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.Cardiology FRACP clinical > Valvular Disease > Flashcards

Valvular Disease Flashcards

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1
Q

What are the differentials for an ejection systolic murmur louder with expiration?

A

Aortic stenosis

HOCM

Supravalvular aortic stenosis (Williams syndrome)

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2
Q

Aortic Stenosis - general indication for AVR

ie. Echo characteristics of severe AS

A

Severe AS = AVA < 1.0cm2

Mean gradient > 40mmHg

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3
Q

Aortic stenosis - indications for replacement

Symptomatic vs asymptomatic AS

A

Symptomatic AS

Severe = mean gradient > 40mmHg, AVA < 1.0cm

Asymptomatic AS:

Mod/severe AS undergoing other cardiac surgery

Severe AS AND:

  • LV systolic dysfunction
  • abnormal BP response to exercise
  • recurrent VT
  • Valve area < 0.6cm2
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4
Q

What are the causes of aortic stenosis?

A

Bicuspid aortic valve (young)

Degenerative calcification (elderly)

Rheumatic valve disease

Congenital

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5
Q

Aortic Stenosis CXR

A

LVH

Valve Calcification

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6
Q

Aortic Stenosis ECG

A

LVH

LV strain - ST depression + TWI in left sided leads

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7
Q

Aortic Stenosis - signs of severity

Pulse and palpation (2 + 2)

A

Low volume and/or slow rising pulse

Narrow pulse pressure

Aortic thrill

Heaving apex beat

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8
Q

Signs of aortic stenosis - characteristics on auscultation (4) + others (2)

A

Long, harsh, late-peaking murmur

S4 (gallop)

Paradoxical split S2

Soft or absent aortic component of S2

Pulmonary HTN

LV failure

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9
Q

Discuss SAVR vs TAVI for symptomatic AS

(4 steps)

A
  1. Refer multidisciplinary heart valve team
  2. Assess Life expectancy > 1 year?
  3. Assess surgical risk and co-morbid conditions
  4. Decision: Intermediate risk and above = TAVI; Low risk = SAVR
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10
Q

Aortic regurgitation - signs of severity

Pulse / Periphery (3)

Palpation / Praecordium (2)

A

Large volume, collapsing pulse

Wide pulse pressure

Signs of pulmonary hypertension

Displaced apex beat

Thrusting - hyperdynamic circulation

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11
Q

Aortic regurgitation - signs of severity

Auscultation (3)

Increased with isometric handgrip

(increased afterload)

A

Long duration of decrescendo diastolic murmur

Third heart sound

Soft A2

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12
Q

What does an Austin Flint murmur signify?

And is the mechanism behind an Austin Flint murmur?

What does an Austin Flint murmur sound like?

A

Marker of severe AR

Aortic regurgitation jet impinging on the anterior mitral valve leaflet

Low pitched, mid-diastolic murmur

Clinically, sounds same as mitral stenosis

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13
Q

Causes of AR

Chronic:

[valvular (2) and root (3)]

Acute (3)

A

Rheumatic fever

Congenital - bicuspid aortic valve

Age - degenerative

Aortitis - Ank Spondylitis, psoriasis etc

Marfan’s syndrome

Infective endocarditis

Dissection

Hypertension

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14
Q

Aortic regurgitation - indications for surgery (asymptomatic)

A

“RULE OF 55”

Ejection fraction < 55

Left ventricular end-systolic dimension (LVESD) > 55mm

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15
Q

Precordial pansystolic murmur - differential diagnosis (4)

A

Mitral regurgitation

Triscuspid regurgitation

Ventricular septal defect

Patent ductus arteriosis

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16
Q

Mitral Regurgitation - signs of severity

Peripheral signs - pulse (1)

Palpation (2)

A

Pulse - normal or jerky (if severe)

Displaced apex beat - enlarged LV

Apical systolic thrill

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17
Q

Mitral regurgitation - signs of severity

Auscultation (5)

A

Soft S1

Widely split S2

Third heart sound S3

Fourth heart sound S4 (if in sinus rhythm)

Mid-diastolic flow murmur

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18
Q

Causes of mitral regurgitation

Chronic (3)

Acute (3)

A

Degenerative

Functional MVP

Rheumatic heart disease

Infective endocarditis

AMI - papillary muscle rupture

Surgery (failing valve)

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19
Q

Investigations for Mitral regurgitation

ECG (3)

CXR (2)

A

p-mitrale

Atrial fibrillation

LVH/RVH

LA enlargement

Cardiomegaly

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20
Q

Mitral regurgitation - indications for surgery if asymptomatic

EF and LVEDD

A

“Rule of 60”

Ejection fraction < 60%

Left ventricular end-diastolic dimension > 60mm

Surgery indicated if symptomatic!

