23. Valvular Heart Disease

Question 1

What 2 valves are found on the right side of heart?

Answer 1

1. tricuspid

2. pulmonary

Question 2

What 2 valves are found on the left side of heart?

Answer 2

1. mitral

2. aortic

Question 3

To what structure is the mitral valve very closely related to?

Answer 3

to the left ventricle; it’s anchored to it ( what will affect the mitral valve will affect the l.ventricle and vice versa)

Question 4

What is mitral valve anchored by?

Answer 4

anchored by cordae tendinae which are attached to papillary muscles

Question 5

What is the aetiology for mitral stenosis? (3)

Answer 5

1. rheumatic heart disease
2. congenital mitral stenosis
3. systemic conditions e.g. systemic lupus erythematosus (SLE) and rheumatoid arthritis

Question 6

What is the main cause of mitral stenosis in the western world?

Answer 6

Mainly rheumatoid arthritis (rarely congenital defects)

Question 7

What is the mitral valve orifice (opening) in cm?

Answer 7

<2cm^2

Question 8

What effect does mitral stenosis have on:

• AV pressure gradient
• L.atrium pressure
• Pulmonary venous and capillary pressures
• Pulmonary vascular resistance
• Pulmonary artery pressure
• Right heart

Answer 8

• AV pressure increases
• L. atrium pressure increases
• Pulmonary venous and capillary pressures increase
• pulmonary vascular resistance increases
• pulmonary artery pressure increases (and pulmonary hypertension develops)
• right heart dilatation with tricuspid regurgitation and pulmonary regurgitation

Question 9

What is the dynamic range for mitral stenosis for it to reach pathology?

Answer 9

dynamic range is relatively wide

Question 10

What 2 features remain and function normally in mitral stenosis? (remain unaffected)

Answer 10

1. l. ventricle pressures

2. systolic pressures

Question 11

What determines mitral stenosis severity? (2)

Answer 11

1. trans-valvular pressure gradient

2. trans-valvular flow rate (cardiac output and heart rate)

Question 12

What factors affect heart rate (and therefore tachycardia)? (4)

Answer 12

1. exercise
2. acute illness
3. pregnancy
4. atrial fibrillation

Question 13

What are clinical manifestations/ symptoms which indicate a mitral stenosis? (6)

Answer 13

1. dyspnoea (mild exertional to pulmonary oedema)
2. haemoptisis ( rupture of thin walled veins)
3. systemic embolisation (left atrium and left atrial appendage enlargement or stroke)
4. infective endocarditis
5. chest pain
6. hoarseness (compression of the l. recurrent laryngeal nerve)

Question 14

What is found on examination in mitral stenosis patients? (6)

Answer 14

1. mitral facies
2. pulse (normal) since l.ventricle is normal
3. JVP (prominent A wave)
4. Tapping apex beat and diastolic thrill
5. right ventricle heave
6. auscultation

Question 15

What might mitral facies signs look like in patients with mitral stenosis?

Answer 15

• rosy cheeks

- other facial areas slightly blue due to cyanosis (especially in severe cases)

Question 16

What will the first and second heart sounds sound like in mitral stenosis patients?

Answer 16

the first heart sound is increased in intensity and second heart sound is normal

Question 17

What investigations are done for mitral stenosis patients to diagnose it?

Answer 17

1. ECG
2. cardiac
3. chest x ray (shows l.atrium englargement)
4. echocardiography (imaging)
5. cardiac magnetic resonance (imaging)

Question 18

What does an ECG show in a mitral stenosis patient?

Answer 18

l. atrium enlargement (pressure bigger than it should be)

Question 19

What is the link between severity of the stenosis and the difference between l.atrial and l.ventricular pressures?

Answer 19

the bigger the pressure difference (pressure gradient) between l.atrium and l. ventricle, the more severer the mitral stenosis

Question 20

What is seen on an echocardiograph in mitral stenosis patients?

Answer 20

1. thickening and scarring of the leaflets

2. fusion of commissures (area where 2 valve leaflets abnormally came together)

Question 21

How many leaflets/ cusps does each valve have?

Answer 21

• tricuspid: 3
• aortic: 3
• pulmonary: 3
• mitral: 2

Question 22

What is the medical treatment for mitral stenosis?

Answer 22

1. diuretics and restriction of Na intake (atrial fibrillation; sinus rhythm restoration or ventricular rate control)
2. anticoagulation; all those with atrial fibrillation but debatale in sinus rhythm

Question 23

When are diuretics used in mitral stenosis? What do they do?

