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Flashcards in Disease of heart valves Deck (83):
1

What are the causes of mitral stenosis?

Rheumatic fever
Congenital
Mucopolysaccharidoses
Endocardial fibroelastosis
Malignant carcinoid
Prosthetic valve

2

What are mucopolysaccharidoses?

A group of metabolic disorders caused by the absence or malfunctioning of lysosomal enzymes

3

What is endocardial fibroelastosis?

A rare heart disorder usually associated with children two years old and younger characterized by a thickening of the endocardium due to an increase in the amount of supporting connective tissue and elastic fibers

4

What is the normal mitral valve orifice area? At what area do symptoms of stenosis begin?

Normal area= 4-6cm squared

Symptoms= <2cm squared

5

How does mitral valve stenosis present?

Dyspnoea
Fatigue
Palpitations
Chest pain
Systemic emboli
Haemoptysis
Chronic bronchitis-like picture

6

What are the signs of mitral valve stenosis?

Malar flush on cheeks due to reduced cardiac output
Low-volume pulse
Atrial fibrillation is common
Tapping, non-displaced apex beat- palpable S1
On auscultation: loud S1; opening snap (pliable valve) rumbling mid diastolic murmur. Graham Steell murmur may occur

7

How is mitral stenosis best heard?

With the bell of the stethoscope
On expiration
With the stethoscope below the left axilla and the patient on their left side

8

What is a Graham Steell murmur?

An early diastolic murmur. EDMs are high pitched and easily missed and occur as 'absence of silence' in early diastole. An EDM occurs rarely in pulmonary regurgitation. If the pulmonary regurgitation is secondary to pulmonary hypertension resulting from mitral stenosis, then the EDM is called a Graham Steell murmur.

9

How do auscultation sounds change as mitral stenosis becomes more severe?

The more severe the stenosis, the longer the diastolic murmur and the closer the opening snap is to S2

10

What signs might be seen on an ECG in mitral stenosis?

Atrial fibrillation
RV hypertrophy
Progression right axis deviation
In sinus rhythm, bifid P waves (P mitrale)

11

What signs might be seen on a CXR in mitral stenosis?

Left atrial enlargement
Pulmonary oedema
Mitral valve calcification

12

What is the diagnostic test for mitral valve stenosis?

Echocardiography

13

When is significant stenosis said to exist in mitral stenosis?

When the valve orifice is <1cm square per 1m squared of the body surface area

14

How is mitral stenosis managed?

1. If in AF rate control is crucial
2. Anticoagulate with warfarin
3. Diuretics to reduce pre-load and pulmonary venous conjestion
4. If this fails to control symptoms, balloon valvuloplasty- if pliable, non-calcified valve, open mitral valvotomy or valve replacement
5. Infective/subacute bacterial endocaritis prophylaxis for GI/GU infected procedures
6. Oral penicillin as prophylaxis against recurrent rheumatic fever

15

What are complications of mitral stenosis?

1. Pulmonary hypertension
2. Emboli
3. Pressure from larger left atrium on local structures e.g. recurrent laryngeal nerve causing hoarseness, the oesophagus causing dysphagia,
4. Bronchial obstruction
5. Infective endocarditis

16

What are the causes of mitral regurgitation?

Functional (LV dilatation)
Annular calcification (elderly)
Rheumatic fever
Infective endocarditis
Mitral valve prolapse
Ruptured chordae tendinae
Papillary muscle dysfunction/rupture
Connective tissue disorders (Ehlers-Danlos; Marfan's)
Cardiomyopathy
Congenital
Appetite supressents e.g. fenfluramine

17

What are the symptoms of mitral regurgitation?

Dyspnoea
Fatigue
Plapitations
Infective endocarditis

18

What are the signs of mitral regurgitation?

Atrial fibrillation
Displaced, hyperdynamic apex beat
RV heave
Pansystolic murmur

19

Where does the murmur heard in mitral regurgitation radiate?

The axilla

20

What is the sign of increasing severity of mitral regurgitation?

The more severe, the larger the left ventricle

21

What signs might be seen on an ECG of a patient with mitral regurgitation?

Atrial fibrillation
P-mitrale if in sinus rhythm
Left ventricular hypertophy

22

What signs might be seen on a CXR in a patient with mitral regurgitation?

