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MBBS Cardiology > Valvular Heart Diseases > Flashcards

Valvular Heart Diseases Flashcards

1
Q

What are the symptoms of mitral stenosis?

A
  • Symptoms of left-sided heart failure: exertional SOB, orthopnoea, PND
  • Less frequent symptoms: haemoptysis, hoarseness, symptoms of right-sided heart failure
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2
Q

What are the PE findings for mitral stenosis?

A

(1) Malar flush
(2) Elevated JVP

(3) Left parasternal heave: RV enlargement
(4) Tapping apex beat

(5) Opening snap
(6) Loud S1
(7) MDM murmur best heard in the left lateral position on expiration
(8) Loud P2

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3
Q

What are the signs of pulmonary HTN?

A

Loud P2, right ventricular heave, elevated neck veins, ascites and edema

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4
Q

What is Lutembacher syndrome?

A

Patients with ASD and mitral stenosis

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5
Q

How to distinguish MS from ASD?

A

ASD:

  • Wide, fixed splitting of S2
  • Absence of loud S1
  • Opening snap
  • Incomplete RBBB
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6
Q

How to describe a diagnosis for valvular lesions? What is the framework?

A

(1) Lesion: e.g. AR, AS, MR, MS
(2) Severity of lesion
(3) Complications
(4) Etiology
(5) Management

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7
Q

What is the most common cause of mitral stenosis?

A

Rheumatic heart disease

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8
Q

What is the mechanism of the tapping apex beat?

A

It is from an accentuated S1

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9
Q

What are the complications of mitral stenosis?

A
  • Left atrial enlargement and AF
  • Systemic embolization, usually to cerebral hemispheres
  • Pulmonary HTN
  • TR
  • Right heart failure
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10
Q

Assess the severity of mitral stenosis.

A
  • S2-opening snap: the narrower the distance between S2 and the opening snap, the greater the severity (time interval between S2 and opening pressure is inversely related to the LA pressure)
  • Longer duration of MDM: greater severity of MS lesion
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11
Q

What are the investigations for a patient with mitral stenosis?

A

(1) ECG
- P mitrale (broad bifid p wave), AF, LA enlargement, RVH
(2) CXR
- Congested upper lobe veins
- Straightening of left border of heart due to prominent pulmonary conus and enlarged LA
- Kerley B lines (horizontal lines at the costophrenic angles)
- Double silhouette from enlarged LA
(3) Echocardiogram: diagnostic tool to assess severity of MS and to judge applicability of balloon mitral valvotomy

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12
Q

What is the normal cross-sectional area of the mitral valve and when does turbulence of flow occurs?

A

Normal: 4-6 cm2

Turbulent flow: < 2 cm2

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13
Q

What are the features of severity of mitral stenosis?

A

Mild MS:

  • Symptoms: usually absent
  • Signs: S2-OS > 120 ms, normal P2
  • Valve area: > 1.5 cm2
  • Pulmonary artery systolic pressure: < 30
  • Mean gradient: < 5

Moderate MS:

  • Symptoms: NYHA class II to III
  • Signs: S2-OS 80-100 ms, normal or loud P2
  • Valve area: 1.0-1.5 cm2
  • Pulmonary artery systolic pressure: 30-50
  • Mean gradient: 5-10

Severe MS:

  • Symptoms: NYHA class II to IV
  • Signs: RV heave, S2-OS < 80 ms, loud P2
  • Valve area: < 1.0 cm2
  • Pulmonary artery systolic pressure: > 50
  • Mean gradient: > 10
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14
Q

How would you manage the patient with mitral stenosis?

A
  • Asymptomatic patient in sinus rhythm: IE prophylaxis
  • Mild symptoms: diuretics (to reduce LA pressure)
  • Mod-severe symptoms / pulmonary HTN: mechanical relief of valve stenosis, inc balloon valvotomy
  • AF: anticoagulants, rate control (BB, CCB)
  • Anticoagulation: consider in patients with LA dimensions at least 55 mm
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15
Q

What are the indications for surgery for mitral stenosis?

