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Cardiology core conditions > Valvular Heart disease > Flashcards

Valvular Heart disease Flashcards

1
Q

What does the mitral valve consist of (anatomy)?

A

Fibrous annulus, anterior and posterior leaflets, chord tendineae and the papillary muscle

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2
Q

What is mitral stenosis?

A

Narrowing (stenosing) of valve orifice area <2cm.

Normal orifice area = 4-6cm

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3
Q

What is the most common cause of mitral stenosis?

A

Due to rheumatic heart disease following previous rheumatic fever due to group A beta-haemolytic streptococcus.

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4
Q

What changes are seen in the mitral stenosis following rheumatic heart disease?

A

Leads to valve thickening, cusp fusion, calcium deposition and a stenotic (narrowed) valve orifice over many years.

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5
Q

What are some other causes of mitral stenosis?

A

Congenital
Mitral annular calcification (elderly)
Carcinoid tumours metastasising to the lung
Prosthetic valve

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6
Q

What is the underling pathology as a result of mitral stenosis?

A

Severe mitral stenosis (v narrow valve orifice) => increased left atrial pressure (to maintain cardiac output) => left atrial hypertrophy and dilation => loss of coordinated atrial contraction => atrial fibrillation with tachycardia

As a result, pulmonary and right heart pressure also increase => pulmonary oedema + hypertension => right ventricular hypertrophy, dilation and failure => tricuspid regurgitation

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7
Q

What are the clinical signs and symptoms of mitral stenosis?

A

Symptoms:

Pulmonary hypertension => Severe dyspnoea, frothy sputum or frank haemoptysis (bloody but small vol), productive cough - blood tinged

Pressure from enlarged left atrium on nearing structures => hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus), bronchial obstruction

Fatigue, palpitations, chest pain

AF => systemic emboli => stroke

Infective endocarditis (rare)

Signs:

Malar flush (due to reduced CO)
Atrial fibrillation (irregularly irregular, low volume pulse)
Tapping non-displaced apex beat (palpable S1)
Right ventricle heaving, sustained

On auscultation: Loud S1, opening snap, rumbling mid-diastolic murmur (heard best on expiration with patient on left side)

JVP raised if right heart failure

*The more severe the stenosis the longer the diastolic murmur and closer the opening tap is to S2.

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8
Q

Who does it affect?

A

Women > Men

Rheumatic fever common in low-middle income countries => increased risk of mitral stenosis

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9
Q

Which investigations are carried out for mitral stenosis?

A
  1. Chest X-ray : enlarged left atrium (double shadow in right cardiac silhouette) ; mitral valve calcifications ; pulmonary oedema
  2. ECG : Atrial fibrillation ; P mitrale (biphasic p-wave i.e. double bump p-wave seen in left atrium enlargement);
  3. Echocardiogram : determines left atrial size and thickening, any calcification and mobility of mitral leaflets.
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10
Q

What is the normal size of mitral valve orifice?

What size of mitral valve orifice do symptoms arise?

A

4-6cm/sq

Symptoms arise at <2cm/sq

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11
Q

Which investigation is diagnostic of mitral stenosis?

A

Echo - significant stenosis if valve orifice <1cm/sq

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12
Q

What is the indication for catheterisation?

A

Severe mitral stenosis + calcifications, previous valvotomy, other valve disease, angina, severe pulmonary hypertension

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13
Q

How do you manage mitral stenosis and its signs i.e. AF?

A

AF: rate control with beta-blockers or DC cardioversion

Anti-coagulation (warfarin) for atrial thrombus prevention and systemic emboli.

Diuretics to reduce preload and pulmonary venous congestion

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14
Q

There are 4 interventions which may be carried out if medical therapy fails to control mitral stenosis symptoms.

Explain briefly trans-septal balloon valvotomy.

Which patients is it ideal for?

What are the risk of this procedure?

What are the contra-indications?

