M103 T3 L4

Question 1

In which areas do we auscultate? Draw a diagram and label them

Answer 1

Aortic area (right of sternal angle)
Pulmonary area (left of sternal angle)
Tricuspid area (left inferior of sternal angle)
Mitral area (far left inferior of sternal angle)

Question 2

What diseases can cause issues with the valves? (DR.Congo)

Answer 2

degenerative valve disease
rheumatic valve disease
congenital valve disease
infections in immunocompromised patients

Question 3

Which valves do each of the four main valve diseases affect the most?

Answer 3

Degenerative - aortic
rheumatic - mitral
congenital - bicuspid aortic valve
infective - left more than right

Question 4

What group are at high risk of getting an infective disease against the valves and why?

Answer 4

IVDUs - IV drug users
on injection, the drugs may not be clean
flow into the venous system, into the right atrium
the first valve it comes into contact will be the tricuspid valve

Question 5

What is the most common cause of someone with triscupid valve infective endocarditis?

Answer 5

IVDUs / drugs

Question 6

What is the effect of the loss of supporting structure?

Answer 6

vascular heart disease

Question 7

What happens if the valves don’t open properly?

Answer 7

results in stenosis and lack of pressure and loss stroke volume

Question 8

What is the most common form of presentation for aortic stenosis?

Answer 8

degenerative

presents in those aged 60+

Question 9

What age do bicuspid valves tend to present in?

Answer 9

40-60 years

Question 10

What are the symptoms of SEVERE aortic stenosis? (SAD)

Answer 10

Syncope upon exertion, Angina, Dyspnoea
fatigue
palpitations
Sudden death (rare in asymptomatic) due to arrhythmias from pressure overload

Question 11

What are the symptoms of mild-moderate aortic stenosis?

Answer 11

Asymptomatic

Murmur discovered on routine physical exam

Question 12

What is the effect of aortic stenosis on the left ventricle?

Answer 12

Pressure overload
Generation of high LV systolic pressure to force blood through the obstruction
Results in left ventricular hypertrophy
Eventual LV decompensation/dilatation
symptoms of heart failure

Question 13

Which heart sounds are heard in aortic stenosis?

Answer 13

systolic murmur OR crescendo / decrescendo murmur

soft S2

Question 14

How is a systolic or crescendo/decrescendo (diamond shaped) murmur produced?

Answer 14

The valve doesn’t open fully, producing turbulence as blood passes across it.
This occurs at the beginning of systole where the pressure gradually rises
AAR the amount of blood and turbulence gradually rises, peaks and then falls as the ventricle begins to relax

Question 15

Why might the soft second heart sound not be heard?

Answer 15

because the valve is so stiff and thickened, it doesn’t close with its usual snap
can’t hear the second heart sound - indication of severity

Question 16

What are the two other names for a systolic murmur?

Answer 16

crescendo / decrescendo murmur

diamond shaped

Question 17

What are the two main causes of incompetence?

Answer 17

aortic dilatation

valvular

Question 18

What are the causes of aortic dilatation?

Answer 18

high blood pressure
aortic dissection
loss of support
connective tissue disease 
hypertension, degenerative, cystic medial necrosis, syphilis

Question 19

What pain is associated with an aortic dissection?

Answer 19

a sudden onset of severe chest or back pain, often described as “tearing”

Question 20

What are the causes of valvular dilatation?

Answer 20

Bicuspid valve

Infective endocarditis

Question 21

How does an early diastolic murmur occur?

Answer 21

At the end of systole the pressure in the ventricle drops and the aortic (and pulmonary) valves close
If the aortic valve leaflets fail to come together and are damaged blood under high pressure in the aorta rushes back into the ventricle (with turbulence)
This happens the most when the pressure in the ventricle is the lowest at the beginning of diastole

Question 22

How does an concomitant systolic murmur occur?

Answer 22

Because in this disorder the aortic valve is often structurally abnormal, there is often turbulence as the blood exits the ventricle during systole

Question 23

What are the symptoms of aortic regurgitation?