Big LA and LV
Mitral valve calcification
Pulmonary oedema

23

As well as an ECG, what other tests may be performed on a patient with suspected mitral regurgitation

Echo: to assess LV function and aetiology (trans-oesophageal to assess severity and suitability for repair rather than replacement)

Coppler echo to assess size and site and regurgitant jet.

Cardiac catheterization to confirm diagnosis, exclude other valve disease and assess coronary artery disease

24

How is mitral regurgitation managed?

1. Control rate if atrial fibrillation
2. Anticoagulate if: AF; history of embolism; prosthetic valve; additional mitral stenosis
3. Diuretics to improve symptoms
4. Surgery for deteriorating symptoms
5. Aim to repair or replace the valve before LV irreversibly impaired
6. SBE/IE prophylaxis for GI/GU infected procedures

25

What is the most common valvular abnormality?

Mitral valve prolapse

26

What is mitral valve prolapse?

Displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole.

"Mitral valve prolapse means that one or more of the mitral flaps are floppy and don't close tightly, often leading to backflow of blood- mitral regurgitation.

Most people with a mitral valve prolapse will not have symptoms, unless the problem causes severe mitral regurgitation, and it is usually discovered by chance during echocardiography carried out for a different reason."

27

What other diseases may occur with mitral prolapse?

ASD
Patent ductus ateriosus
Cardiomyopathy
Turner's syndorme
Marfan's syndrome
Osteogenesis imperfecta
Pseudoxanthoma elasticum
WPW

28

What are the symptoms of mitral valve prolapse?

May be asymptomatic
May occur with atypical chest pain and palpitations
Some patients have symptoms of autonomic dysfunction- anxiety, panic attack, syncope

29

What signs may be auscultated in a patient with mitral valve prolapse?

Mid systolic click and/or late systolic murmur

30

What are the complications of mitral valve prolapse?

Mitral regurgitation
Cerebral emboli
Arrhythmias
Sudden death

31

What is the diagnostic test for mitral valve prolapse?

Echo

32

What is the treatment for mitral valve prolapse?

Beta-blockers may help palpitations and chest pain
If there is severe mitral regurgitation, surgery may be needed

33

What are the causes of aortic stenosis?

Senile calcification is the commonest cause
Other causes are congenital (bicuspid valve, Williams syndrome) and rheumatic fever

34

What triad of symtoms is characteristic of aortic stenosis?

Angina
Syncope
Heart failure

35

What other symptoms may be seen in aortic stenosis?

Dizziness
Faints
Dyspnoea
Systemic emboli
Sudden death

36

What are the signs of aortic stenosis?

Slow rising pulse with narrow pulse pressure
LV heave
Aortic thrill
Ejection systolic murmur (crescendo de-crescendo)

37

How is an aortic stenotic murmur best heard?

Heard at the base, left sternal edge and aortic area. Radiates to the carotids.

38

What might an ECG of a patient with aortic stenosis look like?

P-mitrale
Left ventricular hypertrophy
Left axis deviaiton- left anterior hemiblock
LBBB or complete AV block (calcified ring)

39

When is aortic stenosis classified as severe?

Peak pressure gradient across the aortic valve is >50mmHg and valve area <1cm squared

40

What is the differential diagnosis for aortic stenosis?

Hypertrophic cardiomyopathy

41

What is the best treatment for aortic stenosis?

Valve replacement

42

What is aortic sclerosis

Senile degeneration of the valve- may be a precursor of aortic stenosis

43

How can aortic sclerosis be differentiated from aortic stenosis on auscultation?

Both have ejection systolic murmur but in sclerosis there is no radiation to the carotids. There is a normal pulse- character and volume- and S2 is normal

44

What are the causes of acute aortic regurgitation?

Infective endocarditis
Ascending aortic dissection
Chest trauma

45

What are the causes of chronic aortic regurgitation?

Congenital
Connective tissue disorders- Marfan's, Ehlers-Danlos
Rheumatic fever
Rheumatoid arthritis
SLE
Hypertension
Osteogenesis imperfecta

46

What are the symptoms of aortic regurgitation?

Exertional dyspnoea
Orthopnoea
PND
Palpitations
Angina
Syncope
CCF

47

What are the signs of aortic regurgitation?

Collapsing pulse
Wide pulse pressure
Displaced, hyperdynamic apex beat
High pitched early diastolic murmur

48

How is the murmur of aortic regurgitation best heard?

