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Medicine Phase 2a CVS > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

Examples of diseases affecting the heart

A

Mitral stenosis
Mitral regurgitation
Aortic Stenosis
Aortic regurgitation

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2
Q

*Clinical presentation of mitral stenosis

A

Pulmonary hypertension ->
dyspnoea, pink frothy sputum, left atrial dilatation, right ventricular hypertrophy, palpitations.
Malar flush due to low CO.
Opening snap and diastolic murmur.

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3
Q

What causes malaria flush?

A

Low CO

associated with mitral stenosis due to the resulting CO2 retention and its vasodilatory effects

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4
Q

What is malar flush?

A

plum-red discolouration of the high cheeks

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5
Q

When listening to heart sound of patient, what would be characteristic of mitral stenosis?

A

Mid-diastolic murmur

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6
Q

Pathophysiology of mitral stenosis

A

Inflammation -> Mitral valve thickened/calcified obstructing normal flow from LA to LV.
Therefore LA pressure increases to maintain CO: Raised LA pressure -> LA hypertrophy and dilatation -> palpitations.
Raised LA pressure -> pulmonary hypertension -> RV hypertrophy, dilation and failure with subsequent tricuspid regurgitation.
Raised pulmonary pressure also causes the development of pulmonary capillary oedema (especially with atrial fibrillation)

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7
Q

Aetiology of mitral stenosis

A

Rheumatic valvular disease (usually Strep pyogenes) - main

Others:
Infective endocarditis (3.3%)
Mitral annular calcification (2.7%)

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8
Q

*Diagnostic tests of mitral stenosis?

A

CXR: LA enlargement, pulmonary oedema/congestion, occasionally calcified mitral valve.
ECG: AF, LA enlargement, RV hypertrophy
Echocardiography: assess mitral valve mobility, gradient and measure mitral valve area.

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9
Q

What is area of normal mitral valve?

A

4-6 cm^2

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10
Q

At what size do symptoms of mitral stenosis occur

A

When mitral valve area is less than 2 cm^2

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11
Q

Treatment of mitral stenosis

A
  • Diuretics (furosemide) - for fluid overload
  • Beta-blockers e.g. Atenolol and digoxin which control heart rate and thus prolong diastole for better diastolic filling
  • Percutaneous mitral balloon valvotomy
  • Excise segments of valve, or mitral valve replacement

Also: Infective endocarditis prophylaxis (amoxicillin?)
(Rate control + anticoagulation)

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12
Q

*Clinical presentation of mitral regurgitation

A

*Pansystolic murmur (at apex radiating to axilla)
Mid-systolic click and late systolic murmur in mitral prolapse
Deviated apex beat.
Variable haemodynamic effects:
Palpitation due to increased stroke volume
Fatigue and lethargy due to reduced CO
Right heart failure and eventual congestive cardiac failure symptoms.
Dyspnoea

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13
Q

What heart sound would you associate with mitral regurgitation

A

pan-systolic murmur

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14
Q

Pathophysiology of mitral regurgitation

A

Mitral valve fails to prevent reflux of blood. Regurgitation into the LA -> increased LA dilation and eventually pressure -> increased pulmonary pressure -> pulmonary hypertension
Progressive left atrial dilatation and right ventricular dysfunction due to pulmonary hypertension.
Progressive left ventricular volume overload leads to dilatation and progressive heart failure.
Pure volume overload due to leakage of blood into left atrium during systole

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15
Q

Aetiology of mitral regurgitation

A

Due to abnormalities of the valve leaflets, chordae tendinae, papillary muscles or left ventricle.

Most frequent cause is Myxomatous Degeneration (MVP) - weakening of chord tendinae, resulting in a floppy mitral valve that prolapses.
Dilatation of mitral valve annulus (fibrous ring attached to mitral valve leaflets). Mitral valve prolapse. Infective endocarditis. Rheumatic valvular disease. Marfan’s and Ehler-Danlos.
Papillary muscle dysfunction/rupture.

