CVD - Valvular pathology

Question 1

(3) Etiology of aortic stenosis

Answer 1

• Congenital (bicuspid, unicuspid valve)
• calcification (wear and tear)
• rheumatic disease

Question 2

Definition of aortic stenosis for:

• normal
• mild
• moderate
• severe
• critical

Answer 2

Normal aortic valve area = 3-4 cm2
Mild AS 1.5-3 cm2
Moderate AS 1.0 to 1.5 cm2
Severe AS less than 1.0 cm2
Critical AS less than 0.5 cm2

Question 3

Pathophysiology of aortic stenosis

Answer 3

Outflow obstruction -> increased EDP -> concentric LVH -> LV failure -> CHF,
subendocardial ischemia

Question 4

Symptoms of aortic stenosis

Answer 4

SAD

• syncope
• angina on exertion
• dyspnoea on exertion

PND, orthopnea, peripheral edema

Question 5

O/E of aortic stenosis

Answer 5

• Narrow pulse pressure,
• brachial-radial delay,
• pulsus parvus et tardus,
• sustained PMI

Auscultation: crescendo-decrescendo SEM radiating to R clavicle and carotid, musical
quality at apex (Gallavardin phenomenon)

S4, soft S2 with paradoxical splitting, S3 (late)

Question 6

Ix of aortic stenosis

Answer 6

ECG: LVH and strain, LBBB, LAE, AFib

CXR: post-stenotic aortic root dilatation, calcified valve, LVH, LAE, CHF

Echo: reduced valve area, pressure gradient, LVH, reduced LV function

Question 7

Mx of aortic stenosis

Answer 7

• Asymptomatic: serial echos, avoid exertion
• Symptomatic: avoid nitrates/arterial dilators and ACEI in severe AS
• Surgery if: symptomatic or LV dysfunction.

Valve replacement for aortic rheumatic valve disease & trileaflet valve.

Percutaneous (transfemoral etc) valve replacement an option for those who are not good candidates for surgery

Question 8

Etiology of aortic regurgitation

• supravalvular
• valular
• acute onset

Answer 8

• Supravalvular: aortic root disease (Marfan’s, atherosclerosis and dissecting aneurysm, connective tissue disease)
• Valvular: congenital (bicuspid aortic valve, large VSD), IE
• Acute Onset: IE, aortic dissection, trauma, failed prosthetic valve

Question 9

Pathophysiology of aortic regurgitation

Answer 9

Volume overload -> LV dilatation -> increased SV, high sBP and low dBP -> increased
wall tension -> pressure overload -> LVH (low dBP -> decreased coronary perfusion)

Question 10

Symptoms of aortic regurgitation

Answer 10

Usually only becomes symptomatic late in disease when LV failure develops

Dyspnea, orthopnea, PND, syncope, angina

Question 11

O/E of aortic regurgitation

• pulse characterisation
• apex beat
• on auscultation
• heart sounds

Answer 11

Waterhammer pulse, bisferiens pulse, femoral-brachial sBP >20 (Hill’s test wide pulse
pressure), hyperdynamic apex, displaced PMI, heaving apex

Auscultation: early decrescendo diastolic murmur at LLSB (cusp pathology) or RLSB
(aortic root pathology), best heard sitting, leaning forward, on full expiration

soft S1, absent S2, S3 (late)

Question 12

Ix of aortic regurgitation

Answer 12

ECG: LVH, LAE

CXR: LVH, LAE, aortic root dilatation

Echo/TTE: quantify AR, leaflet or aortic root anomalies

Cath: if >40 yr and surgical candidate – to assess for ischemic heart disease

Exercise testing: hypotension with exercise

Question 13

Mx of aortic regurgitation

Answer 13

• Asymptomatic: serial echos, afterload reduction (e.g. ACEI, nifedipine, hydralazine)
• Symptomatic: avoid exertion, treat CHF
• Surgery if: NYHA class III-IV CHF; LV dilatation and/or LVEF

Question 14

Etiology of mitral stenosis

Answer 14

Rheumatic disease most common cause

congenital (rare)

Question 15

Definition of mitral stenosis

Answer 15

Severe MS is mitral valve area (MVA) less than 1.2 cm2

Question 16

Pathophysiology of mitral stenosis

Answer 16

MS -> fixed CO and LAE -> increased LA pressure -> pulmonary vascular resistance
and CHF; worse with AFib (no atrial kick), tachycardia (decreased atrial emptying time)
and pregnancy (increased preload)

Question 17

Symptoms of mitral stenosis

Answer 17

SOB on exertion, orthopnea, fatigue, palpitations, peripheral edema, MALAR FLUSH,
pinched and blue facies (severe MS)

Question 18

O/E of mitral stenosis

• arrhythmia involved
• auscultation
• heart sounds
• any added sound

Answer 18

AFib, no “a” wave on JVP, left parasternal lift, palpable diastolic thrill at apex

Auscultation: mid-diastolic rumble at apex, best heard with bell in left lateral decubitus
position following exertion

Loud S1, OPENING SNAP following loud P2 (heard best during expiration),
long diastolic murmur and short A2-OS (opening snap) interval correlate with worse MS

Note: Mitral stenosis has an opening snap before diastolic murmur. C.f. Mitral valve prolapse has a CLICK before its systolic murmur.

