Name the 4 heart valves
Aortic: Lv -> Aorta
Pulmonary: Rv -> Pulmonary artery
Mitral: La -> Lv
Tricuspid: Ra -> Rv
How many cusps does aortic valve have?
3
What percentage of population have 2 cusps?
2%- bicuspid aortic valve
When does aortic valve open?
During systole when left ventricular pressure exceeds the aortic pressure
What heart sound does the aortic valve give rise to and how?
The aortic component of the second heart sound (dub)- when the Lv pressure is lower than aortic pressure, causing aortic valve to close
What causes the first heart sound?
Closure of tricuspid and mitral valves
What causes the second heart sound?
Closure of the pulmonary and aortic valves
How common is aortic stenosis?
Fairly- affects 5% of people over 60
What are the symptoms of aortic stenosis?
Breathlessness Chest pain Blackout/syncope Tiredness Palpitations
What is the first thing you do if aortic stenosis is suspected?
Take detailed history and examination History: Red flag symptoms Exercise intolerance Palpitations Symptoms of heart failure Examination: Slow rising pulse Narrow pulse pressure Ejection systolic murmur Soft or absent second heart sound Displaced or heaving apex beat Sings of heart failure/pulmonary oedema
What is the ECG of someone with aortic stenosis like?
Can be normal or signs consistent with aortic stenosis
Tall QRS complexes that interfere with lines above- sign of left ventricular hypertrophy (occurs secondary to aortic stenosis)
What would you look for in blood tests of someone with suspected aortic stenosis?
Anything else that could cause symptoms (anaemia- breathlessness)
Other biomarkers such as BNP (brain natriuretic peptide) which correlates with severity of aortic stenosis
What does measuring velocity through the valve by echocardiography allow you to do?
It allows you to calculate the pressure using Bernoulli principle
What is Bernoulli principle?
In a moving fluid, the velocity of the fluid and the pressure exerted by the fluid are inversely proportional
If you recorded a high velocity through the valve, what does this tell you?
The smaller the area of open valve and the more severe the stenosis
What can be used to work out velocity through valve?
Doppler ultrasound
What causes leaky valves?
A lack of apposition between the cusps
What is the most common type of leaky valve?
Aortic regurgitation
What is the history of someone with aortic regurgitation?
Breathlessness
Palpitations
Symptoms of heart failure
What would be found on examination of someone with aortic regurgitation?
High volume pulse Collapsing pulse Wide pulse pressure Diastolic murmur Signs of heart failure
What investigations are involved for suspected aortic regurgitation?
Simple and uncomplicated procedures first e.g. blood pressure, oxygen saturation, CXR, ECG and blood tests
What causes of stenosis are there?
Calcification
Bicuspid aortic valve
Infective endocarditis
What causes of regurgitation are there?
Rheumatic heart disease
Dilation of the aorta
Bicuspid aortic valve
Infective endocarditis
What treatment options are there for aortic stenosis and regurgitation?
Nothing that stops progression of aortic stenosis or regurgitation
Conservative- supportive measures
Medical- Managing heart failure symptoms (e.g. diuretics). Look for arrhythmia. Anticoagulation
Surgical- Percutaneous intervention, TAVI or open heart surgery
What is TAVI?
Transcatheter aortic valve implanatation- inserte dinto femoral artery in groin and pushed up to aorta so valve can be replaced
What are the two different types of replacement valve and what are they like?
Metallic- used more in younger people because can last upto 30-40 years but requires warfarin
Prosthetic- last for 10-12 years and don’t require warfarin whereas metallic valve does
What is the EUROSCORE?
Algorithm that predicts how well people will fair after surgery. Based on several factors including age, gender, renal function and breathlessness
What would you do if someone has a EUROSCORE < or > than 20?
<20 consider for surgery
>20 consider TAVI
What are the symptoms of mitral regurgitation?
Breathlessness Palpitations Tiredness Cough Symptoms of heart failure
What would you find on examination of mitral regurgitation?
Pansystolic murmur
Displaced apex beat
Atrial fibrillation
What are the symptoms of mitral stenosis?
Breathlessness Fatigue Palpitations Embolic events Haemoptysis
What would you find on examination of mitral stenosis?
Diastolic murmur
Loud first heart sound
Atrial fibrillation
What is the treatment for mitral stenosis?
Mechanical valves are generally put in
What is more common in tricuspid: stenosis or regurgitation?
Regurgitation
What are the symptoms of tricuspid valve like?
Similar to left heart valve disease
What are abnormalities in pulmonary valve usually due to?
Congenital abnormalities