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16
Q

Epidemiology of mitral regurgitation

A

Second most common valvular condition requiring surgery

Mild physiological mitral regurgitation (MR) is seen in 80% of normal individuals

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17
Q

*Diagnostic test of mitral regurgitation

A

*Echocardiography:
• Estimation of left atrium and left ventricle size and function
• Also gives valve structure assessment
• Transoesophageal is very helpful
CXR:
• Left atrial enlargement and central pulmonary artery enlargement

ECG:
• May show left atrial enlargement, atrial fibrillation and left ventricle hypertrophy in severe MR
• But NOT diagnostic

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18
Q

Treatment of mitral regurgitation

A

Repair preferred over replacement (repair when any symptoms at rest or exercise)
Meds:
ACE-inhibitor as vasodilator (smooth muscle relaxer) e.g. ramipril or hydralazine
Beta blocker (Atenolol), calcium channel antagonist and digoxin for heart rate control of AF
Anticoagulation also in AF and flutter
Diuretics e.g. furosemide for fluid overload

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19
Q

*Clinical presentation of aortic stenosis

A

Any elderly person with chest pain, exertion dyspnoea or syncope (loss of consciousness due to lack of blood).
Slow rising carotid pulse.
Left ventricular hypertrophy -> Prominent 4th heart sound
SAD:
Syncope, angina, dyspnoea (on exertion due to HF).
Heart failure and sudden death
Heart Sounds:
-Ejection systolic murmur
-soft or absent second heart sound
(-loudness does NOT tell you anything about severity)

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20
Q

*What heart sound would you associate with aortic stenosis

A

Early systolic murmur

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21
Q

Pathophysiology of aortic stenosis

A

Aortic valve thickened/calcified obstructing normal flow.
Obstructed LV outflow -> Increased afterload -> Increased LV pressure -> Compensatory LV hypertrophy -> Relative ischaemia (of LV myocardium as hypertrophy increases blood demand) -> Angina, arrythmia and LV failure -> Reduced cardiac output.

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22
Q

Aetiology of aortic stenosis

A

Calcific degeneration:
Calcific aortic valvular disease (CAVD) - calcification of aortic valve resulting in stenosis, mainly in elderly.
(Calcification of a) Congenital bicuspid aortic valve (BAV) - has 2 cusps, not 3 due to genetic disease - most common congenital heart disease
Rheumatic valvular disease.

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23
Q

Epidemiology of aortic stenosis

A

Most common valvular condition requiring surgery.
Primarily a disease of ageing
Congenital is second most common cause.
Most common cause of valvular disease in western world.

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24
Q

*Diagnostic tests of aortic stenosis

A

Echocardiography:

  • Left ventricular size & function; LV hypertrophy, dilation and ejection fraction
  • Doppler derived gradient and valve area (AVA), allows for the assessment of the pressure gradient across the valve during systole.

ECG: LV hypertrophy; LA delay; LV strain pattern seen as:
Depressed ST segments and T-wave inversion in leads I, aVL, V5 and V6

CXR: LV hypertrophy; calcified aortic valve

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25
Q

Treatment of aortic stenosis

A

Rigorous dental care due to high risk of Infective Endocarditis
Aortic Valve replacement,
Transcatheter aortic valve replacement (TAVI) - percutaneous alternative for surgical replacement,
Surgical valvuloplasty or Balloon valvuloplasty also

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26
Q

Sequelae of aortic stenosis

A

Left sided HF

Sudden death

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27
Q

*Clinical presentation of aortic regurgitation

A

Early diastolic murmur at left sternal border
Systolic ejection murmur due to increased flow across the aortic valve.
Austin flint murmur: Fluttering of anterior mitral valve cusp due to regurgitant stream

Asymptomatic until 4th or 5th decade.
Exertional dyspnoea
Palpitations, Syncope, Apex beat is displaced laterally.
Wide pulse pressure, Collapsing (water hammer) pulse, angina, left ventricular failure.
Quincke’s sign; de Musset’s sign; Pistol shot femoral

28
Q

Pathophysiology of aortic regurgitation

A

Aortic valve fails to prevent reflux of blood (during diastole). LV hypertrophy to maintain cardiac output (as total volume of blood pumped into aorta must increase).
Progressive dilation leads to HF

Furthermore due to the fact that the remaining blood in the root of the aorta supplies the coronary arteries via the coronary sinus during diastole - regurgitation causes Diastolic blood pressure to fall -> coronary perfusion decreases -> relative ischaemia.
Eventually leads to left ventricular failure.

