Valvular Heart Disease

Question 1

What are the common Heart Lesions?

Question 2

What is the natural history and progression of cardiac valve disease?

Answer 2

1

Question 3

Valvular Heart disease Symptoms

Question 4

What are the clinical features of aortic stenosis? What are the diagnostic investigations?

Question 5

What are the clinical features of aortic regurgitation? What are the diagnostic investigations?

Question 6

What are the clinical features of mitral stenosis? What are the diagnostic investigations?

Answer 6

Clinical features:

• Left Atrium hypertrophy
• Pulmonary odema/hypertension
• mitral face
• opening snap and diastolic murmur, rv heave and diastolic thrill
• dysponea, haemoptysis, chest pain, horeseness

Diagnositic Investigations:

• Echo = current mainstay, can watch valves and also can look at the transvalvular pressures
• ECG - P>0.12 and signs of Right Vent Hypertrophy
• Can also use Cardiac Magnetic Resonance

Olden days used cardiac catheterisation

Question 7

What are the clinical features of mitral regurgitation? What are the diagnostic investigations?

Answer 7

Clinical features:
Acute- Sudden onset of breathlessness, pulmonary oedema, cardiogenic shock
Chronic-Gradual onset of breathlessness, fatigue, (low CO), right heart failure

Investigations:
- Echo

Question 8

What treatment options are available for valvular heart disease?

Question 9

most anterior valve?

Answer 9

Pulomonary Valve

Question 10

MV orifice size?

Answer 10

Usually 4-6 cm2

Question 11

mv ant or post valve leaflets larger?

Answer 11

Anterior is larger

Question 12

Aitiology and development of MVD?

Answer 12

Aeitiology:
Rheumatic Heart Disease
Congenital MS
Systemic conditions eg SLE/ Rheumatoid Arthrisis

Development:
Stenosis of the valve - Harder for blood to flow through - Ventricle still working fine but not as much blood is getting through, so increasing atrial pressure compared to ventricle pressure - increases pressure in LA causes dilatation and expansion, inc into the auricles, Causes increased pressure in back flow into pulmonary circulation and can eventually lead to right heart dilatation with Tricuspid regurgitation and pulmonary regurgitation (due to the increased back pressure.

Question 13

MV stenosis size guideline?

Answer 13

When Mitral Vave Orrifice is less than 2cm2

Question 14

mv stenoisis severity depends on what?

Answer 14

Depends on the atrial/ventricular pressure gradient (trans-valvular pressure gradient)
The volume of blood going through, CO/HR (trans valvular flow rate)

Question 15

Mv stenoisis symptoms and signs

Answer 15

Dysponea
Haemoptisis (thin walled vein rupture)
Hoarseness (due to increased atrium size compressing the L recurrent laryngeal nerve)
Mitral face (red cheeks and nose)
prominent a wave on JVP
Opening snap on auscultation followed by murmor in diastole due to increase in pressure of flow)
RV Heave
Tapping Apex beat, diastolic thrill, normal pulse

Systemic embolisation (due to LA and LA apendage enlargement - stagnant blood - blood clots)
Infective endocarditis

Question 16

Mvs invest

Answer 16

ECHO! Valves and transmitral flow

Can also use ECG - p wave >0.12, signs of left atrium hypertrophy

CXR = left atrium enlargement

Can also use cardio magnetic resonance

Question 17

MvS treatment

Answer 17

Diuretics and restriction of salt intake
If in AF - restore sinus rhythm
Anticoagulatin (preventitive measure for the increased stagnant blood in the left atrium, esp in patients with AF)
Valvotomy (balloon vs surgical, MVR)

Question 18

mv regurgitation aetiology,

Answer 18

Rheumatic Heart Disease
Mitral Valve Prolapse (MVP)
Infective endocarditis
Degenarative (age)
Functional MR due to LV/annular dilatation

Question 19

mv reg invist

Answer 19

ECG - LA enlargement (P wave >0.12 and tall), RVH - prominent R wave in R preicordial leads

