • cardiogenic shock
78
Q

What are the clinical signs of aortic regurgitation?

4

A
  • pulse = large/falling
  • wide pulse pressure (systolic high, diastolic low)
  • hyperdynamic and displaced apex beat
  • early diastolic, decrescendo murmur
79
Q

Why does the pulse of a patient with an aortic regurgitation have a large volume?

A

LVH pushes a lot of blood out

80
Q

Why does the pulse if a patient with aortic regurgitation collapse?

A

As blood travels back into the ventricle through the aortic valve in diastole.

81
Q

What are the investigations carried out for aortic regurgitation?

(4)

A
  • ECG
  • CXR
  • Echocardiogram
  • cardiac MRI
82
Q

What is seen on a ECG of a patient with aortic regurgitation?

(2)

A

ST/T changes (LV strain), LA dilation

83
Q

What can a CXR show in aortic regurgitation?

A

cardiomegaly (in chronic cases)

84
Q

what can be seen on an echocardiogram in aortic regurgitation?

(3)

A
  • thickening/prolapsing of cusp
  • LV function, hypertrophy and dilatation
  • Doppler haemodynamics to assess regurgitant flow
85
Q

What are the treatments of aortic regurgitation?

A

vasodilator therapy (delays need for surgery)

Cardiovascular System (37 decks)

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