29
Q

Aetiology of aortic regurgitation

A

Main:
Infective endocarditis
Congenital bicuspid aortic valve (BAV)
Rheumatic fever

Aortic root dilatation.
Some rheumatological disorders.
Ascending aortic dissection possible.

30
Q

Epidemiology of aortic regurgitation

A

Moderate or severe common after transcatheter aortic valve replacement

31
Q

*Diagnostic tests of aortic regurgitation

A

Echocardiography:
• Evaluation of the aortic valve and aortic root
• Measurement of left ventricle dimensions and function
• Cornerstone for decision making and follow up evaluation

ECG: LV hypertrophy (due to volume overload) - tall R waves and deeply inverted T waves in left-sided chest leads
- deep S waves in right-sided leads

CXR:
• Enlarged cardiac silhouette and aortic root enlargement
• LV enlargement

32
Q

Treatment of aortic regurgitation

A

Treat underlying cause. Vasodilators (ACE-inhibitor such as Ramipril - improve SV and reduce regurgitation but only if patient is symptomatic).
Valve replacement if symptoms are increasing (enlarging heart on CXR/ECHO, ECG deterioration (T wave inversion in lateral leads).
Consider Infective Endocarditis prophylaxis.
Serial echocardiograms to monitor progression.

33
Q

A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble.

Presentation of what?

A

Mitral stenosis

34
Q

What is Percutaneous mitral balloon valvotomy?

A

For mitral stenosis
• Catheter is inserted into the right atrium vie the femoral vein under local anaesthesia
• The interatrial septum is then punctured and the catheter advanced into the left atrium and across the mitral valve
• The balloon is inflated and puts pressure on valve thereby separating the leaflets thereby increasing the size of the mitral valve opening thus enabling more blood to flow from left atrium into left ventricle

35
Q

*How does inflammation due to rheumatic fever lead to mitral stenosis

A

Inflammation due to rheumatic fever leads to commissural fusion and a reduction in mitral valve orifice area, causing the characteristic doming pattern seen on echocardiography

36
Q

*Mitral stenosis: Why do you get Progressive dyspnoea (and what makes it worse)

A

due to left atrial dilation resulting in pulmonary congestion (reduced emptying), which is worse with exercise, fever, tachycardia and pregnancy

37
Q

*Mitral stenosis: Why do you get Haemoptysis

A

due to rupture of bronchial vessels due to the elevated pulmonary pressure

38
Q

*Mitral stenosis: Why do you get Right heart failure

A

due to the development of pulmonary hypertension with symptoms of weakness, fatigue and abdominal or lower limb swelling

39
Q

*Mitral stenosis: Why do you get Atrial Fibrillation

A

due to left atrium dilation giving rise to palpitations

40
Q

*Mitral stenosis: Why do you get systemic emboli

A

due to atrial fibrillation, most commonly in the cerebral vessels

41
Q

*Mitral stenosis: Why do you get Prominent “a” wave in jugular venous pulsations

A

due to pulmonary hypertension and right ventricular hypertrophy

42
Q

*Mitral stenosis: Why do you get Mitral facies/malar flush

A

pinkish-purple patches on the cheeks due to vasoconstriction in response to diminished cardiac output

43
Q

Describe features of the diastolic murmur from mitral stenosis

A

Heard when blood flows over a valve
Low-pitched diastolic rumble most prominent at the apex
Heard best with patient lying on the left side in held expiration
Longer murmur in more severe stenosis

44
Q

Describe features of the loud opening S1 snap

A

Heard at apex when leaflets are still mobile
Due to the abrupt halt in leaflet motion in early diastole, after a rapid initial opening, due to fusion at the leaflet tips
As the valve cusps become more immobile, the loud first heart sound softens and the opening snap disappears

