Valvular Disease

Question 1

What is the most common valvular defect?

Answer 1

Aortic stenosis 2-7% of over65s

Question 2

What are the causes of aortic stenosis ?

Answer 2

Rheumatic heart disease, senile calcification, congenital I.e. Bicuspid valve

Question 3

What sort of symptoms can you expect in atrial stenosis ?

Answer 3

Syncope followed by angina followed by HF also SOB and CP

Question 4

What signs can you expect to see on examination in someone with AS ?

Answer 4

Ejection systolic murmur, loudest on expedition and radiating to carotid arteries (bell)
Slow raising pulse
Signs of left hypertrophy

Question 5

Name 3 major investigations and findings when diagnosing AS

Answer 5

ECG: LEFT hypertrophy, p-mitrale, AV block
Echocardiogram: flow obstruction
CXR: cardio eagle if HF, AORTIC ring calcification, post stenosis dilation of aorta

Question 6

What is the non-surgical management of AS and how good is it ?

Answer 6

Survival 1-3 years
Risk reduction: diet and exercise
Medication: statins, anti-IHD and HTN therapy
Symptom treatment I.e. AF, HF

Question 7

What are the surgical options of As treatment

Answer 7

Transcatheter aortic valve implant(TAVI): good method for frail with 30 day mortality of 5-15%. May be complicated by VT, temponade, stroke, aortic dissection

Aortic valve replacement (AVR): definitive therapy but higher risk

Balloon valvyloplasty: short term solution in patients unfit for surgery

Question 8

What complications can you expect in AS

Answer 8

Sudden death, HF, CCF, pulmonary oedema, infective endocarditis, emboli

Question 9

What are the causes of aortic regargitation

Answer 9

Rheumatic heart disease, congenital, degenerative

Question 10

What are the symptoms of AR

Answer 10

Dyspnoea , Orthopnoea paraxysmal nocturnal dyspnoea palpitations, angina, syncope

Question 11

What are the major signs of AR

Answer 11

Early diastolic decrushendo high peach murmur
Wide pulse pressure
Hypertrophic displaced apex

Question 12

What are the key investigations for AR

Answer 12

ECG: LVH
CXR
ECHO

Question 13

How would you exacerbate left sided heart murmur?

Answer 13

Loudest on expiration

Right sided murmurs are louder on inspiration

Question 14

What are the major causes of valvular disease

Answer 14

• Rheumatic fever
• Congenital
• Except AS: SLE, infective endocarditis

Question 15

what are the major investigations for valvular heart disease

Answer 15

ECG,CXR and ECHO

Question 16

What does TAVI stands for

Answer 16

Transcatheter aortic valve implantation

Question 17

What does AVR stands for

Answer 17

Aortic valve replacement

Question 18

what is the management of ARE based on risk assessment

Answer 18

• Severe symptoms => surgery

* Less severe: ECHO every 2 years or more frequently with ↑symptoms

Question 19

what are the indications for surgery in AR

Answer 19

symptoms and LVEF

Question 20

what sort of surgery is available for AR

Answer 20

aortic valve replacement or repair

Question 21

What is the role of medications in AR

Answer 21

manage symptoms

Question 22

what is the prognosis of AR

Answer 22

• If severe => haemodynamic instability
• LV dilation and HF
• Mortality in symptomatic patients: 10-20%

Question 23

what are the causes of MS

Answer 23

• Rheumatic fever (the most common cause).
• Degenerative calcification (elderly).
• Congenital
• Rheum: SLE, RA
• Infective endocarditis (large vegetation)

Question 24

what are the symptosm o MS

Answer 24

•	Dyspnoea (on exercise)
o	Orthopnoea 
o	Paroxysmal nocturnal dyspnoea 
•	Atrial fibrillation/palpitations 
•	Haemoptysis: (chronic bronchitis-like picture)
•	Chest pain 
•	Symptoms of emboly

Question 25

what are the signs of MS

Answer 25

* Malar flash of cheeks (↓CO) * Low-volume pulse, AF * Rumbling mid-diastolic murmur: on expiration and patient on the left with (bell) * Opening snap * ↑JVP * RV heave and Signs of RV failure

Question 26

what are the investigations for MS and the findings

Answer 26

* ECG: AF, RV hypertrophy, P-mitrale * CXR: oedema, LA hypertrophy, valve calcification, prominent pulmonary vessels * Echocardiogram: Evaluation of stenosis and pulmonary pressure

Question 27

what is the purpose of medical management of MS

Answer 27

symptom control

Question 28

what does PMC stand for and what is it

Answer 28

Percutaneous mitral commissurotomy

Question 29

what are the indications for PMC

Answer 29

symptomatic patients and with pulmonary hypertension

Question 30

what are the complications of PMC

Answer 30

emboli, severe regerg, hemopericardiun

Question 31

what are the complications of untreated MS

Answer 31

``` Pulmonary hypertension • Dilated left atrium • Atrial fibrillation • Thromboembolic events • Right heart failure • Infective endocarditis ```

Question 32

what is the prognosis of MS

Answer 32

* 5 year survival in symptomatic patients without valvotomy: 44% * No symptoms/minimal 80% at ten years * Less than 3 year survival with pulmonary hypertension

Question 33

what are the primary causes of MR

Answer 33

IHD, prosthetic valve dysfunction, SLE, Rheumatic fever, congenital

Question 34

what are the secondary causes of MR

Answer 34

Idiopathic or ischaemic cardiomyopathy

Question 35

What are the symptoms of MR

Answer 35

* Dyspnoea, Fatigue, Palpitations | * Infective endocarditis

Question 36

What are the signs of MR

Answer 36

* Pansystolic murmur at the apex radiating to axilla * AF, Displaced hyperdynamic apex * RV heave, Pulmonary hypertension

Question 37

what investigations are useful in diagnosis of MR and what are the results

Answer 37

* ECG: AF, P-mitrale, LVH * CXR: left cardiomegaly, calcification, pulmonary oedema * Echocardiogram/Doppler echo * BNP levels * Angiography: CAD disease

Question 38

What is the management for MR

Answer 38

Management Medical: symptoms control • Rate control and anticoagulation with fast AF