Question 19

Ix of mitral stenosis

Answer 19

ECG: NSR/AFib, LAE (P mitrale), RVH, RAD

CXR: LAE, CHF, mitral valve calcification

Echo/TTE: shows restricted opening of mitral valve

Cath: indicated in concurrent CAD if >40 yr (male) or >50 yr (female)

Question 20

Mx of mitral stenosis

Answer 20

Avoid exertion, fever (increased LA pressure), treat AFib and CHF, increase diastolic filling time (β-blockers, digitalis)

Surgery if: NYHA class III-IV CHF and failure of medical therapy

Question 21

(many) Etiology of mitral regurgitation

Answer 21

Mitral valve prolapse, congenital cleft leaflets, LV dilatation/aneurysm (CHF, DCM,
myocarditis), IE abscess, Marfan’s
syndrome, HOCM, acute MI, myxoma, mitral valve annulus
calcification, chordae/papillary muscle trauma/ischemia/rupture (acute), rheumatic
disease

Question 22

Pathophysiology of mitral regurgitation

Answer 22

Reduced CO -> increased LV and LA pressure -> LV and LA dilatation -> CHF and pulmonary HTN

Question 23

Symptoms of mitral regurgitation

Answer 23

Dyspnea, PND, orthopnea, palpitations, peripheral edema

Question 24

O/E of mitral regurgitation

• apex beat
• auscultation

Answer 24

Displaced hyperdynamic apex, left parasternal lift, apical thrill

Auscultation: holosystolic murmur at apex, radiating to axilla ± mid-diastolic rumble,
loud S2 (if pulmonary HTN), S3

Question 25

Ix of mitral regurgitation

Answer 25

ECG: LAE, left atrial delay (bifid P waves), ± LVH CXR: LVH, LAE, pulmonary venous HTN Echo: etiology and severity of MR, LV function, leaflets Swan-Ganz Catheter: prominent LA “v” wave

Question 26

Rx of mitral regurgitation

Answer 26

Asymptomatic: serial echos Symptomatic: decrease preload (diuretics), decrease afterload (ACEI) for severe MR and poor surgical candidates; stabilize acute MR with vasodilators before surgery Surgery if: acute MR with CHF, papillary muscle rupture, NYHA class III-IV CHF, AF, increasing LV size or worsening LV function, earlier surgery if valve repairable (>90% likelihood) and patient is low-risk for surgery Most get valve repair (lower rate of IE, no anticoagulation) rather than replacement.

Question 27

Etiology of tricuspid regurgitation

Answer 27

RV dilatation, IE (particularly due to IV drug use), rheumatic disease, congenital (Ebstein anomaly), carcinoid

Question 28

Symptomsof tricuspid regurgitation

Answer 28

Peripheral edema, fatigue, palpitations

Question 29

O/E of tricuspid regurgitation - JVP - [...] sign - auscultation

Answer 29

“cv” waves in JVP, +ve abdominojugular reflux, Kussmaul’s sign, holosystolic murmur at LLSB accentuated by inspiration, left parasternal lift

Question 30

Ix of tricuspid regurgitation

Answer 30

ECG: RAE, RVH, AFib CXR: RAE, RV enlargement Echo: diagnostic

Question 31

Mx of tricuspid regurgitation

Answer 31

Preload reduction (diuretics) Surgery if: only if OTHER surgery required (e.g. mitral valve replacement)

Question 32

Pathophysiology of tricuspid regurgitation

Answer 32

RV dilatation -> TR -> further RV dilatation -> right heart failure

Question 33

Etiology of pulmonary stenosis

Answer 33

Usually congenital, rheumatic disease (rare), carcinoid syndrome

Question 34

Pathophysiology of pulmonary stenosis

Answer 34

Increased RV pressure -> RV hypertrophy -> right heart failure

Question 35

Symptoms of pulmonary stenosis

Answer 35

Chest pain, syncope, fatigue, peripheral edema

Question 36

O/E of pulmonary stenosis

Answer 36

Systolic murmur at 2nd left intercostal space accentuated by inspiration, pulmonary ejection click, right-sided S4

Question 37

Mx of pulmonary stenosis

Answer 37

Balloon valvuloplasty if severe symptoms

Question 38

Ix of pulmonary stenosis

Answer 38

ECG: RVH CXR: prominent pulmonary arteries enlarged RV Echo: diagnostic

Question 39

(many) Etiology of mitral valve prolapse

Answer 39

Myxomatous degeneration of chordae, thick, bulky leaflets that crowd orifice, associated with Marfan’s syndrome, pectus excavatum, straight back syndrome, other MSK abnormalities; less than 3% of population

Question 40

Pathophysiology of mitral valve prolapse

Answer 40

Mitral valve displaced into LA during systole; no causal mechanisms found for symptoms

Question 41

Symptoms of mitral valve prolapse

Answer 41

Prolonged, stabbing chest pain, dyspnea, anxiety/panic, palpitations, fatigue, presyncope

Question 42

O/E of mitral valve prolapse

Answer 42

Ausculation: mid-systolic CLICK (due to billowing of mitral leaflet into LA; tensing of redundant valve tissue); mid to late systolic murmur at apex, accentuated by Valsalva or squat-to-stand maneuvers Note: midsystolic CLICK in mitral valve prolapse (c.f. opening snap in mitral stenosis before diastolic murmur)

Question 43

Ix of mitral valve prolapse

Answer 43

ECG: non-specific ST-T wave changes, paroxysmal SVT, ventricular ectopy Echo: systolic displacement of thickened mitral valve leaflets into LA

Question 44

Mx of mitral valve prolapse

Answer 44

Asymptomatic: no treatment; reassurance Symptomatic: β-blockers and avoidance of stimulants (caffeine) for significant palpitations, anticoagulation if AFib Mitral valve surgery (repair favoured over replacement) if symptomatic and significant MR