Valvular Heart Disease

Question 1

Describe components of the mitral valve?

Answer 1

Anterior MVL and Posterior MVL
Annulus
Papillary muscles and chordae tendinae
Opening is 4-6 cm2

Question 2

Describe the aetiology of Mitral stenosis

Answer 2

Rheumatic Heart Disease
Congenital MS
Systemic conditions - SLE and RA

Question 3

Describe the pathophysiology of mitral stenosis

Answer 3

Atria to ventricle pressure gradient increases so LA pressure increases
Pulmonary venous and capillary pressures increase so PVR increases
PaP increases and PHT develops
RH dilatation with TR and PReg

Question 4

What decides the severity of mitral stenosis?

Answer 4

Trans-valvular pressure gradient and trans-valvular flow rate (CO and HR)

Question 5

What can cause tachycardia?

Answer 5

Exercise, acute illness, pregnancy and atrial fibrillation

Question 6

What are the clinical manifestations of mitral stenosis?

Answer 6

Dyspnoea (mild exertional to pulmonary oedema), Haemoptysis, Systemic embolization, IE, Chest pain and hoarseness (compression of L recurrent laryngeal nerve by large LA)

Question 7

How does systemic embolization occur in MS?

Answer 7

LA and LAA enlargement so blood flow becomes stagnant here

Question 8

What signs can be seen on clinical examination of patient with Mitral stenosis?

Answer 8

Mitral facies (purple discolouration), normal pulse, prominent a wave for JVP, tapping apex beat and diastolic thrill, RV heave and heart sound found in diastole (very quiet)

Question 9

What changes can be seen on an ECG of a patient with mitral stenosis?

Answer 9

P> 0.12 secs can show RVH

Question 10

What investigations are used for mitral stenosis?

Answer 10

ECG and Cardiac catheterisation
CXR
Echo and Cardiac magnetic resonance

Question 11

What changes on CXR can be seen - mitral stenosis?

Answer 11

heart border is larger due to LA and LAA enlargement

Question 12

What can be seen on echo of patient with mitral stenosis?

Answer 12

Thickening and scarring of the leaflets
Fusion of the commissures

Question 13

Describe the medical treatment for a patient with mitral stenosis

Answer 13

Diuretics and restriction of Na intake
AF - SR restoration or ventricular rate control
Anticoagulation

Question 14

What interventional treatment can be used for mitral stenosis?

Answer 14

Valvotomy and MVR

Question 15

Describe the aetiology for mitral regurgitation

Answer 15

Rheumatic heart disease, mitral valve prolapse, IE, Degenerative with age, and functional MR due to LV and annular dilatation

Question 16

Describe the pathophysiology of mitral regurgitation

Answer 16

Effective Regurgitant Orifice is not fixed so effects preload, afterload and LV contractibility
LV compensation then acute or chronic MR

Question 17

Describe pathophysiology of acute mitral regurgitation

Answer 17

ESP and ESV decrease which decreases wall tension

Question 18

Describe the pathophysiology of chronic mitral regurgitation

Answer 18

EDV increases and ESV returns to normal
Eccentric LVH develops

Question 19

What are the clinical manifestations of acute MR?

Answer 19

Breathlessness due to pulmonary oedema and cardiogenic shock

Question 20

Describe the clinical manifestations of chronic MR

Answer 20

Fatigue, exhaustion due to low CO and right heart failure
Dyspnoea or palpitations due to AF

Question 21

What can be seen on examination of patient with mitral regurgitation?

Answer 21

Pulse is normal or reduced in HF, JVP is prominent if right heart failure, brisk and hyperdynamic apex beat, RV heave and S2 is split so early A2 and loud P2

Question 22

Describe the extra heart sound in mitral regurgitation?

Answer 22

Holosystolic, blowing, loud at apex, radiating to axilla and no relationship in intensity and severity

Question 23

What are some lab investigations used for mitral regurgitation?

Answer 23

ECG - LA enlargement is P>0.12 secs and tall, RVH is prominent R waves
CXR - cardiomegaly, LA enlargement, calcification
Cardiac catheterisation and LV angiography

Question 24

What can be seen on echo of Mitral regurgitation?