45
Q

Risk factors of mitral regurgitation

A
  • Associated with females
  • Lower BMI
  • Advanced age
  • Renal dysfunction
  • Prior MI
46
Q

Define blood flow in heart with mitral regurgitation

A

Backflow of blood from the left ventricle to the left atrium during systole

47
Q

Natural history generally with mitral regurgitation

A
  • Compensatory phase: 10-15 years
  • Once patients ejection fraction becomes less than 60% and/or becomes symptomatic then mortality rises sharply
  • Severe mitral regurgitation has a 5%/year mortality rate
48
Q

Where is aortic valve and how many cusps does it have?

A
  • Located on the left side of the heart and separates the left ventricle from the aorta
  • Aortic valve has 3 cusps
  • One of two semi-lunar valves
49
Q

What is normal aortic valve area and when would symptoms of aortic stenosis occur?

A
  • Normal aortic valve area is 3-4cm2

- Symptoms occur when valve area is 1/4th of normal

50
Q

Types of aortic stenosis

A
  • Supravalvular (above valve) e.g congenital fibrous diaphragm above the aortic valve
  • Subvalvular (below valve) e.g congenital condition in which a fibrous ridge or diaphragm is situated immediately below the aortic valve
  • Valvular - most common
51
Q

Risk factors of aortic stenosis

A
  • Congenital bicuspid aortic valve (BAV) predisposes to stenosis and regurgitation - bicuspid valves are more likely to develop stenosis
  • Congenital BAV is predominant in males
52
Q

Can James keep going?

A

Yes he can!!

53
Q

Do you need a break

A

No u fuckin nutter keep going

54
Q

Could you go out tonight

A

Yeah u could but ur not gonna u stupid cunt keep revising until ur not a dumb shit

55
Q

Why is exercise so bad in aortic stenosis

A

Exercise causes a many-fold increase in cardiac output, however due to the severe narrowing of the aortic valve, the cardiac output can hardly increase - thus, the blood pressure falls, coronary ischaemia worsens, the myocardium fails and cardiac arrhythmias develop.

56
Q

*Why is dental care so important in anyone with a valvular heart disease

A

Due to increased risk of infective endocarditis

57
Q

Why are vasodilators contra-indicated in severe aortic stenosis

A

due to the fact that they may trigger hypotension and thus syncope

58
Q

Indications of surgical aortic valve replacement in aortic stenosis

A
  • Any SYMPTOMATIC patients with severe aortic stenosis (include symptoms with exercise)
  • Any patient with decreasing ejection fraction
  • Any patent undergoing CABG with moderate or severe aortic stenosis
59
Q

Describe Transcutaneous Aortic Valve Implantation (TAVI)

A

• Minimally invasive
• Pass catheter up the aorta then inflate balloon across the narrowed
valve which will crack the calcification
• Then pass another catheter which leaves a stent with a valve = new aortic valve

60
Q

A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries.

Presentation of what disease of heart valve

A

Aortic stenosis

61
Q

What is aortic regurgitation

A

Leakage of blood into the left ventricle from aorta during diastole due to ineffective coaptation (bringing together) of the aortic cusps, of which there are three

62
Q

Risk factors of aortic regurgitation

A
  • SLE (ai disease)
  • Marfan’s and Ehlers-Danlos syndrome (connective tissue disorders)
  • Aortic dilatation
  • Infective endocarditis or aortic dissection
63
Q

Differential diagnosis of aortic regurgitation

A
  • Heart failure
  • Infective endocarditis
  • Mitral regurgitation
64
Q

Aortic regurgitation: What is Quincke’s sign

A

capillary pulsation in the nail beds

65
Q

Aortic regurgitation: What is de Musset’s sign

A

head nodding with each heart beat

66
Q

Aortic regurgitation: What is Pistol shot femoral

A

a sharp bang heard on auscultation

Medicine Phase 2a CVS (17 decks)

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