Answer 23

• used when there is atrial fibrillation
• restore sinus rhythm
• restore ventricular rate control

Question 24

When are anticoagulation drugs used in mitral stenosis?

Answer 24

• when patient has atrial fibrillation but debatable in sinus rhythm patients

Question 25

What are 2 interventional medical treatments for mitral stenosis?

Answer 25

1. valvotomy (balloon vs surgical) | 2. MVR; mitral valve replacement

Question 26

What is the most important form of treatment for mitral stenosis patients?

Answer 26

anticoagulation as it prevents possible emboli which can lead to strokes

Question 27

What is the aetiology for mitral regurgitation?(5)

Answer 27

1. rheumatic heart disease 2. mitral valve prolapse (MVP) 3. infective endocarditis 4. degenerative 5. functional mitral regurgitation due to l.ventricle and annular dilatation

Question 28

What is the most common cause of mitral regurgitation in the world?

Answer 28

rheumatic heart disease

Question 29

What is the most common cause of mitral regurgitation in the DEVELOPED world?

Answer 29

mitral valve prolapse (chord tendinae snaps and no longer valve is attached)

Question 30

What population group often suffers from mitral valve prolapse leading to mitral regurgitation?

Answer 30

men in 40-50s

Question 31

Why does l. ventricle enlargement cause mitral regurgitation?

Answer 31

In MI for example, when ventricle enlarges, the anchors of the mitral valve will also enlarge seal no longer created and mitral valve become incompetent

Question 32

What is meant by stenosis?

Answer 32

- narrowing of the oriffice of the valve | - thickening of the cusps occurs

Question 33

What is meant by regurgitation?

Answer 33

- valve doesn't close properly when it pumps blood out | - leaky valve

Question 34

How does effective regurgitant orrifice/ opening have on mitral regurgitation? (refer to preload, afterload and l.ventricle contractility)