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21
Q

Mitral valve prolapse

Auscultation characteristics (2)

A

Systolic click

High pitched, late systolic murmur

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22
Q

Mitral valve prolapse

Dynamic auscultation

Longer (1)

Shorter (2)

A

Longer with: VALSALLLLLLVA

Shorter with: Hand grip or squat

(Squatting makes you shorter!)

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23
Q

Mitral stenosis - signs of severity

Pulse / Periphery (1)

Palpation (1)

A

Narrow pulse pressure

Diastolic thrill - “tapping apex beat”

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24
Q

Mitral Stenosis

Signs of severity

Auscultation (3)

Study These Flashcards
A

Loud S1

Early opening snap

Length of low pitched “rumbling” late-diastolic murmur

25
Causes of mitral stenosis | (2)
Rheumatic fever Rheumatic fever Rheumatic fever Congenital (rare)
26
Investigations for Mitral Stenosis ECG (2) CXR (2)
p-mitrale (bifid p waves) Atrial fibrillation Left atrial enlargement Congestive cardiac failure
27
Mitral stenosis - indications for surgery (2) Type of procedure?
Valves area \< 1.0cm Mean gradient \> 10mmHg Balloon valvotomy consider in first instance unless MR
28
Tricuspid Regurgitation - murmur characteristics (3)
Pan-systolic murmur Loudest at left sternal edge Loudest in inspiration
29
Signs of Pulmonary Hypertension (4) | (also signs of severity of TR)
JVP - prominent "v" waves Palpable P2 Parasternal heave RHF - oedema, ascites, pulsatile hepatomegaly
30
Causes of secondary pulmonary hypertension What other diseases to look for on examination? (6)
Obstructive airways disease Chronic type 2 respiratory failure - kyphoscoliosis or obesity Intersitial lung disease Systemic sclerosis Rhuematoid arthritis SLE
31
Causes of TR (5)
Functional TR from RV dilatation Infective endocarditis Ebstein's anomaly - congenital right atrial dilatation a/w ASD RV papillary rupture Rheumatic Heart Disease (rare than other valve lesions)
32
Pulmonary stenosis - Murmur characterstics (3) Signs of severity (3)
Ejection systolic murmur Loudest at pulmonary area Increased with inspiration Giant "a" waves in JVP (in sinus rhythm) RV heave Pulmonary thrill
33
Pulmonary stenosis causes (4)
Congenital Rheumatic Heart Disease Congenital rubella Tetralogy of Fallot
34
Pulmonary Regurgitation Signs Auscultation (3)
Early diastolic murmur Upper left sternal edge -\> radiates down left sternal edge Loudest in inspiration
35
Causes of pulmonary regurgitation Primary (3) Secondary (2)
Infective endocarditis Rheumatic Heart Disease Iatrogenic - balloon valvuloplasty, swan-ganz, fallot repair complication Primary pulmonary hypertension Secondary pulmonary hypertension
36
HOCM characteristics Pulse (2) Palpation (1) JVP (1)
Jerky carotid pulse Double carotid impulse Double / triple apical impulse Prominent "a" wave - due to decreased RV compliance
37
HOCM - Characteristics on auscultation (3) Dynamic auscultation (2)
Late ejection systolic murmur Loudest at left sternal edge +/- pansystolic murmur from systolic anterior motion of mitral valve Louder with: Valsalva and standing Softer with: squatting and handgrip
38
HOCM investigations ECG (3) CXR (3) TTE (2)
LVH +/- strain Left axis deviation deep Q waves Cardiomegaly Left atrial dilatation Pulmonary congestion Asymmetrical septal hypertrophy Systolic anterior motion of mitral valve
39
Atrial septal defect Auscultation characteristics (2)
HALLMARK = Fixed and widely split second heart sound (S2) ESM in pulmonary area = pulmonary flow murmur Increased flow across pulmonary valve
40
