Valvular Heart Disease Flashcards
(39 cards)
History and examination findings mitral stenosis
History
- Dyspnoea, orthopnoea, PND, haemoptysis (ruptured bronchial veins), ascites, oedema, fatigue (PHTN)
Examination
- General → tachypnoea, mitral facies, peripheral cyanosis (severe)
- Pulse & BP → normal/reduced in volume, AF due to LA enlargement
- JVP → normal, prominent a wave if PHTN, loss of a wave in AF
- Palpation → tapping quality apex beat (palpable S1), RV heave (parasternal impulse), palpable P2 if PHTN present, rarely diastolic thrill (lie on left side)
- Auscultation → loud S1, loud P2, opening snap, low pitched rumbling diastolic murmur (left lateral position), late diastolic accentuation of murmus may occur in sinus rhythm - best heard left lateral, after exercise
Causes of mitral stenosis
- Rheumatic (F>M)
- Severe mitral annular calcification (sometimes associated with hypercalcaemia and hyperparathyroidism → rare)
- After mitral valve repair for mitral regurgitation
Clinical signs of severity in mitral stenosis
- Small pulse pressure
- Early opening snap (raised left atrial pressure)
- Length of mid-diastolic rumbling murmur (persists as long as there is a gradient)
- Diastolic thrill at apex (rare)
- Presence of pulmonary hypertension
- Prominent a wave in JVP (if patient in sinus rhythm)
- Right ventricular impulse
- Loud P2, palpable P2
- Pulmonary regurgitation
- Tricuspic regurgitation
Results of investigations in mitral stenosis
ECG:
- P mitrale (broad bifid p wave)
- Atrial fibrillation (sign of chronicity)
- Right ventricular systolic overload
- Right axis deviation (severe)
CXR
- Mitral valve calcification
- Large left atrium - double left atrial shadow, displaced left main bronchus, big left atrial appendage
- Signs of pulmonary hypertension - large central pulmonary arteries, pruned peripheral arterial tree
- Signs of cardiac failure
If investigations suggest LV dilatation in presence of mitral stenosis murmur consider
- Associated mitral regurgitation
- Associated aortic valve disease
- Associated hypertension
- Associated IHD
ECHO
- Posterior mitral valve leaflet maintains anterior position in diastole
- Valve area 4-6cm normal, <1cm severe
Indications for surgery in mitral stenosis
- Exertional dyspnoea and falling valve area (when valve area falls to about 1cm) with signs of increasing right heart heart pressures
- Should be performed before pulmonary oedema or major haemoptysis occurs
Contraindications to percutaneous mitral balloon valvotomy in mitral stenosis (i.e. indications for surgery)
- Mitral valve area >1.5cm
- Left atrial thrombus
- Moderate to severe MR
- Severe or bicommisural calcification
- Absence of commiserate fusion
- Severe concomitant aortic valve disease, or severe combined tricuspid regurgitation and stenosis
- Comcomitant CAD requiring bypass surgery
History and examination findings in mitral regurgitation
History
Dyspnoea (increased left atrial pressure), fatigue (decreased CO)
Examination
General → tachypnoea
Pulse → normal, or sharp upstroke due to rapid LV decompression, AF common
Palpation → displaced apex, diffuse, hyperdynamic, occasional pansystolic thrill. Parasternal impulse (LA enlargement behind RV) (LA often larger in MR than MS)
Auscultation → soft or absent S1, LV S3, pansystolic, holosystolic murmur at apex radiating to axilla (regurg jet posterior → axilla, anteriorly → sternum. Findings may be increased with handgrip. Can also get diastolic flow murmur
Signs of severe chronic mitral regurgitation
- Small volume pulse (very severe)
- Loud s3
- Soft S1
- Early A2
- Signs of pulmonary hypertension
- Signs of LV failure
- Enlarged left ventricle
- Early diastolic rumble
Causes of chronic mitral regurgitation
- Mitral valve prolapse
- Degenerative - associated with aging
- Rheumatic (M>F) - MR rarely the only murmur present
- Papillary muscle dysfunction (LV failure or ischaemia)
- Cardiomyopathy - hypertrophic, dilated, restrictive
- CTD - Marfan’s, RA, anklyosing spondylitis
- Congenital → endocardial cushion defect (primum ASD, cleft mitral leaflet), parachute valve, corrected transposition
- Secondary/Functional MR → heart failure, ischaemic or non-ischaemic
Results of investigations in mitral regurgitation
ECG
P mitrale, AF, left ventricular diastolic overload, RAD
CXR
Large left atrium, increased LV size, mitral annular calcification, pulmonary hypertension (much less common)
ECHO
Thickened leaflets (rheumatic), prolapsing leaflets, LA size, LV size and function, Doppler detection of regurgitant jet, estimation of RV systolic pressure from TR jet, other abnormalities → aortic valve disease from rheumatic carditis, ASD A/W MV prolapse, calcification of mitral annulus, stress echo → failure of EF to increase during exercise
Features and causes of acute mitral regurgitation
Features
Present with pulmonary oedema and collapse
Murmur may be softer and lower pitched than chronic MR, short and decrescendo
Causes
Myocardial infarction
Infective endocarditis
Trauma/surgery
Spontaneous rupture of a mycomatous cord (sometimes during exercise)
Features of mitral valve prolapse
- Auscultation → midsystolic click followed by a middle or late systolic murmur that extends to the second heart sounds. Blowing quality. occur earlier and become louder with Valsalva and with standing. Softer with squatting and handgrip
Causes
Myxomatous degeneration of the mitral valve tissue - v common, women (but more likely to progress to significant MR in men), severity increases with age