Answer 34

``` Annular enlargement in: -preload -afterload - l. ventricle contractility (regurgitant volume increases) ```

Question 35

What occurs in left ventricular compensation in ACUTE mitral regurgitation?

Answer 35

- end systolic pressure and end systolic volume decreases | - decrease in wall tension

Question 36

What occurs in left ventricular compensation in CHRONIC mitral regurgitation?

Answer 36

- increase in end diastolic volume - end systolic volume returns to normal - ecentric/off centre left ventricular hypertrophy develops

Question 37

What 2 types of regurgitation are most severe and why?

Answer 37

- ACUTE aortic and mitral regurgitation most severe - this is because ventricle has no time to adapt to sudden change (striking emergencies) leading to decrease in end systolic pressures and volume leading to left ventricular compensation and leaving patient in a difficult position

Question 38

Why is acute regurgitation more dangerous than chronic regurgitation?

Answer 38

- in chronic, there is time to see what the situation is, the ventricle can adapt slowly and gradually to changes to accommodate this extra volume of blood over time - in acute, it occurs suddenly and l. ventricle isn't able to deal with more blood coming into l. ventricle spontaneously

Question 39

What happens to l. atrium compliance in mitral regurgitation?

Answer 39

1. compliance REDUCED but also... 2. compliance INCREASE (combination of two occurs in l. atrium during mitral regurgitation)

Question 40

Why is l. atrium compliance REDUCED in mitral regurgitation? (4)

Answer 40

- marked pressure rise - thickening of atrial myocardium - increase in pulmonary vascualar resistance - remodelling of the pulmonary vasculature with pulmonary hypertension

Question 41

Why is l. atrium compliance INCREASED in mitral regurgitation?

Answer 41

- marked volume enlargement | - lesser changes in pulmonary vasculature but develop atrial fibrillation

Question 42

Describe clinical features/ manifestations of ACUTE mitral regurgitations. (valve perforation; small hole inside valve and chordal/papillary muscle) (5)

Answer 42

1. breathlessness 2. pulmonary oedema 3. cardiogenic shock 4. no previous or little history f cardio problems and symptoms presented only for a few days 5. only once murmurs heard can diagnosis be made

Question 43

Describe the clinical features/ manifestations of CHRONIC mitral regurgitations. (5)

Answer 43

1. fatigue 2. exhaustion (low cardiac output) 3. right heart failure 4. dysponoea or palpitations due to atrial fibrillations 5. ventricles start to dilate and function declines

Question 44

What is found on examination in patients with mitral regurgitation? (5)

Answer 44

1. pulse; normal or reduced in heart failure 2. JVP; prominent if right heart failure present 3. Brisk and hyperdynamic apex beat (loud) 4. right ventricle heave 5. auscultation; S1 reduced, split s2; holosystolic blowing radiating to axilla (no relationship between intensity and severity), systolic might be so loud that heart sounds might not even be heard

Question 45

What investigations are done for mitral regurgitation? (4)

Answer 45

1. ECG 2. Chest X ray 3. cardiac catherisation (not used anymore) 4. echocardiography

Question 46

What will be seen on ECG in mitral regurgitation? (2)

Answer 46

- l. atrium enlargement (p>0.12 sec tall) | - right ventricular hypertrophy (prominent r wave in r precordial leads)

Question 47

What will be seen on chest x ray in mitral regurgitation? (2)

Answer 47

- l. atrium enlargement | - calcification of mitral annulus

Question 48

What will be seen in cardiac catherisation in mitral regurgitation? (2)

Answer 48

- l. ventricle angiography; obsolete (not used anymore)

Question 49

What will echocardiography show in mitral regurgitation patients? (4)

Answer 49

1. l. ventricle dimensions 2. cause of mitral regurgitations; e.g. leaflet dysfunction, chordae tendinae or papillary muscle fault, annular disease 3. severity of mitral regurgitation and papillary muscles fault 4. accurate cardiac volumes (volumetric determination of regurgitation)

Question 50

What looks abnormal in an echocardiograph?

Answer 50

left ventricle looks sphere shaped (abnormal)

Question 51

What is the medical treatment for an ACUTE mitral regurgitation? (4)

Answer 51

- preload and afterload reduction may be life-saving - sodium nitroprusside - dobutamine - intra-aortic balloon pump (IABP)

Question 52

What is the medical treatment for a CHRONIC mitral regurgitation? (1)

Answer 52

- mainly l. ventricle function preservation | - lack of evidence that any therapy is beneficial for haemodynamic improvement

Question 53

What is the interventional treatment for mitral regurgitation? (2)

Answer 53

1. mitral valve apparatus repair | 2. mitral valve replacement

Question 54

What is the difference between time duration for treatment of acute and chronic mitral regurgitation?

Answer 54

- acute needs to be treated immediately since ventricle not used to the change - chronic can wait decades to treat, lots of time to control it since ventricle underwent adaptation

Question 55

Which valve is biggest; mitral or aortic?

Answer 55

Mitral (bigger orfices), 3-4cm^2

Question 56

What is the most common valve stenosis in the world? Why?

Answer 56

aortic stenosis; because subjected to highest velocities of blood and creates highest pressure

Question 57

What are 3 main causes for aortic stenosis?

Answer 57

1. degenerative 2. rehumatic heart disease 3. bicuspid valve (instead of having 3 cusps like in normal)

Question 58

Is bicuspid aortic valve congenital?

Answer 58

Yes; some people develop complications into adulthood whereas other don't at all

Question 59