A
  1. Trans-septal balloon valvotomy: catheter via femoral vein through atrial septum => balloon splits up the commissures.
  2. Ideal for patients with pliable valves
  3. Risk of significant mitral regurgitation => valve replacement
  4. Contraindications: heavy calcifications or mitral regurgitation and thrombus in left atrium.
    * Transoesphageal echo prior to this procedure to exclude atrial thrombus
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15
Q

There are 4 interventions which may be carried out if medical therapy fails to control mitral stenosis symptoms.

Explain briefly closed valvotomy.

Which patients is it ideal for?

A

Fused cusps are forced apart using a dilator via the apex of the left ventricle.

Only suitable for patients with mobile, non-calcified and non-regurgitating mitral valves.

*Good result for 10 years

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16
Q

There are 4 interventions which may be carried out if medical therapy fails to control mitral stenosis symptoms.

Explain briefly open valvotomy.

What are its benefits vs closed valvotomy?

A

Cusps are dissected apart. Cardiopulmonary bypass is required.

Open dissection reduces the likelihood of causing traumatic mitral regurgitation.

*preferred to closed valvotomy

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17
Q

There are 4 interventions which may be carried out if medical therapy fails to control mitral stenosis symptoms.

What is the indication for mitral valve replacement?

A
  1. Mitral regurgitation is present alongside mitral stenosis
  2. Badly diseased/calcified stenotic valve that can’t be reopened without significant regurgitation
  3. Severe mitral stenosis and thrombus in left atrium despite anti-coagulant.
    * Artificial valves lasts for 20 years + anti-coagulation to prevent thrombus formation
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18
Q

What is mitral regurgitation?

A

Backflow through the mitral valve during systole.

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19
Q

What is the underlying pathology as a result of mitral regurgitation?

A

Regurgitation into the left atrium => left atrial dilation => left ventricle enlargement/hypertrophy/failure

In acute mitral regurgitation, left atrium doesn’t have time to dilate => increases left atrium pressure => increases pulmonary venous pressure => pulmonary oedema

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20
Q

Mitral regurgitation occurs due to abnormalities of the valve leaflets, annulus, chordae tendineae or papillary muscle.

What are the causes of mitral regurgitation?

A

Left ventricle dilation (functional)

Annular calcifications (elderly)

Rheumatic heart disease

Infective endocarditis

Ischaemic heart disease

Cardiomyopathy (dilated or hypertrophy)

Collagen disease i.e. Marfan’s, Ehlers Danlos syndrome

Degenerative (myoxomatous) disease => valves becomes thickened with nodule formation => prevents them from closing properly => regurgitation

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21
Q

What are the signs and symptoms of mitral regurgitation?

A

Symptoms:

Dyspnoea and Orthopnoea => due to pulmonary venous hypertension

  1. direct from mitral regurgitation
  2. secondarily from left ventricular failure

Fatigue & Lethargy => due to reduced cardiac output

Palpitations

Symptoms of right heart failure in late disease

Subacute infective endocarditis

Signs:

Laterally displaced hyper dynamic apex beat + systolic thrill if severe

Pansystolic murmur at apex radiating to axilla

Soft S1, split S2, loud P2 => pulmonary hypertension

Atrial fibrillation

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22
Q

Which investigations are carried out for mitral regurgitation?

A
  1. ECG: P-mitrale (bifid p-wave = atrial enlargement i.e. dilation or hypertrophy), atrial fibrillation, tall R-waves in left lateral leads I & V6 = left ventricular hypertrophy
    * LVH present in 50% of mitral regurgitation
  2. Chest X-ray: Left atrial and ventricular enlargement, valve calcifications, pulmonary oedema
  3. Echocardiogram: Dilated left atrium and ventricle, chordal or papillary rupture. Severity of regurgitation assessed using colour doppler.
    * Echo assesses LV function, mitral regurgitation severity and aetiology
  4. Cardiac catheterisation: to confirm diagnosis and exclude other valve disease. Appropriate for valve repair/replacement.
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23
Q

What is the conservative management for mitral regurgitation?

