Valve pathologies Flashcards by John Darlington

What investigations should be conducted into mitral stenosis and state some potential findings:

CXR

enlarged left atrium
Dilation of pulmonary vessels

ECG

Bifib - p-wave (long closure of the left atrium)
AF
Right axis deviation

Echocardiogram

assess degree of dilation
also assess for tricuspid regurgitation due to back log
TOE - assess thrombus formation

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What are the symptoms of mitral stenosis:

Dyspnoea
Chronic bronchiolitis
Dysphagia 
Hoarseness - compression on laryngeal nerve 
Fatigue

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What is the murmur that can occur on the right side of the heart due to mitral stenosis affecting the pulmonary valve?

Graham Steel Murmur

- early diastolic murmur due to pulmonary regurgitation

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What is the management of mitral stenosis?

Control AF
+
VTE prophylaxis

Diuretics

Surgically:

Trans-septal Balloon valvotomy
Open valvotomy
Mitral valve replacement

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What are some signs of mitral regurgitation?

Laterally displaced/ Hyperdynamic apex beat
- this is a sign of severe MR

Systolic thrill

Soft S1 sound

Signs of pulmonary congestion

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What are some causes of mitral regurgitation?

Post M.I/ Ischemia

Annular calcification of valvular apparatus
- seen in elderly

Iatrogenic
- valvuloplasty for mitral

Autoimmune

Infective endocarditis

Dilated cardiomyopathy

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What investigations are done into mitral regurgitation?

CXR
- left ventricular hypertrophy

Echocardiogram with doppler

assess leaflets
chordae tendinea
papillary muscle function

Cardiac Catherization
- uses dye to see retrograde flow

*cardiac catherization is usually diagnostic

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What is the management for mitral regurgitation?

Medication:

ACE
Diuretics

Surgical:
valve replacement before LV function is completely lost

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What are the causes of aortic stenosis?

Calcific aortic valvular disease

immune mediated calcification
common in males
elderly age
high LDLs

Rheumatic fever

Bicuspid calcification

Other causes:

CKD
Paget’s disease

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When will some with aortic stenosis start to develop symptoms?

Once reduced to 1/3rd size

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What pathology causes a displaced apex beat?

Dilation of the heart

dilated cardiomyopathy
Mitral valve regurgitation (usually secondary to the dilated ventricle)
Aortic regurgitation

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What signs are seen in aortic stenosis?

Slow rising pulse

Narrow pulse pressure

Left ventricular heave

Aortic thrill

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What may occur with regards to S2 heart sounds in aortic stenosis? and what does this indicate?

Reverse splitting
- only splitting is heard during expiration

*this is because during expiration the A2 in aortic stenosis takes longer to shut (it should be other way round) and in inspiration the P2 catches up to match the A2 - thus the splitting disappears

**this is a sign of severe disease

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What is the murmur heard in aortic stenosis?

Crescendo decrescendo Systolic ejection click

radiating to the carotids
low pitched

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What are the main differentials for aortic stenosis?

Obstructive cardiomyopathy

Aortic sclerosis (no radiation to carotids)

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What is the treatment for aortic valve stenosis?

Aortic valve replacement

Valvuloplasty
- balloon dilation

TAVI
- used for those who are not suitable for surgical replacement of aortic valve

What are the causes of aortic regurgitation?

Acute:

infective endocarditis
rheumatic fever
Aortic dissection

Chronic:

long standing hypertension
RA
ankylosing spondylitis
Syphilis

What are the signs of aortic regurgitation?

Bounding pulse/ collapsing pulse

Wide pulse pressure

Capillary pulsation

Head nodding

Pistol shot femorals
- a large band heard over the femoral with each heart beat

Hyperdynamic Apex beat
- which is often laterally positioned

What is the murmur heard in aortic regurgitation?

Early diastolic
- left sternal edge

*heard better when patient sits up and exhales and holds

What is the murmur which can occur in severe aortic regurgitation and why does it occur?

Austin flint murmur

Jet of blood back in can imping on the anterior mitral cusp causing a mid-diastolic murmur

What tests are done into aortic regurgitation?

CXR
- ventricular enlargement

Echocardiography
- diagnostic

Cardiac catherization

this is to assess severity and perfusion of coronary using dyes.
important for surgery

What is the treatment of aortic regurgitation?

Treat underlying cause

Hypertension management
- ACE inhibitor
+
- beta blockers

Surgical replacement of valves

What valvular pathology may be seen with carcinoid syndrome?

Tricuspid stenosis

What is the murmur heard with tricuspid stenosis?

Mid-diastolic murmur

- heard best over the lower left sternal edge

List some causes for tricuspid regurgitation:

High pulmonary pressures - cor-pulonale Infective endocarditis Rheumatic fever Epstein's anomaly

What is the imaging of choice in suspected endocarditis of a mechanical heart valve?

TOE

Which bacteria may not grow in cultures but can cause infective endocarditis?

Chlamydia species Legionella Bartonella *if blood cultures are negative it is usually worth searching for these

What are the associated complications with pregnancy and prosthetic valves?

Biological valves: - preferred as no anticoagulation needed - wear down very fast in women of child baring age Mechanical: - need warfarin which is teratogenic so most switch to LMWH. - increased mortality of 1-4% in women with mechanical heart valves

What parameters are used to assess the severity of aortic stenosis?

Area of annulus Peak velocity Pressure gradient Calcification

How is aortic stenosis managed in adults?

Replacement - either open valve replacement or - TAVI Inter-arterial balloon septostomy *repair is not done in adults. only children.

Where would you see a mitral valvotomy scar?

Laterally thoracotomy scar

Would you hear a third heart sound with mitral stenosis?

No 3rd heard sound is associated with rapid ventricular filling. this can be a useful indicator between mitral stenosis and mitral regurgitation

if someone collapses and a whooshing noise was heard by the patient, what is the likely cause?

Aortic stenosis

What are the three parameters which are measured in order to diagnose an aortic stenosis?

Velocity (decreased narrowing increases pressure) Pressure gradient (pressure between the aorta and the ventricle) Diameter of stenosis (<2cm) (<1cm is severe) +/- Calcification levels

What are the indications for surgery in Aortic stenosis?

Symptomatic Congestive heart failure >40mmHg gradient pressure

What medication are people put on following CABG?

``` Aspirin Clopidogrel Statin ACE Beta blocker +/- Eplerenone ```