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Stage 3 > Cardiology: Valve disease > Flashcards

Cardiology: Valve disease Flashcards

1
Q

Which valve disease produces an ejection systolic murmur?

A

Aortic stenosis

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2
Q

Where is an ejection systolic murmur (aortic stenosis) the loudest?

A

Right mid-clavicular 2nd ICS - on expiration

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3
Q

Where does an ejection systolic murmur (aortic stenosis) radiate?

A

Carotids

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4
Q

What are other signs of aortic stenosis?

A

1) Slow rising pulse
2) Narrow pulse pressure
3) Heaving apex (left ventricular hypertrophy)
4) May present with heart failure, angina or syncope
5) Soft S2 heart sound
6) Associated with age related calcification

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5
Q

What do you see on ECG in aortic stenosis?

A

Signs of left ventricular hypertrophy
1) Increased QRS voltage (height)
2) Left axis deviation
3) Poor R wave progression

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6
Q

How do you manage aortic stenosis?

A

1) Symptomatic - TAVI (transcatheter aortic valve implantation)
2) If fit and young - surgical aortic valve replacement

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7
Q

What can CXR show in aortic stenosis?

A

Cardiomegaly + calcified aortic valve (if cause)

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8
Q

What is the primary test for the diagnosis and evaluation of severity in aortic stenosis?

A

Echo - severe AS can be quantified via doppler echo

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9
Q

When can exercise testing be used in AS?

A

In physically active patients to assess the true severity of asymptomatic patients with echo confirmed AS

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10
Q

What is the classic triad of symptoms in aortic stenosis?

A

1) Heart failure
2) Syncope
3) Angina
These symptoms are related to end-stage AS and patients may remain asymptomatic for a long period until decompensation occurs with concurrent illness

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11
Q

What are additional symptoms of aortic stenosis?

A

1) Asymptomatic
2) Exertional dyspnoea
3) Decreased exercise tolerance

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12
Q

What are indications for intervention in aortic stenosis?

A

1) Symptomatic
2) Asymptomatic with LVEF < 50%
3) Asymptomatic with LVEF > 50% + physically active + have symptoms or a fall in BP during exercise testing

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13
Q

When is a TAVI (transcatheter aortic valve implantation) favoured for aortic stenosis management?

A

1) Severe comorbidities
2) Previous heart surgery
3) Frailty
4) Restricted mobility
5) > 75

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14
Q

When is a surgical aortic valve replacement (SAVR)

A

Low risk + < 75

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15
Q

What are the classic signs in aortic sclerosis (age-related senile degeneration of the valve)

A

1) Ejection systolic murmur that does not radiate to the carotids
2) Normal S2, pulse character and volume

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16
Q

What is mitral regurgitation?

A

Backflow of blood across the mitral valve during systole due to incompetence of the mitral valve

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17
Q

What are the features of acute mitral regurgitation?

A

Cardiac emergency
1) Sudden onset pulmonary oedema
2) Hypotension
3) Cardiogenic shock

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18
Q

What is the main cause of ischaemic acute mitral regurgitation?

A

Papillary muscle rupture secondary to MI

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19
Q

What is the main cause of non-ischaemic acute mitral regurgitation?

A

Ruptured chordae tendineae due to:
1) Mitral prolapse (myxomatous disease)
2) Infective endocarditis
3) Rheumatic heart disease - acute or chronic
4) Trauma
5) Spontaneous rupture

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20
Q

What are causes of acute mitral regurgitation in patients with a prosthetic valve?

A

1) Tissue valvelet rupture due to endocarditis, degeneration or calcification
2) Paravalvular regurgitation due to infection or suture rupture
3) Valve thrombus or infection causing impaired closure

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21
Q

What are causes of chronic mitral regurgitation?

A

1) Leaflet dysfunction e.g. degenerative, rheumatic fever, SLE, IE, connective tissue disorders,
2) Chordae dysfunction - trauma, myxomatous valve disease causing prlapse
3) Papillary muscle dysfunction - MI, dilated cardiomyopathy
4) Annular dysfunction - calcification, dilated cardiomyopathy, CT disorders
5) Prothesis dysfunction

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22
Q

How does acute mitral regurgitation present?