What does rheumatic disease cause for aortic stenosis? (2)

Answer 59

- fusion of the commissures and retraction | - stiffening of free cusp margins

Question 60

What does degenerative disease cause for aortic stenosis? (2)

Answer 60

- linked to atherosclerosis | - slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins

Question 61

Describe steps that lead to l. ventricular failure from aortic stenosis? (6)

Answer 61

1. aortic stenosis (narrowing) increases l. ventricular pressure 2. severe concentric hypertrophy and left ventricular mass 3. increased l. ventricular end diastolic pressure (l.atrial pressure increases pulmonary hypertension too) 4. increased myocardial oxygen consumption 5. myocardial ischaemia develops 6. l. ventricular failure

Question 62

Describe the asymptomatic phase in aortic stenosis. What happens once person becomes symptomatic?

Answer 62

- long asymptomatic phase - progressive and slow over years - when patients become symptomatic, their survival rate drops instantly (fast treatment is needed immediately)

Question 63

What are cardinal symptoms for aortic stenosis? (4)

Answer 63

1. chest pain (angina) 2. syncope/ dizziness (exertional pre-syncope) 3. breathlessness on exertion 4. heart failure

Question 64

What is found on clinical examination in aortic stenosis patients? (5)

Answer 64

1. pulse: small volume and slowly rising (cardiac output is low) 2. JVP: prominent if r. heart failure present, low BP 3. vigorous and sustained apex beat 4. right ventricle heave 5. auscultation; late peaking, loud at base, harsh murmur and radiating to carotids

Question 65

What investigations are needed for aortic stenosis? (4)

Answer 65

1. ECG 2. chest x ray 3. cardiac catherisation (no longer used) 4. echocardiography 5. CMR: cardiovascular magnetic resonance imaging

Question 66

What does ECG show in aortic stenosis?

Answer 66

- l. ventricular hypertrophy voltage criteria | - ST/T changes (l.ventricle stain)

Question 67

What does chest x ray show in aortic stenosis patients?

Answer 67

calcification of aortic valve

Question 68

What does cardiac catherisation show in aortic stenosis patients?

Answer 68

- peak l. ventricle peak aortic gradient (obsolete/ no longer used)

Question 69

What does echocardiography show in aortic stenosis patients? (3)

Answer 69

1. demonstrates aortic valve cusp mobility and severity of stenosis 2. l. ventricle function and hypertrophy 3. doppler haemodynamic assessment of pressure gradient and aortic valve area

Question 70

Who is limited to treatment for aortic stenosis?

Answer 70

patients who develop heart failure

Question 71

What is interventional treatment for aortic stenosis?

Answer 71

aortic valve replacement or repair

Question 72

What is 2 areas lead to aetiology for the aortic regurgitation?

Answer 72

1. aorta | 2. leaflets

Question 73

What aortic aetiology leads to aortic regurgitation? (2)

Answer 73

1. dilated aorta (Marfan's or hypertension) | 2. connective tissue disorders

Question 74

What leaflet aetiology leads to aortic regurgitation? (4)

Answer 74

1. bicuspid aortic valve 2. rheumatic heart disease 3. endocarditis 4. myxomatous degeneration (leaflets become dysfunctional)

Question 75

Describe the steps that lead to l. ventricular failure from aortic regurgitation. (6)

Answer 75

1. l. ventricle accommodates both stroke volume and regurgitant volume 2. increased l.ventricle end diastolic volume and l. ventricle systolic pressure 3. increased l. ventricular hypertrophy and l. ventricle dilatation 4. increased myocardial oxygen consumption 5. myocardial ischaemia develops 6. l. ventricular failure

Question 76

What are symptoms for CHRONIC aortic regurgitation? Why can they be addressed over time?

Answer 76

- long asymptomatic phase which means they take longer to develop and treatment phase is longer since ventricle adapted - exertional breathlessness

Question 77

Why are symptoms for ACUTE aortic regurgitation addressed immediately?

Answer 77

- poorly tolerated as wall tension cannot acutely adapt | - l. ventricle pressure x l. ventricle radius / wall thickness

Question 78

What is seen on clinical examination in aortic regurgitation? (4)

Answer 78

1. pulse: large volume and collapsing (Corrigan sign) 2. wide pulse pressure 3. hyperdynamic, displaced apex beat 4. auscultations: normal s1 and normal s2, early diastolic, descrescendo and soft murmur heard

Question 79

What investigations are done for aortic regurgitation? (3)

Answer 79

1. ECG 2. chest x ray 3. cardiac catherisation (obsolete/ no longer performed) 4. echocardiography 5. cardiovascular magnetic resonance imaging (CMR)

Question 80

What does ECG show in aortic regurgitation?

Answer 80

ST/T changes (l. ventricle strain seen on left anterior descending coronary artery_

Question 81

What does chest x ray show in arotic regurgitation?

Answer 81

cardiomegaly in chronic aortic regurgitation

Question 82

What is done prior to cardiac catherisation?

Answer 82

aortogram; cathether used to inject dye into aorta, rays taken as dye travels through aorta showing blood flow

Question 83

What does echocardiography allow us to see in aortic regurgitation? (echocardiogram= ulrtasound of heart, looking at it from different dimensions) (3)

Answer 83

- shows AV cusp anatomy (thickening, prolapsing number of cusps, vegetations) - l. ventricle function, dilatation and hypertrophy - haemondynamic assessment of regurgitation flow

Question 84

What is the best medical treatment for aortic regurgitation?

Answer 84

vasodilator therapy (shown to delay timing for surgical intervention; 2-3 years)

Question 85

What is the best interventional treatment for aortic regurgitation? (2)

Answer 85

- aortic valve replacement | - aortic valve repair