Valvular heart diseases

Question 1

Describe the murmur heard in a patient with aortic stenosis

Answer 1

• Ejection systolic.
• Crescendo-decrescendo (‘diamond-shaped’), meaning it gets louder and then goes quiet.

Question 2

Describe the murmur heard in aortic regurgitation.

Answer 2

• Early diastolic,
• High-pitched and blowing in nature (decrescendo)

Question 3

Describe the murmur heard in mitral stenosis.

Answer 3

• Mid diastolic murmur.
• Low-pitched and rumbling.
• Opening snap.

Question 4

Describe the murmur heard in mitral regurgitation.

Answer 4

Pansystolic (a.k.a. holosystolic). High-pitched and blowing.

Question 5

What can a collapsing (Corrigan’s) pulse indicate?

Answer 5

Aortic regurgitation or PDA.

Question 6

Radiation into carotids is suggestive of ____________.

Answer 6

Aortic stenosis.

Question 7

What might a radio-radial delay indicate?

Answer 7

Aortic coarctation
Subclavian stenosis
Aortic dissection
Aneurysm

Mechanism: the narrowing of one of the vessels affects blood flow to one arm more than the other.

Question 8

S1 sound signifies….

Answer 8

Mitral and tricuspid valve closure.

Question 9

Are left-sided murmurs easier to hear on expiration or inspiration?

Answer 9

Expiration.

‘RILE’ = Right -inspiration, Left - expiration.

Question 10

How does aortic stenosis affect blood pressure and pulse character?

Answer 10

Slow-rising pulse (usually carotids - diminshed and delayed upstroke) and Narrowed pulse pressure, often defined as less than 25-30 mmHg.

Occurs due to reduced stroke volume and increased afterload from the narrowed aortic valve, resulting in low systolic and relatively higher diastolic blood pressures.

Question 11

Mitral stenosis murmur accentuation manoeuvre.

Answer 11

Left lateral decubitus position. Expiration.

Question 12

Causes of mitral stenosis.

Answer 12

Rheumatic heart fever.
Mitral annular calcification.
Autoimmune conditions (e.g., SLE).
Congenital mitral valve dysfunction.

Question 13

Causes of mitral regurgitation.

Answer 13

Mitral valve prolapse.
Rheumatic fever.
Myocardial infarction.
Infective endocarditis.
Cardiomyopathy.

Question 14

What are the leading causes of aortic stenosis?

Answer 14

• Age-related calcification
• Congenital unicuspid/bicuspid aortic valve
• Rheumatic fever
• • any processes that might cause inflammatory changes in valve e.g. hypertension, infective endocarditis, dyslipidaemia

Question 15

What aortic valve change usually precedes stenosis? What clinical sign might help you differentiate this?

Answer 15

Aortic sclerosis. (senile degenerative change)

Ejection systolic murmur but no carotid radiation, and normal pulse character/volume.

Question 16

What is usually the first symptom of aortic stenosis?

Answer 16

Exertional dyspnoea.

Question 17

What is the classical triad of aortic stenosis symptoms?

Answer 17

‘SAD’: syncope, angina, and dyspnoea (exertional)

Other symptoms: palpitations, fatigue, heart failure symptoms.

Question 18

Possible ECG findings in aortic stenosis

Answer 18

Left ventricular hypertrophy (increased effort to pump blood)

e.g. Increased QRS voltage, absent Q waves, left axis deviation

Question 19

Definition of mean pressure gradient.
e.g. in aortic stenosis

Measured in echocardiogram

Answer 19

The average pressure difference between the left ventricle and aorta during systole; higher gradients signify more severe AS (>40mmHg)

Question 20

Which 2 surgical options would you recommend for patients with aortic stenosis?

For patients who are symptomatic or have severe disease

Answer 20

• Aortic valve replacement (open heart) - needs to be surgically fit
• Transcatheter aortic valve implantation (TAVI) :)

Balloon valvuloplasty is a less invasive procedure that improves blood flow, but is usually temporary.

Question 21

Why are patients with symptomatic aortic stenosis usually advised to receive prompt replacement surgery?

Answer 21

Poor prognosis of survival without surgery:

2-3 years with angina/syncope,
1 year with heart failure