A

Cardiac emergency - sudden onset:
1) SOB
2) Exertional dyspnoea
3) Fatigue
4) Weakness
(pulmonary oedema, hypotension + signs of cardiogenic shock)

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23
Q

How does chronic mitral regurgitation present?

A

1) Mild-moderate MR = asymptomatic until significant systolic dysfunction, pulmonary hypertension or symptomatic AF
2) Fatigue + exertional dyspnoea are most common - due to decreased cardiac output + increased pulmonary pressures due to increased left atrial pressures

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24
Q

What are the potential complications of mitral regurgitation?

A

1) Heart failure
2) Thromboembolism secondary to AF
3) Haemoptysis secondary to pulmonary hypertension + symptoms of right heart failure (less common than in mitral stenosis)
4) Infective endocarditis + associated symptoms can also complicate MR

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25
Q

Describe the murmur heard in mitral regurgitation?

A

Pansystolic murmur, loudest at the apex on expiration + rolling to the left, radiates to axilla

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26
Q

Where does a mitral regurgitation murmur radiate?

A

Axilla

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27
Q

What other examination findings are found in mitral regurgitation?

A

1) Quiet/absent S1
2) If patients are in decompensated heart failure - bilateral lung crepitations, raised JVP, S3/S4, peripheral/sacral oedema

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28
Q

How do you diagnose and assess severity of mitral regurgitation?

A

Echo

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29
Q

What are ECG findings in mitral regurgitation?

A

1) P-mitrale - broad-notched P wave due to left atrial enlargement
2) Left ventricular hypertrophy
3) Left axis deviation

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30
Q

Which heart chamber enlarges in mitral regurgitation?

A

Left atrium

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31
Q

What are CXR findings in mitral regurgitation?

A

1) Pulmonary oedema
2) Left atrial enlargement

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32
Q

How do you treat mitral regurgitation?

A

1) Treat concurrent complications e.g. AF, thromboembolism, heart failure
2) Definitive management if symptomatic = surgery

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33
Q

What is the definitive management for symptomatic mitral regurgitation?

A

Surgery

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34
Q

What are the two types of surgery for symptomatic mitral regurgitation?

A

1) Mitral valve repair (mitral valvuloplasty) - preferable as is preserves all components of the native valve and avoids use of prostheses
2) Mitral valve replacement - offers the choice between a mechanical valve (lifelong anticoagulation but long-lasting), and a bioprosthetic valve (limited durability but no need for anticoagulation)

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35
Q

What is the difference between a mechanical and bioprosthetic valve?

A

1) Mechanical - lifelong anticoagulation but long-lasting
2) Bioprosthetic - no need for anticoagulation but limited durability

36
Q

What is mitral valve prolapse?

A

An abnormal bulging of one or both of the mitral valve leaflets into the left atrium during ventricular systole

37
Q

What does mitral valve prolapse cause?

A

Mitral regurgitation (5% of cases)

38
Q

How do you diagnose mitral valve prolapse?

A

Echo (+ clinical examination)

39
Q

How is mitral valve prolapse defined on echo?

A

Abnormal systolic displacement of one or both leaflets into the left atrium - >2mm above the annular plane on echo

40
Q

Which conditions predispose to mitral valve prolapse?

A

1) Marfan’s syndrome
2) Ehlers-Danlos
3) Pseudoxanthoma elasticum
4) Osteogenesis imperfecta
5) Turner’s syndrome
(MVP can be primary i.e. related to degeneration in the absence of other causes)

41
Q

What are the symptoms of mitral valve prolapse?

A

Inconsistent symptoms and do not reliably indicate MVP but may include:
1) Chest pain
2) Palpitations
3) Dyspnoea
4) Exercise intolerance
5) Dizziness
6) The majority of cases remain asymptomatic unless prolapse is severe

42
Q

What are examination findings in mitral valve prolapse?

A

1) A non-ejection click (NOT early systolic click) which is variable in timing - due to snapping of the mitral chordae during systole when the valve bows into the atrium
2) Mitral regurgitation murmur

43
Q

What is mitral stenosis?

A

The impaired opening of the mitral valve affecting blood flow from the left atrium to ventricle

44
Q

What is the most common cause of mitral stenosis?

