Mixed And Multivalvular Disease

Question 1

Some notes

Answer 1

• Common
• Challenge is which valves involved and what, if any, is dominant lesion
• common combinations are mixed AV, mixed MV and AV disease with MR
• TR rarely occurs in solitude and is most commonly due to pulmonary hypertension due to left heart disease
• when it is not possible to state main lesion, assess severity of all of them to dictate management

Question 2

Aetiology

Answer 2

Endocarditis
Rheumatic
Degenerative
Congenital

Question 3

Best signs to assess where dominant lesion is?

Answer 3

1. Dominant lesion can be determined by assessing impact on:
   - pulse character
   - BP
   - apex beat

Question 4

Response of ventricle is good final arbiter of predominant lesion. Determine if ventricle is under a predominant Volume load (1. Which lesions?), pressure loads (2.) or no changes load

Answer 4

1. AR, MR, VSD, PDA
2. AS, HOCM
3. MS

Question 5

Mixed MV disease

Answer 5

Aetiology is rheumatic.
Distinguishing features are apex beat and auscultatory findings.
(MR vs MS)
Pulse - n or jerky vs n or low volume
Apex position - laterally displaced vs undisplaced
Apex character - thrusting +/- thrill vs tapping
S1 - soft vs loud
S3 - occasional presence vs not present

Question 6

Pitfalls with mixed MV disease

Answer 6

1. Severe MS can cause pulm HTN causing RVH displacing apex beat laterally and posteriorly
2. RVH can also cause TR which can be misinterpreted as MR. Look for signs of TR if pansystolic murmur
3. Severe MR can also cause TR which makes things even more difficult

Question 7

Mixed aortic disease

Answer 7

Any or all causes of AS can lead to AR - particularly bicuspid valve.
Most discriminating factors are pulse character, BP and apex beat

AR vs AS

Pulse - collapsing vs slow-rise, anacrotic
SBP - high vs low
Pulse pressure - wide vs narrow
Apex position - laterally displaced vs minimally displaced
Apex character - thrusting vs heaving
S2 - normal vs soft

Question 8

Pitfalls of mixed AV disease

Answer 8

Significant AR causes large ESLV volume, for which the LV compensates by ejecting large volume. This increased flow can result in systolic murmur. To distinguish this from mixed disease, concentrate instead on haemodynamic consequences of aortic valve disease

Question 9

AS and MR

Answer 9

AS often leads to MR (functional MR). They are frequently seen together.

Discriminating factors are pulse rhythm, pulse character, SBP, pulse pressure, apex position, apex character and presence of S4 (may be present in AS)

Question 10

AR and MR

Answer 10

Difficult to distinguish predominant lesion as both cause volume load.
Wide PP and high SBP in AR dominance.
If still no clue assess severity of each. If one requires intervention then likely to do other also unless mild

Question 11

MS and aortic valve disease

Answer 11

• severe MS significantly impairs LV filling and therefore causes low cardiac output state. This therefore reduces the signs of AR and AS. So if either of these appear moderate in presence of significant MS then MS is likely to be mist prominent.
• if there is evidence of severe AS/AR in context of MS then MS can’t be that severe. So AS/AR will be dominant