Answer 24

LV dimensions
Cause of MR - leaflet dysfunction, papillary muscles or annular disease
Severity of MR and Pap (pulmonary arterial pressure)

Question 25

What can be measured on CMR imaging?

Answer 25

Accurate cardiac volumes and volumetric determination of Reg vol.

Question 26

What is the medical treatment for mitral regurgitation?

Answer 26

Acute - preload and afterload reduction Chronic - Haemodynamic improvement and LV function preservation

Question 27

What is the interventional treatment for MR?

Answer 27

Mitral valve apparatus repair and mitral valve replacement

Question 28

Describe the aortic stenosis aetiology

Answer 28

Degenerative, rheumatic heart disease and bicuspid (congenital) AVA < 1.5-2 cm2 instead of normal 3-4cm2

Question 29

Describe the rheumatic pathophysiology of aortic stenosis

Answer 29

Adhesion, fusion of the commissures and retraction and stiffening of the free cusp margins

Question 30

Describe the degenerative pathophysiology of aortic stenosis

Answer 30

Linked to atherosclerosis, is a slow inflammatory process resulting in thickening and calcification of the cusps from base to free margins

Question 31

Describe aortic stenosis pathophysiology

Answer 31

Increased LV systolic pressure - severe concentric hypertrophy and Increased LV mass - increases LVEDP (end diastolic pressure) - increased MVO2 - myocardial ischaemia - LV failure

Question 32

What are the symptoms of aortic stenosis?

Answer 32

Long asymptomatic phase, life expectancy decreases when symptoms appear Chest pain, syncope, dizziness, breathlessness on exertion and HF

Question 33

What can be seen on examination of patient with aortic stenosis?

Answer 33

Small volume pulse which is slow rising, JVP prominent if RH failure and low BP, vigorous and sustained apex beat, RV heave and less audible S2

Question 34

Describe the heart sound heard in aortic stenosis

Answer 34

S2 - less audible A2 Late peaking, loud at base, harsh and radiating to carotids

Question 35

What lab investigations are used in aortic stenosis?

Answer 35

ECG - LVH voltage criteria, ST/T changes showing LV strain CXR - calcification Cardiac catheterisation - peak LV aortic gradient

Question 36

What can be measured and seen on echo for aortic stenosis?

Answer 36

Demonstrates AV cusp mobility LV function and hypertrophy Doppler haemodynamic assessment of pressure gradient and aortic valve area

Question 37

Describe the medical and interventional treatment of aortic stenosis

Answer 37

Medical - if develop heart failure Interventional - aortic valve replacement or repair

Question 38

Describe the aetiology of aortic regurgitation - aorta

Answer 38

Dilated aorta - Marfan's, hypertension Connective tissue disorder

Question 39

Describe the aetiology of aortic regurgitation - leaflets

Answer 39

Bicuspid aortic valve, rheumatic heart disease, endocarditis and myxomatous degeneration

Question 40

Describe the pathophysiology of aortic regurgitation

Answer 40

LV accommodates both SV and RegVol - increased LVEDV and LV systolic pressure - LV hypertrophy and LV dilatation Causes increased MVO2 - myocardial ischaemia - LV failure

Question 41

What are the symptoms of chronic AR?

Answer 41

Long asymptomatic phase then exertional breathlessness

Question 42

What are the symptoms of acute AR?

Answer 42

Poorly tolerated as wall tension so cannot acutely adapt

Question 43

What can be seen on clinical examination of aortic regurgitation?

Answer 43

Pulse is large volume and collapsing, wide pulse pressure, hyperdynamic and displaced apex beat

Question 44

Describe the heart sound in aortic regurgitation

Answer 44

Normal S1 and S2 Early diastolic, decrescendo, soft murmur Very quiet

Question 45

What are the lab investigations for AR?

Answer 45

ECG - ST/T changes for LV strain and LAD CXR - cardiomegaly in chronic AR Cardiac catheterisation

Question 46

What does Echo demonstrate in AR?

Answer 46

Demonstrates AV cusp anatomy (thickening, no of cusps and vegetations) LV function, dilatation and hypertrophy Doppler haemodynamic assessment of regurgitant flow

Question 47

What is the medical treatment and interventional treatment for AR?

Answer 47

Vasodilator therapy will delay timing for surgical intervention Aortic valve replacement