Valvular Heart Disease

Question 1

Infective endocarditis
- pathophysiology
- causative organisms
- risk factors

Answer 1

Endocardium infected, damages valves => vegetation formation
-can dislodge and cause infarcts

Saureus - most common in developed countries
- acute
- IVDU, piercings

Sviridans - most common in developing countries
-poor dental hygiene

Sepidermidis - most common post valve surgery

Sbovis - colorectal cancer link

Question 2

Infective endocarditis
- presentation
- diagnosis and investigations
- management

Answer 2

Fevers, chills
MR -
TR - IVDU
Oslers - immune complex deposition in hands
Splinter hemorrhages, Janeway - microinfarcts
Organ infarcts

3x Blood culture + echo

1st line - ABx
Native valve endocarditis - amox + gent
NVE + severe sepsis/pen allergy/MRSA - vanc + gent
NVE + severe sepsis + positive G-ve - vanc + mero
Prosthetic valve - vanc OR gent + rifampicin

2nd line - surgery to repair/replace valve if
-ABx not effective
-abscess/fistula
-HF
-emboli

Question 3

Main cause and presentation of
- mitral stenosis
- mitral regurgitation
- aortic stenosis
- aortic regurgitation

Answer 3

ALL CAN PRESENT WITH SOB, MURMURS, HF
Mitral stenosis - rheumatic heart disease => palpitations

Mitral regurgitation - old age, LH dilation/HF, post MI (papillary muscle rupture), rheumatic fever

Aortic stenosis
-old age (calcification) => chest pain
-young (bicuspid valve) - Turners
-supravalvular AS - William’s syndrome
-post-rheumatic disease
-subvalvular AS - HOCM

Aortic regurgitation - idiopathic, dissection, Marfans, EDS

Question 4

Main cause and presentation of
- tricuspid stenosis
- tricuspid regurgitation
- pulmonary stenosis
- pulmonary insufficiency

Answer 4

GENERALLY RARER

ALL CAN PRESENT WITH ASCITIES, PERIPHERAL EDEMA, HEPATOMEGALY, HIGH JVP, MURMUR

Tricuspid stenosis - RARE (rheumatic heart disease, congenital)

Tricuspid regurgitation -

• mild => no treatment needed
• severe - RV dilation, VSD, congenital

Pulmonary stenosis - congenital

Pulmonary regurgitation - RARE, treatment not needed

Question 5

Valvulopathies
- presentation
- diagnosis
- management

Answer 5

Chest pain
SOB, SOBOE

Echo

AS
Low risk of complications - surgical aortic valve repair
Elderly/frail - TAVI

MR
Severe - surgical repair/replace

Question 6

Aortic stenosis
-presentation
-investigations
-management

Answer 6

Chest pain, SOB, exertional dizziness
Murmur
-ejection systolic with carotid radiation
-decreased with valsalva

Signs of severe disease
-narrow pulse pressure
-slow rising
-quiet S2
-S4 - LV hypertrophy developed to cope with As
-thrill - LVH

CXR, ECG
Establish diagnosis - TTE

Asymptomatic => observe
Asymptomatic + valvular gradient 40mmHg + LV ejection fraction U55% => refer for surgery

Symptomatic => refer for surgery

Surgical AVR - young, low/medium operative risk patients
TAVR - high operative risk
Balloon valvuloplasty - children with no calcification
-may also use in patients with critical AS + not suitable for valve replacement

Question 7

Aortic regurgitation
-presentation
-investigations
-management

Answer 7

Early diastolic murmur
Collapsing pulse => wide pulse pressure
Quincke’s - nailbed pulsation
De Musset - head bobbing

CXR, ECG
Establish diagnosis - TTE

Medical management of any associated heart failure
Symptomatic - AVR
Asymptomatic + LV ejection fraction U55% - AVR
Asymptomatic only - regular review

Question 8

Mitral regurgitation
-presentation
-investigations
-management

Answer 8

Majority asymptomatic
Symptoms arise from LV failure
-fatigue
-SOB
-pulmonary edema

Blowing pansystolic
Apex => axilla

ECG - broad p wave = atrial enlargement
Establish diagnosis - TTE

Acute medical management - nitrates, diuretics, inotropes to increase CO
HF management
If acute and severe (LVEF U60%) - surgery