Valvular Disease & Endocarditis

Question 1

What produces the first heart sound?

Answer 1

• closure of the mitral valve before ventricular contraction

Question 2

What produces the second heart sound?

Answer 2

• closure of the aortic valve before ventricular relaxation

Question 3

What is the third heart sound?

Answer 3

• sloshing in

- blood coming into contact with a compliant/dilated ventricle

Question 4

When to dilated ventricles occur?

Answer 4

• mitral regurg

- HF with dilated cardiomyopathy

Question 5

What is the 4th heart sound?

Answer 5

• a stiff wall
• blood pushing against non-compliant ventricle during atrial contraction (ventricular diastole)
• LVH
• Post MI fibrosis
• failure of relaxation = diastolic HF

Question 6

Define stenosis

Answer 6

• pathological narrowing of a valve diameter

Question 7

What causes stenosis?

Answer 7

• increased pressure = hypertrophy = dilation = failure

Question 8

Define regurgiatation

Answer 8

pathological reverse flow of blood when valves should be closed

Question 9

What causes regurgitation?

Answer 9

increased volumes = dilation = failure

Question 10

Diastolic valvular pathologies

Answer 10

LHS
- mitral stenosis
- aortic regurg
RHS
- tricuspid stenosis
- pulmonary regurg

Question 11

Systolic valvular pathologies

Answer 11

LHS
- aortic stenosis
- mitral regurg
RHS
- pulmonary stenosis
- tricuspid regurg

Question 12

Causes of valve disease

Answer 12

• degeneration = calcification/old age
• infection = rheumatic fever, infective endocarditis
• abnormal valve
• abnormal surrounding myocardium = ischaemia, hypertrophy, dilatation

Question 13

Mitral Regurg Causes

Answer 13

• myocardium dilatation
• ischaemic (post MI, ruptured chorea-tendonae)
• rheumatic fever
• infective endocarditis
• mitral valve prolapse
• calcification (elderly)

Question 14

Effects of mitral regurg

Answer 14

• LA enlargement
• LVH = SV and ejection fraction reduction
• LV failure
• AF

Question 15

Symptoms of mitral regurg

Answer 15

Exertional dyspnoea
palpitation
ankle swelling (CHF)

Question 16

Signs of mitral regurg

Answer 16

Pulse = irregularly irregular
Apex = thrusting, displaced
Soft S1 HS
Pan systolic systolic murmur

Question 17

Mitral regurg Ix

Answer 17

AF ECG

CXR Pulmonary Congestion

Question 18

Causes of aortic stenosis

Answer 18

• senile calcification
• bicuspid aortic valve congenital
• rheumatic (rare)

Question 19

Pathophys of aortic stenosis

Answer 19

• increased afterload
• concentric hypertrophy of LV to maintain SV
• decreased myocardial compliance in diastole = diastolic dysfunction
• reduced coronary blood flow, increased myocardial workload
• reduction in size of LV
• pulmonary venous hypertension

Question 20

Symptoms of aortic stenosis

Answer 20

• chest pain = myocardial ischaemia
• breathlessness
• syncope

Question 21

Signs of aortic stenosis

Answer 21

• pulse slow rising
• displaced apex
• quiet S1 if severe
• ejection systolic murmur

Question 22

Aortic stenosis Ix

Answer 22

ECG LVH

CXR cardiac enlargement, calcification of aortic ring

Question 23

Acute causes of aortic regurg

Answer 23

• infective endocarditis

- dissection of aortic root (ascending aorta)

Question 24

Chronic causes of aortic regurg

Answer 24

• degeneration
• rheumatic fever
• infective endocarditis
• degeneration of bicuspid valve
• spondyloarthropathy (ANK SPON)
• aortitis (vasculitis)

Question 25

Aortic regurg Pathophys

Answer 25

- volume overload of LV ACUTE - rapid increase in LV pressure - pulmonary oedema and decreased CO CHRONIC - LV dilatation until decompensated = LV impairment, HF - increased SV and low diastolic pressures

Question 26

Symptoms of Aortic regurg

Answer 26

- breathlessness - palpitations - RHF signs - cardiovasc collapse as loss of CO if acute

Question 27

Signs of aortic regurg

Answer 27

- de musset sign - corrigans sign - muellers sign - quincke sign - water hammer/collapsing pulse - traube's sign - bilateral inspiratory crackles - early diastolic murmur = blowing high pitched - Austin flint murmur = late diastolic

Question 28

Aortic regurg Ix

Answer 28

ECG LVH | CXR = aortic root prominence

Question 29

Causes of mitral stenosis

Answer 29

- Rhemutaic heart disease!! | - congenital (rare)

Question 30

What does mitral stenosis mimic?

Answer 30

- atria myxoma | - atrial thrombus

Question 31

Mitral Stenosis Pathophys

Answer 31

- high pressure in LA - increased LA size - pulmonary hypertension and R. HF - AF - associated regurg

Question 32

Symptoms of mitral stenosis

Answer 32

- breathlessness - palpitations - ankle swelling

Question 33

Signs of mitral stenosis

Answer 33

- mitral facies - irreg pulse - CHF signs - Loud S1 - low pitched diastolic murmur crescendo

Question 34

Mitral stenosis Ix

Answer 34

- ECG P mitrale | - CXR enlarged LA = double margin

Question 35

Echo of mitral valve disease - what to look at?

Answer 35

- valve appearance - LA size - LV size and function - Doppler to asses stenosis and regurg - estimate pulmonary pressures - R. heart size and function

Question 36

Echo of aortic valve disease - what to look at?

Answer 36

- valve appearance - valve gradient - valve area - severity of AR based on colour flow and CW doppler - LV size and function

Question 37

When to treat aortic stenosis?

Answer 37

- when symptomatic | - OR when certain severity parameters met on Echo

Question 38

When to treat mitral regurg?

Answer 38

- before patient becomes symptomatic | - to prevent irreversible changes in cardiac function

Question 39

Intervention for valvular disease

Answer 39

- repair - replace = tissue or metallic - balloon valvuloplasty - transcatheter aortic valve implantation

Question 40

How to repair a valve?

Answer 40

- annuloplasty ring | - through the groin

Question 41

RF for valve disease

Answer 41

- pathological valve - replacement - structural heart disease

Question 42

Dukes criteria major?

Answer 42

- typical organism on blood culture or positive serology + positive echo

Question 43

Dukes criteria minor?

Answer 43

- predisposing factors - fever - vascular phenomena clubbing, splinter haemorrhage - splenomegaly - immunological phenomena - suggestive echo - suggestive microbiology

Question 44

Peripheral signs of endocarditis

Answer 44

Look at slide 50 Qreview - nodes - clubbing