A

(1) Patients with severe symptoms of pulmonary congestion and significant MS (mitral valve area is 1.5 cm2 or less)
(2) Patients with pulmonary HTN (pulmonary artery systolic pressure > 50 at rest) or haemoptysis
(3) Recurrent thromboembolic events despite therapeutic anticoagulation

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16
Q

Surgical procedures to treat MS

A
  1. Closed commissurotomy
    (a) Closed mitral valvotomy: involves the use of mechanical dilators inserted through the LV apex; complicated by MR, systemic embolization and restenosis
    (b) Balloon valvuloplasty
  2. Open commissurotomy: requires cardiac bypass and allows surgical repair of the valve under direct vision
  3. Valve replacement: risks include thromboembolism, endocarditis and primary valve failure
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17
Q

What are the factors that determine the success of balloon valvuloplasty?

A
  • Good mobility of valves
  • Little calcification
  • Minimal subvalvular disease
  • Mild MR
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18
Q

What are the indications for mitral valve replacement?

A

Patients who are not good candidates for percutaneous balloon valvotomy or mitral valve repair:

  • Mod-severe MS and NYHA class III-IV
  • Severe MS (mitral valve area < 1) and severe pulmonary HTN (pulmonary artery systolic pressure > 60)
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19
Q

When do pregnant patients with MS become symptomatic?

A

During the 2nd trimester, due to a significant increase in blood volume which increases pulmonary pressures

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20
Q

What are the causes of mitral stenosis?

A
  • Rheumatic heart disease (most common)
  • RA
  • SLE
  • Calcification of mitral annulus and leaflets
  • Malignant carcinoid
  • Congenital stenosis
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21
Q

What are the conditions that simulate mitral stenosis?

A
  • Left atrial myxoma
  • Ball valve thrombus in the left atrium
  • Cor triatriatum (rare congenital heart condition where a thin membrane across the LA obstructs pulmonary venous flow)
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22
Q

What are the complications for any valvular heart lesion?

A

CHF, pulmonary HTN, IE, AF, stroke, signs of over-anticoagulation

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23
Q

What is the Ortner syndrome?

A

Refers to hoarseness of voice caused by left vocal cord paralysis a/w enlarged LA in MS

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24
Q

What are the symptoms for mitral regurgitation?

A
  • Asymptomatic
  • SOB (pulmonary congestion)
  • Fatigue (low CO)
  • Palpitation (from AF or LV dysfunction)
  • Fluid retention (late-stage disease)
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25
Q

What are the signs for mitral regurgitation?

A

Palpation:

  • Normal or jerky pulse (short and rapid upstroke)
  • Displaced apex beat, thrusting nature (forceful in character)
  • Left parasternal heave (pulmonary HTN)

Auscultation:

  • Soft S1
  • Pansystolic murmur that radiates to the axilla, best detected on expiration
  • Loud pulmonary S2 (pulmonary HTN)
  • S3 (gallop) present
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26
Q

What are the causes of chronic mitral regurgitation?

A
  • Mitral valve prolapse (most common cause)
  • IE
  • Rheumatic heart disease
  • Coronary artery disease
  • Cardiomyopathy
  • Connective tissue disorders
  • Annular calcification
  • Papillary muscle dysfunction
  • Left ventricular dilatation
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27
Q

What are the causes of acute mitral regurgitation?

A
  • Endocarditis (from perforation of mitral valve leaflet or the chordae)
  • Acute MI (papillary muscle rupture)
  • Trauma
  • Myxomatous degeneration of the valve
28
Q

What are the investigations for mitral regurgitation?

