Valvular heart disease Flashcards Preview

CAM201 Clinical Skills > Valvular heart disease > Flashcards

Flashcards in Valvular heart disease Deck (26):
1

Management principles of valvular heart disease

Medical

  • Prevent endocarditis
  • Prevent thromboembolism and arrhythmias
  • Reduce preload (diuretics)
  • Reduce afterload (vasodilators)

Surgical

  • Repair
  • Replace
    • Tissue (xenograft, homograft)
    • Prosthetic
    • Bioprosthetic

2

Why do hearts fail?

  • Increased cardiac work causes hypertrophy
  • Increased volume load causes dilation
  • Effiency decreases after a certain dilatation (Starlings Law)
  • Hypertrophy increases ventricular stiffness
  • Decreased cardiac output causes catecholamine drive
    • Prolonged catcholamine drive results in catecholamine depletion
  • Decreased cardiac output reduces GFR causing fluid retention and aldosterone release
  • Chronic volume and pressure overload leads to eventual muscle failure. 

3

Forward heart failure manifestations

  • Fatigue
  • Dyspnoea
  • Syncope
  • Angina

4

Backwards heart failure

  • Pulmonary oedema
  • Right heart strain and failure
  • Elevated JVP
  • Hepatosplenomegaly 
  • Ascites
  • Peripheral oedema 

5

Metral stenosis aetiology

  • Rheumatic
  • Congenital
  • Calcification

6

Mitral stenosis haemodynamics

Elevated LA pressure

Elevated pulmonary arterial pressure

  • JVP prominent 'a' wave and gradual 'y' descent

Normal LV diastolic pressure

7

Mitral stenosis treatment

Medical

  • Diuretic - pulmonary congestion
  • Control atrial fibrillation
  • Prevent thrombo-embolism: anticoagulate all with paroxysmal atrial fibrillation/ atrial fibrillation, sinus rhythm and old. 

Surgical

  • Balloon mitral valvuloplasty
  • Closed mitral valvotomy
  • Open mitral valvotomy
  • Mitral valve replacement

8

Mitral regurgitation aetiology

  • Mitral valve prolapse
  • Rheumatic
  • Infective endocarditis
  • Ischaemic heart disease
  • Collagen vascular disease
  • Cadiomyopathy
  • Congenital
  • Appetite suppressant drugs

9

Areas of the mitral valve that can be damaged causing mitral regurgitation

Annulus

  • Calcification

Leaflet

  • Myxomatous degeneration
  • Rheumatic deformity
  • Infectious perforation

Chordae

  • Myxomatous degeneration
  • Spontaneous rupture
  • Rheumatic shortening
  • Infectious destruction

Papillary

  • Infarction 
  • Ischaemic lengthening

Functional

  • LV dilatation and PM displacement

10

Mitral regurgitation haemodynamics

  • LV volume overload
  • LV dilatation
  • LA dilatation (atrial fibrillation)
  • Elevated pulmonary pressures

11

Clinical presentation of acute mitral regurgitation

Symptoms

  • SOB
  • Orthopnoea
  • Decreased CO

Signs

  • ​Variable murmur
  • S3

12

Clinical presentation of chronic MR

Symptoms

  • ​Variable

Signs

  • PSM (pre-systolic murmur)
  • LV enlargement
  • PHT (pressure half-time)
  • S3

13

Mitral regurgitation medical treatment

Diuretics

  • Decrease LV filling pressures
  • Decrease peripheral oedema

Vasodilators

  • Reduce LV afterload
  • Increase forward aortic flow

14

Mitral regurgitation surgical treatment

  • Mitral valve repair
  • Mitral valve replacement

15

Aortic stenosis aetiology

Congenital

  • 1st-3rd decade

Rheumatic

  • 4th decade

Senile calcific degeneration

  • 7-8th decade
  • 2% incidence

Bicuspid

  • 5-6th decade
  • 1% incidence
  • Males > females

16

Aortic stenosis pathophysiology

  • LV hypertrophy
  • Decreased compliance
  • Increased LVEDP
  • High pulmonary pressures
  • Decreased forward output
    • Reduced (glomerular filtration rate) leading to fluid retention
    • Reduced coronary flow leading to myocardial ischaemia 

 

  • LV pressure overload --> LV hypertrophy --> diastolic LV dysfunction/ischaemia
  • Systolic function usually preserved until late. 
  • Systolic function improves with AVR
  • Outcome is dependent on symptoms. 

17

Aortic stenosis symptoms and signs

Symptoms

  • None
  • SOBOE, dizziness, HF, syncope, angina
  • GI bleeding (angiodysplasia)

Examination

  • Pulse --> decreased amplitude, delay
  • Sustained apex
  • S2 - soft and single --> paradoxical splitting
  • ESM - loud --> late peak --> soft

18

Aortic stenosis treatment

Medical

  • No effective therapy
  • Diuretics for LVF
  • ACEI relative contraindicated

Surgical

Balloon aortic valvuloplasty

  • Improves AVA 0.8cm --> 1.0cm
  • Improves symptoms short term
  • Procedural mortaltiy 5%
  • No improvement in mortality

Aortic valve replacement

  • Only if symptomatic
  • Severe AS and poor LVF
  • In association with CABG
  • Mortality 0.6-5%
  • 2 year survival 4x greater than medical treatment

19

Aortic regurgitation aetiology

Valve

  • Rheumatic
  • Infective endocarditis
  • Congenital (bicuspid valve)
  • SLE/Rh A

Aortic root disease

  • Second degree to dilatation of ascending aorta
    • Degerative
    • Cystic medial necrosis of aorta
    • Marfans
    • Aortic dissection
    • Symphilitic aortitis
    • Ankylosing spondylitis
    • Hypertension

20

Acute aortic regurgitation clinical features

  • No time for LV to enlarge (LVEDV N)
  • LEDP increased
  • Premature closure of MV (quiet S1) 
  • LV systolic pressure n
  • Increase total SV, decrease forward SV

21

Chronic AR clinical features

  • Maintained forward SV
  • Volume and pressure overload
  • LV decompensation
    • May be asymptomatic, LVF, angina

Upon examination

  • Hyperdynamic circulation
  • Wide pulse pressure
  • Dilated LV
  • Long EDM

 

22

De Musset sign

Head bobs with each heart beat. 

SIgn of aortic regurgitation. 

23

Corrigan pulse

Sign of AR.

Collapsing pulse. 

24

Traube sign

Sign of AR.

Pistol shot sound over femoral artery. 

25

Quincke sign

Patient's fingertips pulsating

26

Chronic AR treatment

Medical (to decrease afterload)

  • Vasodilators

Surgery

  • AVR prior to irreversible LV dysfunction