A

Mild-moderate mitral regurgitation = conservative management

  1. AF: control rate if fast
  2. Anticoagulate if AF, history of embolism, prosthetic valve, additional mitral stenosis
  3. Diuretics improve symptoms
  4. Prophylaxis against endocarditis
  5. Regular echo monitoring
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24
Q

What is the management for symptomatic severe mitral regurgitation?

A

Surgery to repair/replace valve before LV is irreversibly impaired.

25
Q

What is prolapsing mitral valve also known as Barlow’s syndrome or floppy mitral valve?

A

It is due to excessively large mitral valve leaflets, an enlarged mitral annulus, abnormally long chordal or disordered papillary muscle contraction.

26
Q

Who does prolapsing mitral valve commonly affect?

A

Women > Men

Familial incidence

27
Q

What causes prolapsing mitral valve?

Any changes seen in histology?

A

Unknown cause but assoc. with connective tissue disorders i.e. Marfan’s syndrome, Ehlers-Danlos syndrome.

Histology: myxomatous degeneration of mitral valve leaflets.

28
Q

What is aortic stenosis?

A

A chronic progressive disease that limits left ventricular outflow

29
Q

What are the causes of aortic stenosis and what changes are seen as a result of these changes?

A

Senile calcification of tricuspid valve: most common cause mainly seen in elderly.

Inflammatory process with macrophages and T-lymphocytes => thickening of sub endothelium and fibrosis => lesion contains lipoprotein which calcify => increased leaflet stiffness + reduces systolic opening

Congenital bicuspid valve stenosis: Congenital or familial bicuspid. Familial bicuspid valve present at an earlier age.
Bicuspid aortic valve assoc. with aortic coarctation, root dilation, aortic dissection

Rheumatic disease: progressive fusion, thickening and calcification of the aortic valve

30
Q

What are the risk factors for valve calcification?

A 
Old age
Male
High lipoprotien
LDL cholesterol
Hypertension
Diabetes
Smoking
31
Q

What is the underlying pathology as a result of aortic stenosis?

A

Obstructed left ventricular emptying => increased left ventricular pressure & left ventricular hypertrophy => relative ischaemia => angina arrhythmias and left ventricular failure

32
Q

What are the signs and symptoms of aortic stenosis?

A

No symptoms until aortic stenosis is severe.

Symptoms:
The classic triad: angina, syncope, heart failure
Exertional dyspnoea

Signs:

Slow rising carotid pulse with narrow pulse pressure
Left ventricle heave
Aortic thrill
Non-displaced apex beat
Ejection systolic murmur (heard at base left sternal edge and aortic area - radiates to the carotids)
Soft/inaudible aortic S2
Prominent 4th heart sound (S4)

33
Q

What is the prognosis for aortic stenosis?

A

Poor prognosis once symptoms occur - death within 2/3 years without any surgical intervention

34
Q

What investigations are carried out for aortic stenosis?

A

ECG:

Left ventricular hypertrophy with strain = depressed ST segment and inverted T-wave in leads (I, AVL, V5, V6) orientated toward left ventricle.

P-mitrale (bifid p-wave) due to left atrial enlargement

Left bundle branch block or complete AV block (calcified ring)

Chest X-ray:

Left ventricular hypertrophy, calcified aortic valve, post-stenotic dilation of ascending aorta

Echo:

Echo is diagnostic.

Thickened, calcified immobile aortic valve cusps + left ventricular hypertrophy

Assesses severity of aortic stenosis via doppler echo - valve gradient flow

35
Q

What are the differentials for aortic stenosis?