A

(1) ECG
- p mitrale (broad bifid p waves), LVH, AF

(2) CXR
- Pulmonary congestion, cardiomegaly, LA enlargement, pulmonary artery enlargement

(3) Echocardiography

29
Q

List the differences between MR and TR

A

(1) MR has a jerky/normal pulse; TR has a normal pulse
(2) MR has a left ventricular heave; TR has a left parasternal heave
(3) MR: intensity of murmur increases with expiration; TR: intensity of murmur increases with inspiration
(4) MR radiates to axilla; TR doesn’t
(5) MR: has hepatic pulsations; TR doesn’t

30
Q

Explain the pathophysiology of a jerky pulse

A

Due to reduced systolic ejection time secondary to a large volume of blood regurgitating back into the LA

31
Q

Where does the MR murmur radiate to?

A

(1) Axilla
(2) To the neck: the regurgitant jet strikes the LA wall next to the aortic root and the murmur radiates to the base of the heart when the posterior mitral leaflet or ruptured chordae tendinae is involved

32
Q

What are the causes of pansystolic murmur?

A

(1) MR
(2) TR
(3) VSD

33
Q

List the congenital cardiac conditions that can be associated with MR

A

(1) ?Ostium primum ASD
(2) Partial atrioventricular canal
(3) Corrected TGA

34
Q

How to determine the severity of MR?

A
  • The larger the LV on clinical examination, the greater the severity
  • S3 suggests that the disease is severe (caused by rapid ventricular filling)
  • Colour Doppler ultrasonography
35
Q

What is the prognosis for MR?

A
  • Prognosis worsened when RV function is reduced
  • Patients with a RVEF < 30% are particularly at high risk
  • Ischaemic MR carries the worse prognosis
36
Q

What are the mechanisms of MR?

A

(1) Functional
- Mitral valve is structurally normal and disease results from valve deformation caused by ventricular remodelling, e.g. cardiomyopathy, myocarditis

(2) Organic
- Intrinsic valve lesions, e.g. endocarditis, rheumatic heart disease, ruptured papillary muscle, annular calcification

Can be subclassified by leaflet movement (Carpentier’s Classification)

  • Type I: normal valve movement, e.g. endocarditis
  • Type II: excessive movement, e.g. ruptured papillary muscle
  • Type III: restrictive movement (IIIa: diastolic restriction; IIIb: systolic restriction)
37
Q

What is the follow-up like for an asymptomatic patient with MR?

A

Mild MR

  • No evidence of LV enlargement/dysfunction or pulmonary HTN
  • f/u once yearly

Moderate MR
- Annual clinical evaluation and echocardiography

Severe MR
- f/u q6-12 months with hx, PE and echocardiography

38
Q

What is the medical management for patients with MR?

A
  • Asymptomatic patients: IE prophylaxis

- Heart failure: diuretics and inotropes, major consideration for surgery

39
Q

What are the indications for surgery for patients with MR?

A
  • Moderate to severe symptoms despite medical therapy (NYHA Class III/IV), provided LV function is adequate
  • LV end systolic dimension > 45 mm: consider mitral valve repair or replacement even in the absence of symptoms
40
Q

When is successful valve repair less likely in MR cases?

A

Less likely when the etiology is ischaemic, infectious or rheumatic, when there is significant calcification, or when there is anterior/bileaflet prolapse

41
Q

Things to know about MR caused by a flail leaflet

A
  • Lesion usually results in high degrees of regurgitation

- Surgery is almost unavoidable within 10 years after diagnosis and is a/w improved prognosis

42
Q

Which valves are most often affected by rheumatic heart disease?

A

[MAT-P]

Mitral valve > aortic > tricuspid > pulmonary

43
Q

How would the patient present for aortic regurgitation?

A
  • Asymptomatic
  • SOB, fatigue
  • Symptoms of left ventricular failure (later stages)
44
Q

What are the signs for aortic regurgitation?