May be associated with ASD (secundum), HCOM, Marfan’s
Complications
MR, Infective endocarditis
Indications and options for surgery mitral regurgitation
Chronic → Class III, IV symptoms or asymptomatic patients with left ventricular dysfunction (LVEF ≤60%)
Acute → haemodynamic collapse
Options
MV replacement or repair → repair is the recommended technique when results are expected to be durable
Mitraclip (transcatheter edge-edge MV repair) → if high surgical risk, favourable anatomy, and life expectancy > 1 year
Secondary MR
Guideline directed medical therapy for heart failure
Surgical repair/replacement not shown to reduce hospitalisation or death
Mitraclip (transcatheter edge-edge repair) → reduces hospitalisation for HF and all-cause mortality compared to GDMT alone
Features of aortic stenosis
History
Exertional chest pain, dyspnoea, syncope
Examination
Pulse → Plateau or anacrotic pulse late peaking and small volume
Palpation → hyperdynamic apex beat, may be slightly displaced. Systolic thrill at base
Auscultation → narrow split or reverse S2 (delayed LV ejection), harsh midsystolic ejection murmur loudest over aorta and extending into carotids → loudest sitting up in full expiration. ejection click in congenital AS
Features of severe aortic stenosis
- ECHO - Valve area <1cm, jet velocuty >4m/sec, mean gradient >40mmHg
- Plateau pulse
- Carotid pulse reduced in volume
- Thrill in aortic area
- Soft of absent S2
- LVF
- Pressure loaded apex beat
- Length, harshness and lateness of the peak of the systolic murmur
- S4
- Paradoxical splitting of the second heart sound
Causes of aortic stenosis
- Degenerative calcific AS - elderly
- Congenital bicuspid valve (<65)
- Rheumatic
- Radiation
- William’s syndrome (supravalvular AS)
- HOCM (subvalvular AS)
Notes on low-flow, low gradient aortic stenosis
- High velocity and gradient depends on normal flow of blood → patients with low flow (LV dysfunction, altered haemodynamics) will have lower gradients
- Aortic valve area will be <1
- Conventional LFLG AS - reduced LVEF (<50%) and stroke volume (<35ml)
- Paradoxical LFLG AS - preserved LVEF and reduced stroke volume
Results of investigations in aortic stenosis
- ECG → LVH
- CXR:
- LVH, Valve calcification
ECHO
Doppler estimation of gradient
Calcification of valve area
Valve cusp mobility
LVH
Left ventricular dysfunction
Management of aortic stenosis
- 5 year survival in severe, inoperable AS = 5%
- HF → 2 years survival, syncope 3 years, angina 5 years
- Treat when symptomatic. Or asymptomatic with severe AS and LVEF < 55% without another cause, or symptoms on exercise testing, or fall in BP ≥20mmHg during exercise testing
- If not meeting above criteria → consider itnervention if very severe AS (gradient ≥ 60mmHg), severe valve calcification, markedly high BNP
- Surgical replacement vs TAVI
- Low risk patients → reduced death, stroke and mortality in TAVI group, other studies almost identical outcomes between groups
- Intermediate risk group → no significant difference in death or stroke between groups
- Generally - younger, lower risk = SAVR, older, higher risk = TAVI
- Valve-in-valve TAVI
- Considered in those with degeneration of a previous bioprosthetic aortic valve instead of re-do surgery → lower risk of death, stroke, pacemaker, hospitalisation.
- Risk of coronary obstruction → needs to be assessed carefully on CT
Mechanical or tissue
Tissue offered to patients over 65 or to younger patients who wish to avoid warfarin. Life expectancy of tissue valve = 15 years. TAVR are also tissue valves.
Complications of TAVI
- Incomplete valve deployment
- Paravalvular leak
- Mitral regurgitation
- Valve position/migration
- Aortic root injury /dissection
- Pericardial effusion
Features of aortic regurgitation
History
(Late stage) → exertional dyspnoea, fatigue, palpitations and angina
Examination
Appearances or Marfan’s, ank spond, Argyll Robertson pupils
Pulse → collapseing (water hammer), wide pulse pressure. Biferens pulse (beat twice) - severe AR or combined AS/AR, Hill’s sign → increased BP >20mmHg in the legs compared to arms
Neck → Corrigan’s sign (prominent carotid pulsations)
Palpation → apex beat displaced and hyperkinetic, diastollic thrill at LSE
Ausculation → soft A2, decrescendo high pitched diastolic murmur, often systolic ejection murmur (concomitant AS), Austin-Flint murmur → low pitched, rumbling mid-diastolic murmur and presystolic murmur at apex (mitral valve leaflet shudders from regurg jet)
Signs of severe aortic regurgitation
- Collapsing pulse, wide pulse pressure
- Long decrescendo diastolic murmur
- Left ventricular S3
- Soft A2
- Austin Flint murmur
- Signs of LVF
Causes of aortic regurgitation
Congenital/leaflet abnormalities
Bicuspid, unicuspid. VSD
Acquired leaflet abnormalities
Senile calcification, infective endocarditis, rheumatic heart disease, radiation
Congenital/genetic aortic root abnormalities
Ehlers-Danlos, Marfan syndrome, osteogenesis imperfecta
Acquired aortic root abnormalities
Idiopathic aortic root dilatation, systemic hypertension, autoimmune → SLE, ank spond, Reiter’s, aortitis → syphilis, Takayasu’s, aortic dissection, trauma
Results of investigations in aortic regurgitation
ECG → left ventricular hypertrophy
CXR → left ventricular dilatation, aortic root dilatation or aneurysm, valve calcification
ECHO → left ventricular dimensions and function, Doppler estimation of size or regurg jet, vegetations, aortic root dimensions, valve cusp thickening or prolapse (associated AS)