A

Hypertrophic cardiomyopathy

Aortic sclerosis

36
Q

What is the management for aortic stenosis for

i. symptomatic patients
ii. asymptomatic patients
iii. patients unfit for surgery
iv. young patient

A

i. If symptomatic => aortic valve replacement
ii. If asymptomatic with severe aortic stenosis and deteriorating ECG or symptoms during exercise, LVEF <50% => aortic valve replacement
iii. If unfit for surgery = percutaneous valve replacement with a transcatheter aortic valve implantation.
iv. If young with aortic stenosis = valvotomy then later aortic valve replacement

37
Q

What is aortic sclerosis and its main signs?

A

Senile degeneration of the valve.

Ejection systolic murmur but no carotid radiation and normal pulse + S2

38
Q

What is aortic regurgitation?

A

Reflux of blood from the aorta through the aortic valve into the left ventricle during diastole

39
Q

What is the underlying pathology as a result of aortic regurgitation?

A

To maintain cardiac output, the volume of blood pumped into the aorta must increase = left ventricular enlargement (dilation)

Aortic regurgitation during diastole => fall in diastolic pressure => fall in coronary perfusion

Fall in coronary perfusion + increase in left ventricle size (increase in oxygen demand) => cardiac ischaemia

40
Q

What are the causes of chronic aortic regurgitation?

A 
Rheumatic heart disease
Connective tissue disease i.e. Marfan's ; Ehlers-Danlos
Rheumatoid arthritis 
SLE
Appetite suppressants
Ankylosing spondylitis 
Hypertension
Osteogenesis imperfecta
Syphilis aortitis
Pseudoxanthoma elasticum
Takayasu arteritis
41
Q

What are the signs and symptoms of aortic regurgitation?

What are some rare signs of aortic regurgitation?

A

Symptoms occur late and present with left ventricular failure

Symptoms:

Exertional dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea 
Angina 
Syncope
Palpitations

Signs:

Collapsing (water-hammer) pulse, large volume, sinus rhythm
Wide pulse pressure
Displaced laterally, diffuse, hyper-dynamic, forceful apex beat

On Auscultation: high-pitched early diastolic murmur at left sternal edge, 4th intercostal space with patient leaning forward and breath held at expiration

Ejection systolic murmur at base and into neck => volume overload

Rare signs:

Corrigan’s sign: carotid pulsation

Quickne’s sign: capillary pulsating in nail bed

de Musset’s sign: head nodding with each heart beat

Pistol shot femoral: sharp bang heard on auscultation over femoral artery in time with each heart beat

Duroziez’s sign: to and fro murmur when pressure applied distally on femoral artery auscultation

42
Q

What are the investigations carried out for aortic regurgitation?

A

ECG: Left ventricular hypertrophy due to volume overload = tall R waves and deep inverted T waves in left sided chest leads (V5, V6) ; normal sinus rhythm

Chest X-ray: Left ventricular enlargement, dilation of ascending aorta, pulmonary oedema.

Echocardiogram: Dilated left ventricle, enlarged aortic root. Echo is diagnostic.

Severity of aortic regurgitation checked via a colour doppler

43
Q

What is the medical management of aortic regurgitation?

A

Main goal of medical therapy = reduce systolic hypertension => ACEi

ECHO every 6-12 months to monitor

Treat underlying cause i.e. syphilis or infective endocarditis

Acute aortic regurgitation treat with vasodilators inotropes. ACEi in patients with left ventricular dysfunction.

Beta-blockers may slow down aortic dilation in Marfan’s

44
Q

When is surgery indicated in aortic regurgitation?

A

Acute severe aortic regurgitation e.g. endocarditis

Increasing symptomatic (dyspnoea, angina)

Severe aortic regurgitation with enlarged ascending aorta

Asymptomatic patients with LVEF <50% (poor prognosis)

Asymptomatic patients with LVEF >50% but with dilated left ventricle

Undergoing CABG or other cardiac valve replacement

*both prosthetic and tissue valves are used. Tissue valves for elderly

45
Q

What is tricuspid stenosis caused by?