A

Rheumatic heart disease

45
Q

How does rheumatic heart disease cause mitral stenosis?

A

Streptococcal antigens secondary to bacterial infection cross-react with the valve tissue, causing damage

46
Q

What are other causes of mitral stenosis (predominant in developed countries with lower incidence of rheumatic fever)?

A

1) Mitral annular calcification (age-related)
2) Congenital mitral stenosis (rare)
3) Mucopolysaccharidosis (metabolic disorder affecting connective tissue)
4) Carcinoid syndrome, causing valve disease
5) Systemic disease, incl. SLE and rheumatoid arthritis
Atrial outflow obstruction due to other conditions, such as atrial myxoma, may cause symptoms similar to MS

47
Q

How does mitral stenosis typically present?

A

1) Gradual exertional dyspnoea + reduced exercise tolerance
2) Malar flush
3) Low volume pulses
4) SOB
5) Haemoptysis
6) Elevated JVP - prominent a wave

48
Q

Describe the murmur in mitral stenosis?

A

Mid-diastolic, loudest at the apex, on expiration rolled to the left

49
Q

What do you see on ECG in mitral stenosis?

A

1) P-mitrale (a broad notched P wave due to left atrial enlargement)
2) Right ventricular hypertrophy
3) Right axis deviation
4) AF - caused by left atrial enlargement

50
Q

How do you manage asymptomatic mitral stenosis?

A

Regular follow up ECHO

51
Q

How do you manage symptomatic mitral stenosis?

A

1) Balloon valvuloplasty (if valve is pliable and non-calcified)
2) Percutaneous mitral valvotomy (moderate disease)
3) Open valve repair/replacement (severe disease)

52
Q

What is aortic regurgitation?

A

The reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve

53
Q

What are causes of acute aortic regurgitation?

A

1) Infective endocarditis
2) Aortic dissection
3) Traumatic rupture of the valve leaflets - e.g. blunt chest trauma, deceleration injury
4) Iatrogenic - balloon valvotomy, TAVI

54
Q

What are the most common acute causes of aortic regurgitation?

A

Infective endocarditis + aortic dissection

55
Q

How can valve replacements be complicated by acute AR?

A

1) Degeneration of a tissue prosthetic valve
2) Thrombosis of a mechanical valve causing incomplete closure
3) Paravalvular leak

56
Q

What are valvular causes of chronic AR?

A

1) Calcific aortic valve disease (age related)
2) Myxomatous degeneration
3) Congenital disease e.g. bicuspid aortic valve
4) Rheumatic heart disease - most common cause in the developing world
5) Infective endocarditis
6) Rheumatic causes e.g. rheumatoid arthritis, antiphospholipid syndrome
7) Marfan’s syndrome

57
Q

What are causes of aortic root dilation which lead to incomplete valve closure and aortic regurgitation?

A

1) Congenital bicuspid aortic valve
2) Genetic syndromes e.g. Marfan’s, Ehlers-Danlos, osteogenesis imperfecta
3) Systemic vasculitides e.g. GCA, Takayasu’s arteritis

58
Q

How does acute aortic regurgitation present?

A

1) Sudden cardiovascular collapse
2) Pulmonary oedema
3) Pallor
4) Sweating
5) Peripheral vasoconstriction

59
Q

How does chronic aortic regurgitation present?

A

More insidious, patients may remain asymptomatic for many years
1) Exertional dyspnoea
2) Orthopnoea
3) Paroxysmal nocturnal dyspnoea
4) Stable angina - in some patients with severe AR, even in the absence of CAD (due to reduction in diastolic coronary perfusion)

60
Q

What are the peripheral examination findings in aortic regurgitation?

A

1) Waterhammer (Corrigan’s) pulse
2) Widened pulse pressure (low diastolic pressure)
3) De Musset’s sign - bobbing of the head in synchrony with the beating heart
4) Quincke’s sign - pulsation of nail beds
5) Traube’s sign - pistol shot like bruit heard on auscultation of the femoral pulse
6) Muller’s sign - pulsation or bobbing of uvula

61
Q

What are auscultation findings in aortic regurgitation?

A

1) Early diastolic murmur - heard best in aortic area whilst the patient is leant forward and on exhalation
2) Soft S1 ± ejection flow murmur

62
Q

What is the definitive investigation for aortic regurgitation?

