Murmurs

Question 1

How does Mitral regurg occur?

Answer 1

MV fails to close correctly during systole

Abnormal regurg of blood from LV, through mitral valve, into LA during systole

Question 2

How is mitral regurg caused?

Answer 2

PRIMARY: Degenerative (Annular calcification), Acute (papillary muscle rupture- MI, infective endocarditis), MV prolapse, Rheumatic fever
SECONDARY: LVF, Cardiomyopathy, CAD

Question 3

How does MV prolapse occur?

Answer 3

Weakened CT of chordae tendenae – mid systolic click, systolic murmur

Question 4

What are the risk factors for mitral regurg?

Answer 4

Female
↓BMI
↑Age
Prev MI/MV stenosis/MVP
CT disorder (Marfan's, Ehler's Danlos)

Question 5

How are the signs of mitral regurg?

Answer 5

REGURGS:
R: RV heave
E: Exertional dyspnoea
squattin
G: Click late, murmur short
mUrmur: PANSYSTOLIC
R: Radiates to L axilla
Gone: Displaced apex beat
S: Soft S1, Split S2

Question 6

How is mitral regurg investigated?

Answer 6

ECHO w/Doppler: CONFIRMS DIAGNOSIS, assess LV function & aetiology & severity (degree of retrograde flow into LA)
ECG: Broad P wave, LA enlargement
CXR: Enlarged LA&V, pulmonary oedema if acute
Cardiac Catheterisation: ALSO CONFIRMS DIAGNOSIS

Question 7

How is mitral regurg managed?

Answer 7

ACUTE: Pulmonary oedema management (LMNOP’S)
Surgery: Mechanical valve

Question 8

What are the complications of mitral regurg?

Answer 8

AF- Backflow into LA
LHF- ↑Blood in left atrium → ↑Pre-load → volume overload → hypertrophy of myocardium → CCF
Acute PO- Following MI → papillary muscle rupture → acute mitral regurg
Chronic PO- Chronic regurg into LA → back pressure of blood into pulmonary circulation → ↑PO

Question 9

Which drugs prolong QTc?

Answer 9

Sotalol
TCAs
SSRIs
Haloperidol
Methadone
Erythromycin

Question 10

How does Mitral stenosis occur?

Answer 10

Obstruction of mitral valve due to commissural fusion →
↓blood flow from LA, through mitral valve, into LV →
↑pressure in LA→ pulmonary congestion (LVF) → RVF

Question 11

What are the causes of Mitral stenosis?

Answer 11

Degenerative: Calcification
Rheumatic fever
Infective endocarditis
Congenital

Question 12

How does mitral stenosis present?

Answer 12

Signs of LVF (Dyspnoea→ Orthopnoea → PND )
Palpitations (AF)
Malar flush
↑JVP 
Mid-diastolic rumbling murmur
Loud S1
RV heave
Laterally displaced apex beat

Question 13

How is mitral stenosis investigated?

Answer 13

ECHO: TTE/TOE- DIAGNOSTIC: Assess severity, significant stenosis = <1cm
ECG: P mitrale, ?AF
CXR: LA enlargement, MV calcification, prominent pulmonary vessels

Question 14

How is mitral stenosis managed?

Answer 14

Acute AF: Follow protocol
GTN +/- Diuretics for dyspnoea
Surgery: Balloon valvuloplasty, open mitral valvectomy/replacement

Question 15

What are the complications of mitral stenosis?

Answer 15

Pulmonary HTN

AF

Question 16

What is the mechanism of AF in mitral stenosis?

Answer 16

Due to LA hypertrophy → stretch pacemaker cells → ↑risk of AF → Systemic emboli → stroke, renal failure, MI

Question 17

How does aortic regurg occur?

Answer 17

Aortic root dilatation/valvular disease
Aortic valve does not close properly (incompetent)
Leakage of blood from aorta into LV during diastole
↑SV in LV + ↑sBP + ↓dBP = ↑Pulse pressure
Eventually LV hypertrophy

Question 18

What are the causes of aortic regurg?

Answer 18

ACUTE: Infective endocarditis, aortic dissection, chest trauma
CHRONIC: CT disorders, Rheumatic fever, RA, SLE, Bicuspid defect

Question 19

How does aortic regurg present?

Answer 19

FLOW BACK:
F: Fatigue & syncope
L: Light/soft S1
O: Orthopnoea/dyspnoea/PND
W: Wide pulse pressure
B: Basal Crackles
A: Apex beat displaced
C: Collapsing pulse
K: DiastoliK murmumr (high pitched decrescendo)

Question 20

What is an Austin Flint murmur?

Answer 20

Cooing dove sound in aortic region
Indicates valve has collapsed & is absolutely incompetent
Indicates Severe AR = valve replacement

Question 21

How is aortic regurg investigated?

Answer 21

ECHO: DIAGNOSTIC- visualise retrograde flow w/doppler MUST have ECHO every 6-12m
ECG: ↑R wave progression
CXR: Signs of HF
Cardiac catheterisation: Assess severity

Question 22

How is aortic regurg managed?

Answer 22

HTN management

Surgery: Valve replacement/ valve sparing replacement

Question 23

What are the indications for aortic valve replacement surgery?

Answer 23

↑symptoms
Enlarging heart on CXR/ECHO
ECG deterioration (T wave inversion in lateral leads)
IE refractory to medical Rx

Question 24

How does aortic stenosis occur?

Answer 24

Aortic valve fails to open fully
↑Pre-load in LV
↓blood in aorta → concentric LV hypertrophy
Due to ↑stress on ventricle → ↓CO
↓end organ perfusion → respiratory + CV Sx

Question 25

What are the causes of aortic stenosis?

Answer 25

Degenerative: Lipid deposition on aortic valve
Bicuspid valve: Congenital → ↑inc risk of calcification
Post-inflammation
Rheumatic fever

Question 26

What are the signs & Sx of aortic stenosis?

Answer 26

Classic Triad: Angina + HF + Syncope
Narrow pulse pressure
Slow rising pulse
Crescendo, ejection systolic murmur- radiates to carotid
Aortic thrill
LV heave

Question 27

How is aortic stenosis investigated?

Answer 27

ECHO w/DOPPLER = DIAGNOSTIC, visualise defect & severity, LBBB,
ECG: P mitrale,
CXR: Valve calcification
Cardiac catheterisation

Question 28

How is aortic stenosis managed?

Answer 28

Valve replacement (TAVI)