Valvular Heart Disease |

Question 1

4 main types of valvular heart disease:

Answer 1

• Aortic stenosis
• Aortic regurgitation
• Mitral stenosis
• Mitral regurgitation

Question 2

Cardiovascular clinical exam - 5

Answer 2

• General appearance
• Arterial pulse - radial + carotid
• Venous pulse - JVP
• Palpation - apex + heaves
• Auscultation - heart sounds and murmurs

GAVPA

Question 3

What is the main disease valvular diseases can cause and its main signs/symptoms

Answer 3

Heart failure

• Raised JVP
• Pitting Oedema
• Hepatic congestion

Question 4

Apex beat Palpation - 3 causes of change

Answer 4

Tapping apex beat - mitral stenosis

Displaced and weak - LV dilatation

Displaced and heaving - LV hypertrophy

Question 5

Parasternal heave - how and cause

Answer 5

Hand left of sternum

RV overload

Question 6

What is a cardiac murmur

Answer 6

Audible turbulence of blood flow
Can be innocent or pathological

Normally caused by valve restricting exit or allowing blood to leak back in

Question 7

Describing a murmur - 6

Answer 7

• Timing - systole or diastole
• What type of murmur
• Where is it the loudest
• Where does it radiate to
• What grade of murmur
• Is it influenced by respiration

Question 8

What causes the first heart sound and what does it indicate

Answer 8

Mitral and tricuspid valves closing
Start of systole

Question 9

What causes second heart sound and what does it indicate

Answer 9

Aortic and pulmonary valves closing
Start of diastole

Question 10

Types of systolic murmur

Answer 10

Pansystolic - consistent sound

Ejection systolic - crechendos

Question 11

Types of diastolic murmur

Answer 11

Early diastolic

Mid diastolic

Question 12

What are the 4 areas murmurs are listened for

Answer 12

Right 2nd intercostal space, sternal edge - aortic valve
Left 2nd intercostal space, sternal edge - pulmonary valve
Left 4th intercostal space, sternal edge - tricuspid valve
Left 5th intercostal space, mid-clavicular line - mitral valve

Question 13

What two places do you check for radiation and what does it mean if murmur is heard here

Answer 13

Carotids - aortic stenosis

Axilla - mitral regurgitation

Question 14

Grades of murmur

Answer 14

1. Very quiet
2. Easy to hear
3. Loud
4. Loud with thrill
5. Very loud with thrill
6. Audible without stethoscope

Question 15

What effect does respiration have on sound of murmurs

Answer 15

Right side murmurs are louder with inspiration

Question 16

What is an innocent murmur and when is it heard

Answer 16

Physiological increased flow

Soft + Early systolic

Affected by position and exercise

Question 17

What is valve stenosis

Answer 17

When valves do not open properly

Question 18

What is valve regurgitation

Answer 18

Valves do not close properly

Question 19

What is aortic stenosis

Answer 19

Where aortic valve is too small, narrow, or stiff obstructing blood flow from LV to aorta

Question 20

Aortic stenosis - causes

Answer 20

Congenital defect - bicuspid not tricuspid - younger patients

Calcifications on aortic valve - older patients

Rheumatic heart disease

Question 21

Aortic stenosis - symptoms

Answer 21

No symptoms unless severe

When severe:
- Dyspnoea
- Exercise induced syncope
- Angina

Question 22

Aortic stenosis - signs + auscultation

Answer 22

Low volume pulse
Left ventricular hypertrophy + displaced apex

Ejection systolic murmur
Best heard at 2nd right intercostal space, sternal edge

Radiates to carotids

Question 23

Investigations for all valvular diseases

Answer 23

Chest X ray
ECG
Echocardiogram

Others if needed: Cardiovascular Magnetic Resonance, Cardiac CT

Question 24

Aortic stenosis - management + benefits

Answer 24

Conventional valve replacement preferred (AVR)
- Long term

Patients unable to tolerate operation
Trans-catheter Aortic Valve replacement (TAVI)
- Percutaneous

Or Balloon Aortic valvotomy

Question 25

2 Types of prosthetic valves and differences

Answer 25

Mechanical - Warfarin - Last lifetime :. Younger patients Bio-prosthetic - No warfarin - Last 10 years :. Older patients

Question 26

What is Aortic Regurgitation

Answer 26

Reflux of blood from the aorta through aortic valve into ventricle during diastole

Question 27

Aortic Regurgitaion - causes

Answer 27

Valve disease - Rheumatic fever - Infective endocarditis - Connective tissue diseases - Bicuspid aortic valve Aortic root disease (affect annulus) - Aortic dissection - Marfans - Hypertension

Question 28

Aortic Regurgitation - symptoms

Answer 28

Dyspnoea Symptoms normally don’t develop until LV failure Angina

Question 29

Aortic Regurgitation - Signs

Answer 29

Collapsing pulse **High pitched early diastolic** murmur Best heard at 4th left intercostal space, sternal edge with patient leaning forward and breath held in expiration Apex beat is displaced laterally and downwards Cardiomegaly

Question 30

Aortic Stenosis - management

Answer 30

Treat underlying cause if appropriate ACEi used when severe Beta blockers in Marfans patients Valve replacement in symptomatic patients or when LV function is reduced

Question 31

What is Mitral Stenosis

Answer 31

Obstruction to the flow through mitral valve during diastole

Question 32

Mitral stenosis - causes

Answer 32

Rheumatic fever - main cause Calcification in older patients Can be congenital but rare

Question 33

Mitral stenosis - symptoms

Answer 33

Dyspnoea Fatigue Palpitations - AF - increased atrial pressure causing it to enlarge which can cause AF

Question 34

Mitral Stenosis - signs

Answer 34

Malar flush - plum red discolouration of high cheeks **Mid-diastolic** murmur best heard at Apex Tapping Apex beat Straight left heart border

Question 35

Mitral Stenosis - management

Answer 35

Diuretics Treat AF Valve replacement Balloon valvuloplasty if can’t tolerate

Question 36

What is Mitral Regurgitation

Answer 36

When blood leaks back through the mitral valve during systole

Question 37

Mitral regurgitation - causes

Answer 37

Primary valve disorder - Infective endocarditis - MI causing valve prolapse - Rheumatic fever - Valve becomes myxomatosis (floppy) Chordae rupture - prolapse Papillary muscle rupture - ischaemic Can occur secondary to LV dysfunction (HF) E.g. cardiomyopathy or MI

Question 38

Mitral Regurgitaion - symptoms

Answer 38

Dyspnoea Peripheral oedema Fatigue

Question 39

Mitral Regurgitation - signs

Answer 39

Displaced apex - cardiomegaly **Pan-systolic** murmur best heart at Apex 5th left intercostal space, mid-clavicular line Radiates to **axilla**

Question 40

Aortic stenosis - management

Answer 40

Diuretics ACEi if HF develops Open heart surgery and valve repair (for prolapse) or replacement Percutaneous - MitraClip if can’t tolerate surgery