A

Inspection:

  • de Musset’s sign: head nodding in time with the heart beat
  • Argyll Robertson pupil: for syphilis that can cause aneurysms (bilateral small pupils that can accommodate but not constrict in the presence of light)
  • Corrigan’s sign: visible carotid pulsation in neck
  • Muller’s sign: systolic pulsations of the uvula
  • Stigmata of Marfan syndrome: high-arched palate, arm span > height

Palpation:

  • Collapsing pulse (rapid fall with low diastolic pressure)
  • Corrigan’s water hammer pulse sign: patient lies supine with arms beside the body. Radial pulse is compressed until it disappears, the arm is then lifted perpendicular to the body and the pulse becomes palpable again even though the same pressure is maintained over the radial artery
  • Quincke’s sign: capillary pulsation in fingernails
  • Apex beat is displaced and thrusting in nature

Auscultation:

  • Ejection click: suggests underlying bicuspid aortic valve
  • Early diastolic, high-pitched murmur heard at the left sternal edge with diaphragm, best heard with the patient lying forward and at the end of expiration
  • Ejection systolic murmur at the base of heart (neck area) in severe AR
  • Austin Flint murmur (mid-diastolic murmur) may be heard at the apex
  • Loud pulmonary component of S2
  • Presence of S3
  • Traube’s sign: booming sound (pistol-shot sound) heard over femorals
  • Duroziez’s sign: to and fro systolic and diastolic murmur produced by compression of femorals by the stethoscope
45
Q

Explain the pathophysiology behind Duroziez’s sign (in AR)

A

Duroziez’s sign is produced by the compression of the femoral artery.
A systolic murmur will always be heard. As compression increases, a diastolic murmur will be heard in significant AR due to retrograde flow of blood back to heart in diastole.

46
Q

List the causes of chronic aortic regurgitation

A
  • Rheumatic fever
  • HTN
  • Bicuspid aortic valve
  • Atherosclerosis
  • Bacterial endocarditis
  • Syphilis
  • Idiopathic dilatation of aortic root and annulus
  • Rheumatological conditions:
    (a) Marfan syndrome
    (b) RA
    (c) Seronegative arthritis: ankylosing spondylitis, Reiter syndrome
    (d) Cystic medial necrosis
47
Q

What are the investigations for aortic regurgitation?

A

CXR: valvular calcification, cardiomegaly
ECG: LVH and strain, left atrial hypertrophy
Echocardiogram
MRI / spiral CT scan: assess aortic root size

48
Q

What are the clinical signs that indicate the severity of aortic regurgitation?

A
  • Duration of the diastolic murmur: the longer the murmur, the more severe the lesion
  • ?Presence of ESM murmur at base of heart in severe AR
  • Austin Flint murmur
  • Soft S2
  • Presence of S3
  • Signs of left ventricular failure
  • Wide pulse pressure
  • Hill’s sign: systolic pressure is higher in the leg than in the arm; indicates severity of AR
  • -> mild AR: < 20
  • -> moderate AR: 20-40
  • -> severe AR: > 60
49
Q

What is the definition of the Austin Flint murmur?

A

It is an apical, low-pitched, diastolic murmur heard at the apex which is caused by the vibration of the anterior mitral cusp in the regurgitant jet.

50
Q

What are the causes of acute aortic regurgitation?

A

Traumatic causes:

  • Trauma
  • Aortic dissection
  • Rupture of sinus of Valsalva

Infective causes:
- Infective endocarditis

Other cause(s): 
- Failure of prosthetic valve
51
Q

Explain the term and pathophysiology behind ‘cor bovinum’

A

Heart may become larger and heavier in chronic AR when compared to other chronic heart diseases

Pathophysiology: slow and progressive left ventricular dilatation and hypertrophy in an attempt to normalize wall stress

52
Q

What is the role of vasodilators in aortic regurgitation?

A

Vasodilator therapy: nifedipine

- reduces or delays the need for aortic valve replacement in asymptomatic patients with severe AR

53
Q

What is the management for aortic regurgitation?

