Valvular Heart Disease Flashcards
(34 cards)
Causes of aortic stenosis.
Senile calcification - most common
Congenital - bicuspid valve
William’s syndrome
Rheumatic heart disease
How does AS present
Think of AS in any elderly patient with
- chest pain
- exertional dyspnoea
- syncope
What is the classic triad of AS
Angina
Syncope
Heart failure
Clinical features of AS
Chest pain Syncope Dyspnoea Dizziness Faints Systemic emobli - if infective endocarditis Sudden death Slow rising pulse with narrow pulse pressure - feel for diminished and delayed carotid upstroke Heave Non-displaced apex beat LV heave Aortic thrill Ejection systolic murmer
Describe the murmurs associated with AS
Ejection systolic murmur - aortic stenosis murmur
- heard at the base, LL sternal adge and over the aortic region
- radiation to carotids
Quiet A2 - inaudible in severe stenosis
May be an ejection click or a fourth heart sound
What investigations should be performed in ?AS
ECG CXR Echo - diagnostic Cardiac catheter - assesses valve gradient, LV function, coronary artery disease - risk of generating an embolus
Describe changes on ECG in AS
LVH with strain pattern P-mitrale Left axis deviation Poor R-wave progression LBBB Complete AV block (due to the calcified ring)
Describe CXR changes in AS
LVH
Calcified aortic valve
Post-stenotic dilation of the ascending aorta
Describe the use of echo in AS, and what can be seen
Doppler echo can estimate the gradient across the valves
- severe if peak gradient >40mmHg (but beware this may be due to a poor left ventricle not being able to generate the gradient)
Size of valve area <1cm2
If aortic jet velocity is >4m/s there is an increased risk of complications
Differential diagnoses for AS
Hypertrophic cardiomyopathy
Aortic sclerosis
What is aortic sclerosis
Senile degeneration of the valve
Ejection systolic murmur present, but no carotid radiation
Normal pulse - character and radiation
Normal S2
Management of AS
Symptomatic - poor prognosis without surgery
- prompt valve replacement recommended
Non-symptomatic
- if severe stenosis and a deteriorating ECG, valve replacement is also recommended
If patient isn’t medically fit for surgery
- percutaneous valvuloplasty /replacement (TAVI - transcatheter aortic valve implantation)
Causes of acute aortic regurgitation
Infective endocarditis
Chest trauma
Ascending aortic dissection
Causes of chronic aortic regurgitation
Congenital Connective tissue disorders - Marfan's syndrome, Ehlers-Danlos Rheumatic fever Takayasu arteritis Rheumatoid arthritis SLE Seronegative arthritides (AnkSpond, psoriatic arthropathy) Hypertension Osteogenesis imperfecta
Signs and symptoms of AR
Exertional dyspnoea Orthopnoea PND e.g. coughing at night Palpitations Angina Syncope Collapsing pulse Wide pulse pressure Displaced, hyperdynamic apex beat High pitched, early diastolic murmur - heard best in expiration with the patient sat forwards Carotid pulsatation Head nodding with each heartbeat Capillary pulsation in nail beds Pistol shot sound over the femoral artery
Investigations required in ?AR, and what would you expect to see
ECG - LVH
CXR - cardiomeagly, pulmonary oedema and dialted ascending aorta
Echo - diagnostic
Cardiac catheterisation - assesses severity of lesion, anatomy of the aortic root, LV function, coronary artery disease and other valve diseases
Management of AR
Goal of medical therapy is to reduce systolic hypertension
- ACEI
Echo every 6-12 months to monitor
Valve replacement surgery - aim to perform before significant LV dysfunction occurs
When is surgery indicated in AR
Severe AR with enlarged ascending aorta
Increasing symptoms
Enlarging left ventricle or deteriorating LV function on echo
Infective endocarditis refractory to medical therapy
What is mitral regurgitation
Backflow through the mitral valve during systole
Cause of MR
Functional - LV dilatation Annular calcification - elderly Rheumatic fever Infective endocarditis Mitral valve prolapse Ruptured chordae tendinae Papillary muscle dysfunction and rupture (e.g. post-MI) Connective tissue disorders Cardiomyopathy Congenital - more likely to be associated with other defects as well
Clinical features of MR
Dyspnoea Fatigue Palpitations Symptoms of causative factor - e.g. fever AF Displaced, hyperdynamic apex beat Pansystolic murmur - apex radiating to axilla Soft S1 and split S2 Loud P2 if pulmonary hypertension
Investigations required in ?MR
ECG - P-mitrale if in sinus rhythm (indicates increased LV size) and LVH
CXR - large LA and LV, mitral valve calcification and pulmonary oedema
Echo
Cardiac catheterisation - confirms diagnosis, excludes other valve disease and assesses coronary artery disease
Describe the use of echo in the assessment of MR
Assesses LV function and MR severity and aetiology
TOE is required to assess severity and suitability for repair rather than replacement
Management of MR
Control rate if caused by fast AF Anticoagulation if - AF - history of embolism - prosthetic valve - presence of mitral stenosis as well Diuretics improve symptoms Surgery - indicated in deteriorating symptoms - aim to replace or repair the valve before LV is irreversibly impaired