CXR - Cardiomegaly, LA enlargement, mitral annulus

ECHO - structure and pressures

Cardiac resonnance

Question 20

Mitral regurgitation pathophysiology

Answer 20

Acute: increase vol in ventricles meaning increased systolic pressure, reduced end systolic volume

Chronic: Much the same but it leads to left ventricular hypertrophy

Question 21

Mitral regurgitation symptoms

Answer 21

Acute: Breathlessness, pulmonary oedema, cardiogenic shock

Chronic: Fatigue, exhaustion, right heart failure, dyspnoea/palpatations due to afib

Question 22

Signs Mitral regurgitation

Answer 22

Brisk, hyperdynamic apex beat
RV heave
Reduced/non existant s1 (valve leaflets don’t meet), holosystolic blowing murmur radiates to axilla, split s2
prominent jvp if RH failure present

Question 23

Mitral regurgitation treatment

Answer 23

Acute: reduce pre and afterload - Vasodilator (Sodium Nitroprusside), heart contractility increasor (doboutamine), reduce afterload by inta-aortic balloon (IABP). Surgery within 24-48h

Chronic: follow up, if indicated Mitral valve repair/replacement

Question 24

How do IABP work?

Answer 24

They inflate during diastole - fools body into thinking there is a higher aosrtic pressure and also helps blood get back into coronary arteries

Deflate during systole (just before aortic valve opens), this reduces the pressure and afterload that the heart has to work against.

Question 25

Aortic Valve area?

Answer 25

3-4cm2

Question 26

Aortic valve area in stenosis?

Answer 26

1.5-2cm

Question 27

Aortic valve stenosis aetiology

Answer 27

Mainly degenarative due to increasing age of population Rheumatic fever Higher occurance in bicuspid aortic valve

Question 28

Aortic stenosis pathophysiology

Answer 28

Aortic stenoiss - increased work for heart to pump out blood - left ventricle hypertrophy - heart failure and more risk of myocardial ischaemia due to increase work of heart and bigger heart muscle.

Question 29

Aortic stenosis signs and symptms

Answer 29

Symptoms: - long asymptomatic phase - dyspnoea on exertion - diziness, syncope - chest pain (angina) Signs - murmour between s1 and s2 - on systole - rv heave - vigurous and sustained apex beat - low bp - if rhf present then jvp prominent - small pulse and slow rising

Question 30

Investications aortic stenosis

Answer 30

ECHO - can use doppler haemodynamic assesment of pressure gradient ECG - signs of LVH,LV strain causing ST change Cardiac magnetic resonance CXR might see calcification of AS

Question 31

Aortic stenosis treatment

Answer 31

Only when heart failure has developed (which would mean sortic valve replacement/repair)

Question 32

Aeiology of aortic regurgitation

Answer 32

Aorta: - Dilated Aorta (Marfans/hypertension) - Connective tissue disorders Leaflets: - Rheumatic Heart Disease - Bicuspid - Endocarditis - Myxomatous degeneration

Question 33

Aortic regurgitation symptoms

Answer 33

Acute: - wall tension can't adapt, so poorly tollarated Chronic - long asymptomatic phase - Exertional breathlessness

Question 34

Aortic regurgitation pathophisiology

Answer 34

Blood back from from aorta into ventricle, increased volume and pressure in ventricle, left ventricular hypertrophy and dilatation, increased risk of ischemia due to increased muscle mass and increased oxygen demand, left ventricular heart failure

Question 35

AR on clinical exam

Answer 35

Large pulse volume and collapsing pulse, wide pulse pressure Descending murmur after S2 (early diastolic), can be quiet Hyperdynamic, displaced apex beat

Question 36

Investigations aortic regurgiation

Answer 36

ECHO! - can use the doppler haemodynamic assesment too ECG - displaced left axis and signs of LVH, ST/T changes CXR - cardiomegally in chronic Can see functioning on cardiac magnetic resonance

Question 37

Therapy intervention for aortic regurgitation

Answer 37

The only one with real intervention before surgery - vasodilator therapy shown to delay timing for surgical intervention. Then Aortic valve replacement (more commonly the case)/repair