With the bell of the stethoscope
In expiration
With the patient sitting forward

49

What is Corrigan's sign?

Carotid pulsation

50

What is de Musset's sign?

Head nodding with each heart beat

51

What is Quincke's sign?

Capillary pulsations in nail bed?

52

What is Duroziez's sign?

In the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur. If 2cm distal, it gives a diastolic murmur as blood flows backwards.

53

What is Traube's sign?

Pistol shot sound over the femoral arteries

54

What is an Austin Flint Murmur?

Mid diastolic murmur heard in mitral stenosis due to the fluttering of the anterior mitral valve cusp caused by the regurgitant stream. Denotes severe AR

55

What is the main goal of therapy in aortic regurgitation?

To reduce systolic hypertension

56

Describe the management of aortic regurgitation

1. Reduce systolic hypertension using ACEis
2. Echo every 6-12 months to monitor
3. Surgery if indicated

57

What are the indications for surgery in aortic regurgitation?

Increasing symptoms
Enlarging heart on CXR/echo
ECG deterioration- T wave inversion in lateral leads
IE refractory to medical therapy

58

What are the predictors for poor post operative survival in aortic regurgitation?

Ejection fraction 12 months

59

What causes tricuspid regurgitation?

Functional- RV dilatation e.g. due to pulmonary hypertesion induced by LV failure
Rheumatic fever
Infection endocarditis
Carcinoid syndrome
Congenital
Drugs- ergot-derived dopamine antagonists e.g. bromocriptine

60

What are the symptoms of tricuspid regurgitation?

Fatigue
Ascites
Oedema
Hepatic pain on exertion
Dyspnoea
Orthopnoea

61

What signs might be seen on the JVP wave in tricuspid regurgitation?

Giant V waves and prominent y descent

62

What are the signs of tricuspid regurgitation?

RV heave
Pansystolic murmur
Pulsatile hepatomegaly
Jaundice
Ascites

63

How is the murmur of tricuspid regurgitation best heard?

At the lower sternal edge in inspiration

64

How is tricuspid regurgitation managed?

1. Treat underlying cause
2. Drugs- diuretics, digoxin, ACEi
3. Valve replacement

65

What are the causes of tricuspid stenosis?

Rheumatic fever is the main cause
Also congenital, IE

66

What are the symptoms of tricuspid stenosis?

Fatigue
Ascities
Oedema

67

What are the signs of tricuspid stenosis?

Giant a wave and slow y descent in JVP
OPening snao
Early diastolic murmur
AF can occur

68

How is tricuspid stenosis treated?

diuretics
surgical repair

69

What are the causes of pulmonary stenosis?

Usually congenital
Acquired causes: rheumatic fever, carcinoid syndrome

70

What are the symptoms of pulmonary stenosis?

Dyspnoea
Fatigue
Oedema
Ascites

71

What are the signs of pulmonary stenosis?

Dysmorphic facies (congeintal causes)
Prominent a wave in JVP
RV heave
Ejection click, ejection systolic murmur radiating to the left shoulder

72

What signs of pulmonary stenosis might be seen on an ECG?

Right axis deviation
Peaked P waves- P pulmonale
RVH
RBBB

73

What is the diagnostic test for pulmonary stenosis?

Cardiac catheterization

74

What is the treatment of pulmonary stenosis?

pulmonary valvuloplasty or valvotomy

75

What causes pulmonary regurgitation?

Any cause of pulmonary hypertension

76

What is valulopasty?

A balloon catheter is inserted across a stenotic valve and inflated

77

When can valvuloplasty be used?

In mitral or pulmonary stenosis when the valve is pliable and non-calcified with no regurgitation

78

What is valvotomy?

Incision into a stenosed cardiac valve to relieve the obstruction. Rarely performed

79

What are the different types of mechanical valves?

Ball-cage, tilting disc or double tilting disc

80

What is the major risk of mechanical valves? How is this risk managed?

Thrombosis
Life-long anticoagulation

81

What are homografts? When are they used?

Cadaveric valves. Used in young patients and for the replacement of infected valves

82

What are xenografts? What is their disadvantage? What is their advantage?

Valves made from porcine valves or pericardium
Do not require anticoagulation
Less durable- need replacement after 8-10 years

83

What are the complications of prosthetic valves?

Systemic embolism
IE
Haemolysis
Structural valve failure
Arrhythmias