Signs of severity for ASD Indicating haemodynamically significant R to L shunting Palpation (1) Auscultation (2) Signs of Pulmonary hypertension (4)
Systolic thrill over pulmonary area Tricuspid flow murmur = mid-diastolic murmur at LSE Loud P2 Raised JVP with prominent "v" waves Palpable P2 Parasternal heave RHF: oedema, ascites, hepatomegaly
41
VSD characteristics Palpation (1) Auscultation (2)
Thrill at LSE Harsh pan-systolic murmur at LSE Increased with expiration
42
VSD - indications for surgery TTE (2)
Decreased gradient = increasing RV pressure Left to right shunt with Qp:Qs \> 1
43
PDA - charactersitics Pulse (2) Palpation (1) Auscultation (1)
Large volume pulse Collapsing pulse Hyperkinetic (displaced, thrusting) apex beat Continuous "machinery" murmur in left 1st intercostal space
44
Eisenmenger syndrome Characteristics (4)
Central cyanosis Clubbing Pulmonary hypertension Polycythaemia
45
Causes of Eisenmenger syndrome (3) And how to differentiate underlying aetiology (as murmurs disappear once R to L shunting occurs)
ASD - fixed split S2 VSD - single and loud S2 PDA - differential cyanosis/clubbing of toes NOT fingers
46
Differentials for PSM (4)
Mitral regurgitation Triscuspid regurgitation Ventral septal defect PDA (also will be diastolic)
47
Differentials for ESM / midsystolic murmur (4)
Aortic stenosis Hypertrophic obstuctive cardiomyopathy ASD with pulmonary flow murmur Pulmonary stenosis
48
Differentials for late systolic murmur
Mitral valve prolapse HOCM
49
Differentials for mid-late diastolic murmur (2)
Mitral stenosis Atrial mxyoma
50
S1 = closure of mitral valve - start of systole Causes of loud S1 (1) Causes of soft S1 (1)c
Loud S1 Mitral stenosis Hyperdynamic circulation Soft S1 Mitral regurgitation
51
A2 - closure of aortic valve at end of systole Causes of loud A2 (2) Causes of soft A2 (1)
Loud A2 congenital aortic stenosis Hypertension (from increased after load) Soft A2 Aortic regurgitation
52
P2 = closure of pulmonary valve at end -systole Causes of loud P2 (1) Causes of soft P2 (1)
Loud P2 Pulmonary hypertension Soft P2 Pulmonary stenosis
53
S3 gallop Low pitched, early diastolic sound Due to rapid ventricular filling Can be physiological Pathological causes (3)
Mitral regurgitation Dilated cardiomyopathy LVF / RVF
54
S4 Late diastolic low pitched sound Always pathological Associated with poorly compliant ventricle Associated conditions (5)
Aortic stenosis Hypertension Ischaemic heart disease HOCM Pulmonary hypertension
55
Dominant "a" waves (3) Dominant "v "waves (1) Cannon "a" waves (1) REMEMBER a waves cannot be seen in AF!
Dominant "a" waves Pulmonary hypertension Tricuspid stenosis, pulmonary stenosis Dominant "v" waves Tricuspid regurgitation Cannon "a" waves Complete heart block (atrium contracting against closed MV/TV)
56
Valsava Louder (systolic murmurs) Softer (systolic murmurs) Length (MVP)
Louder = HOCM Softer - AS and MR MVP longer with VALSALLLLVA
57
Isometric handgrip Louder Softer Length (MVP)
Louder - MR (due to increased afterload, more regurgitation) Softer - HOCM and AS MVP shorter
58
What are the components of Fallot's Tetrology? (4)
RV hypertrophy Subvalvular pulmonary stenosis (infundibular stenosis) VSD Over-riding aorta ("astride" the VSD)
59
What is a Blalock-Taussig shunt? What are the clinical findings associated with a BT shunt? (3) What are the features on auscultation? (3)
A shunt between the LEFT subclavian and LEFT pulmonary artery Left arm smaller than Right Left arm BP lower than Right Left arm pulses diminished compared to Right To-and-fro systolic and diastolic murmur Loudest in subclavivular area Radiates posteriorly

.Cardiology FRACP clinical (1 decks)

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