A

Echo

63
Q

What are second line investigations for aortic regurgitation?

A

1) Cardiac MRI - if moderate-severe AR with inconclusive Echo findings
2) Invasive cardiac catheterisation and angiography - when imaging inconclusive, gives more detail

64
Q

How is aortic regurgitation managed?

A

1) Beta blockers ± losartan - can slow aortic root dilation and reduce risk of AR progression esp. in pts at risk e.g. Marfan’s or bicuspid aortic valve by lower systolic BP
2) Severe asymptomatic AR - monitor yearly, if LV diameters or systolic functions show significant changes follow up 3-6 monthly
3) Surgery - if symptomatic, reduced EF, significant enlargement of ascending aorta or IE refractory to medical therapy

65
Q

What is a waterhammer pulse?

A

Bounding, forceful pulse with a rapid upstroke and descent

66
Q

What is malar flush due to in valve disease?

A

Cutaneous vasodilation due to carbon dioxide retention

67
Q

What does an a wave on JVP indicate?

A

Raised right atrial pressure

68
Q

What happens in pulmonary stenosis?

A

The blood flow is obstructed from the RV into the pulmonary bed, resulting in a pressure gradient greater than 10 mmHg across the pulmonary valve during systole

69
Q

What is usually the cause of pulmonary stenosis (one word)?

A

Congenital

70
Q

Which congenital syndromes are associated with pulmonary stenosis?

A

1) Noonan syndrome
2) William’s syndrome
3) Tetralogy of Fallot
4) Congenital rubella infection

71
Q

What is one cause of acquired pulmonary stenosis (rare)?

A

Carcinoid syndrome

72
Q

How do you manage pulmonary stenosis?

A

Surgery - valvotomy (valvular) or balloon angioplasty (Williams syndrome - supravalvular)

73
Q

When is treatment indicated in pulmonary stenosis?

A

Transvalvular pressure gradients > 50 mmHg

74
Q

What are the symptoms of tricuspid regurgitation?

A

Tend to be asymptomatic even when severe

75
Q

What are the examination findings in tricuspid regurgitation?

A

1) Signs of right sided heart failure - ascites, peripheral oedema, pulsatile hepatomegaly
2) Heart sounds - pansystolic murmur (loudest in the left parasternal region on inspiration)
3) JVP - prominent systolic v wave

76
Q

What murmur indicates tricuspid regurgitation?

A

Pansystolic murmur - loudest in left parasternal region on inspiration

77
Q

What murmur is present in pulmonary stenosis?

A

Ejection systolic murmur - loudest in pulmonary area with deep inspiration

78
Q

What signs are present in pulmonary stenosis?

A

1) Ejection systolic murmur - loudest in pulmonary area with deep inspiration
2) Widely split S2
3) Thrill in the pulmonary area on palpation
4) Raised JVP with giant A waves
5) Peripheral oedema
6) Ascites

79
Q

What are the four co-existing pathologies in Tetralogy of Fallot?

A

1) Ventricular septal defect (VSD)
2) Overriding aorta
3) Pulmonary stenosis
4) Right ventricular hypertrophy

80
Q

What is the JVP finding in tricuspid regurgitation?

A

Prominent systolic v wave

81
Q

How do you diagnose pulmonary stenosis?

A

Echo - to detect + quantify TR and heart function

82
Q

What are ECG findings in pulmonary stenosis?

A

Non-specific - all peaked p waves or incomplete RBBB

83
Q

What other investigations can be done in pulmonary stenosis?

A

1) Cardiac MRI - used for evaluating right ventricular size and function
2) Cardiac catheterisation - may be required prior to surgery to assess for CAD

84
Q

How do you manage pulmonary stenosis?

A

1) Treat any underlying causes
2) Treat the heart failure or fluid overload
3) Consider surgery if severe + non-responsive to treatment - surgical options = ring annuloplasty or valve replacement

85
Q

What is a non-valvular cause of pansystolic murmur?

A

Ventricular septal defect

86
Q

What are two non-valvular causes of an ejection systolic murmur?

A

1) Flow murmur - anaemia, pregnancy, thyrotoxicosis
2) HOCM

Stage 3 (61 decks)

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