Answer 23

Often asymptomatic
Chest pain (due to decreased coronary perfusion and diastolic BP reduces)
Breathlessness due to the pressure effect and the pumping vasculature and pulmonary oedema
Syncope – uncommon
Catastrophic decompensation if acute, there’s no time for the left ventricle and the left atria to become more compliant to take on this extra volume - causes fulminant pulmonary oedema

Question 24

What are the symptoms of dilated cardiomyopathy?

Answer 24

can be asymptomatic
feeling tired
leg swelling
shortness of breath
chest pain 
fainting

Question 25

What causes mitral regurgitation?

Answer 25

a problem with the valve apparatus itself chordal rupture / papillary muscle failure annular dilation

Question 26

Why might leaflets not come together?

Answer 26

the valves are attached to papillary muscles in the left ventricle if someone's had a heart attack, the artery that's supplying that territory (where that papillary muscle is) becomes ischaemic and that muscle can rupture. That will bring this leaflet down so it doesn't work appropriately and therefore will not come together

Question 27

What are the effects of mitral regurgitation?

Answer 27

Volume overload in left ventricle Pressure overload of right heart Left ventricular dilatation Decompensation

Question 28

What happens during pressure overload of the right heart?

Answer 28

During systole blood is ejected backwards into the left atrium Extra blood in atrium leads to elevation of left atrial pressure and increased ventricular filling during subsequent diastole

Question 29

What happens during pressure overload of left heart?

Answer 29

Pressure overload of right heart Can lead to right ventricular hypertrophy or right heart failure Transient elevation of left atrial pressure during systole

Question 30

How is a pan-systolic murmur generated?

Answer 30

If the leaflets fail to coapt, either because the annulus is stretched (with a ‘hole’ in the middle), or because the leaflets are damaged or abnormal, blood leaks back into the left atrium with turbulence as it passes across the abnormal valve Blood regurgitates back in atrium almost immediately and for the whole of systole because the left atrium is a low pressure chamber and during systole the left ventricle is under high pressure

Question 31

What are the symptoms of mitral regurgitation?

Answer 31

Breathlessness due to back pressure of pulmonary circulation Lethargy and reduced exercise tolerance due to breathlessness and reduced cardiac output Palpitations – atrial fibrillation due to pressure overload in atrium Peripheral oedema – decompensation Chest pain – concomitant CAD

Question 32

What happens to the lungs and the ventricles in mitral stenosis?

Answer 32

Lung / right heart - breathlessness, congestion, etc due to pressure back up because of failure of ejection of left atrial volume the left ventricle physiology usually preserved LV function compromised when atrial contraction lost (low LV filling) or when high circulating volume (high right heart pressure)

Question 33

What are the heart sounds of mitral stenosis?

Answer 33

Mid-diastolic rumbling murmur Opening snap Loud first heart sound

Question 34

What are the symptoms of mitral stenosis?

Answer 34

``` Breathlessness Peripheral oedema Haemoptysis Heart palpitations Systemic emboli Fatigue stridor dysphagia ```

Question 35

How is valvular heart disease treated?

Answer 35

medical treatment - looks at treating heart failure and arrhythmia symptoms surgical treatment - valve repair or replacement percutaneous treatment - BAV / TAVI

Question 36

What techniques can be used to determine the presence of valvular heart disease in asymptomatic patients?

Answer 36

``` clinical assessment (stress) echocardiography exercise testing MRI scan Multislice CT Cardiac catherisation ```

Question 37

How can prosthetic (especially metallic) heart valves be identified?

Answer 37

if the first heart sound is metallic - mitral valve | if the second heart sound is metallic - aortic valve

Question 38

For which type of patients was trans-catheter valve replacement initially used?

Answer 38

for patients who were turned down for having for being too high risk for surgical open heart surgery

Question 39

What is aorto-valvuloplasty and how does it work?

Answer 39

where the balloon will be passed from the aorta across the aortic valve into the left ventricle It will then be inflated and will break down the calcium, which can lead to improved opening of the aortic valve

Question 40

What are the risks of aorto-valvuloplasty?

Answer 40

can damage the aortic valve leaflets | causing aortic regurgitation

Question 41

What happens if the valves don't meet properly?

Answer 41

regurgitation where the blood flows in the opposite direction