A

Tricuspid stenosis = uncommon,

Caused by:
Rheumatic heart disease
Often assoc. with mitral and/or aortic valve disease
Carcinoid syndrome

46
Q

What is the underlying pathology as a result of tricuspid stenosis?

A

Reduced cardiac output => right atrial pressure increase => systemic venous congestion => hepatomegaly => ascites + peripheral oedema

47
Q

What are the signs and symptoms of tricuspid stenosis?

A

Symptoms:

Abdominal pain (hepatomegaly)
Ascites
Peripheral oedema

Signs:
Prominent jugular wave
Pre-systolic pulse over the liver
Rumbling mid-diastolic murmur at lower left sternal edge + louder on inspiration

48
Q

What are the investigations and management of tricuspid stenosis?

A

Investigations:
Chest X-ray: right atrial bulge

ECG: enlarged right atrium = tall Waves in lead II

Echo: thickened, immobile tricuspid valve

Management:
Diuretic therapy and salt restriction

Tricuspid valve replacement - possible multiple valve replacement as tricuspid stenosis rarely isolated

Tricuspid valvotomy

49
Q

What causes functional and organic tricuspid regurgitation?

A

Functional: due to right ventricle dilation i.e. cor pulmonale, MI, pulmonary hypertension

Organic: due to rheumatic heart disease, infective endocarditis, carcinoid syndrome

50
Q

What are the signs and symptoms of tricuspid regurgitation?

A

Symptoms of right heart failure due to high right atrial and systemic venous pressure.

Signs:
Increased jugular venous pressure

Hepatomegaly with pulsation in systole

Right ventricular impulse palpated in left sternal edge

Pansystolic murmur on inspiration at lower left sternal edge

Atrial fibrillation

51
Q

What are the investigation and management of tricuspid regurgitation?

A

Investigation:
Echo: dilation of right ventricle and thickening of the valves

Management:
Function tricuspid regurgitation = medical therapy

Severe organic tricuspid regurgitation = repair of tricuspid valve i.e. annuloplasty and sometimes a tricuspid valve replacement needed

52
Q

What causes pulmonary stenosis?

A

Usually congenital assoc. with Fallot’s tetralogy, congenital rubella syndrome

Rarely from rheumatic fever or carcinoid syndrome

Pulmonary stenosis may be valvular, subvalvular or supravalvular

53
Q

What is the underlying pathology as a result of pulmonary stenosis?

A

Obstruction to right ventricle emptying results in right ventricular hypertrophy => right atrial hypertrophy

54
Q

What are the signs and symptoms of pulmonary stenosis?

A 
Symptoms:
Fatigue
Syncope
Symptoms of right heart failure 
*Mild pulmonary stenosis = asymptomatic

Signs:
Harsh mid-systolic ejection murmur on inspiration at left sternal edge, 2nd intercostal space

Murmur is assoc. with a thrill

Right ventricle heave + S4

55
Q

What is the investigation and management of pulmonary stenosis?

A

Investigations:
Chest X-ray: prominent pulmonary artery due to post stenotic dilation

ECG: right atrial and ventricular hypertrophy

Doppler echo = investigation of choice

Management:
Pulmonary valvotomy (balloon or direct valvotomy)
56
Q

What causes pulmonary regurgitation?

A

Most common acquired lesion of pulmonary valve.

Caused by dilation of the pulmonary valve ring as a result of pulmonary hypertension or tetralogy of Fallot repair

57
Q

What is the clinical presentation and management of pulmonary regurgitation?

A

Decrescendo diastolic murmur

Usually no symptoms / treatment rarely needed

58
Q

Two types of valves can be used in valve replacement surgery.

  1. Mechanical valve
  2. Tissue (bioprosthetic) valve i.e. human, porcine or bovine

What are their pros and cons?

A

Mechanical (prosthetic) valve = longer durability but more thrombogenic => lifelong anticoagulant

Tissue valve = shorter durability ~10 years but not depended on long-term anti-coagulant (only used short-term post operation).

Cardiology core conditions (8 decks)

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