A

AR is treated surgically: valve replacement surgery

Types of valves:

  • Mechanical prostheses: used in the young as the valves are more durable
  • Tissue valves: preferred in the elderly (as it is less durable, prone to calcification and degeneration) and for patients who have a contraindication to anticoagulation
54
Q

What are the indications for surgery for patients with AR?

A
  1. Symptoms of heart failure and diminished left ventricular function (EF between 20-30% to 50%)
  2. Concomitant angina and severe AR
  3. Reduction in exercise ejection fraction of at least 5%
  4. Aortic root dilatation is at least 50 mm: aortic valve replacement and aortic root reconstruction are indicated in patients with dx of the proximal aorta and AR of any severity
  5. End-systolic dimension of 55 mm: as this represents the limit of surgically reversible dilatation of the the LV
55
Q

What is the follow-up plan for a patient with aortic regurgitation?

A
  1. Asymptomatic with mild AR
    - Follow-up once a year
  2. Asymptomatic with severe AR, significant LV dilatation
    - Follow-up q6 months with an echocardiogram
  3. Asymptomatic with severe AR, significant LV dilatation that is more severe (end-systolic dimension > 50 mm)
    - Follow-up q4 months with serial echocardiograms
  4. Patients with valve replacement
    - Monitor for signs of aortic valve prosthesis failure (esp tissue valves) and endocarditis
56
Q

What are the symptoms of aortic stenosis?

A
  • Asymptomatic
  • SOB
  • Angina
  • Syncope
  • Fatigue
57
Q

What are the signs of aortic stenosis?

A

Palpation:
- pulsus parvus et tardus (parvus = weak; tardus = late)
(low volume pulse with delayed upstroke)
- Apex beat which is heaving in nature
- Systolic thrill over aortic area and carotids

Auscultation:

  • Ejection click (after S1)
  • Ejection systolic murmur at the base of the heart that radiates to the carotids
  • Soft S2
  • S3 (indicate presence of systolic dysfunction and raised filling pressures)
  • S4 (atrial sound)
58
Q

Recall the definition of aortic sclerosis

A

Aortic sclerosis: defined as the calcification and thickening of the trileaflet aortic valve

59
Q

List the clinical findings that distinguish aortic stenosis from aortic sclerosis

A

Aortic stenosis: heaving apex beat, presence of thrill, radiates to carotids

Aortic sclerosis: X heaving apex beat, X thrills, localized

60
Q

What are the causes of aortic stenosis?

A

Can classify by age!

< 60 years: rheumatic (rheumatic fever), congenital causes
60-75 years: calcified bicuspid aortic valve
> 75 years: degenerative calcification

61
Q

What are the differential diagnoses for ejection systolic murmur?

A
  • Aortic stenosis
  • Pulmonary stenosis
  • Supravalvular aortic stenosis
  • Hypertrophic obstructive cardiomyopathy
62
Q

Explain the term ‘ejection systolic murmur’

A
  • It is a crescendo-decrescendo murmur that begins after S1, which peaks in mid or late systole and ends before S2
63
Q

Pathophysiology of syncope in aortic stenosis

A
  • LV suddenly X contract against the stenosed valve
  • Cardiac arrhythmia
  • Marked peripheral vasodilatation without concomitant increase in cardiac output (esp after exercise)
64
Q

What are the investigations for aortic stenosis

A
  • ECG: LVH, left atrial hypertrophy, LAD, conduction abnormalities (due to calcification of conducting tissues
  • CXR: calcification of aortic valve, cardiomegaly
  • Echocardiogram
65
Q

What are the clinical signs of severity in aortic stenosis?

A
  • Narrow pulse pressure
  • Systolic thrill and heaving apex beat
  • Soft S2
  • Narrow or reverse split S2
  • S4
  • Heart failure
66
Q

What is the management for aortic stenosis?

A
  • Patient who is asymptomatic, valvular gradient < 50: observation; surgery X recommended
  • Valve replacement

MBBS Cardiology (1 decks)

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