Valvular Heart Disease

Question 1

Mitral stenosis

Answer 1

Narrowing of mitral valve opening

Question 2

Aetiology of mitral stenosis

Answer 2

Rheumatic heart disease
Congenital
Systemic conditions e.g rheumatoid arthritis

Question 3

Size of mitral orifice in mitral stenosis

Answer 3

<2cm2

Question 4

Effects of mitral stenosis

Answer 4

Increases arterial ventricle pressure gradient
Increase left heart pressure
Increase pulmonary venous and capillary pressure
Increased pulmonary vascular resistance
Pulmonary hypertension
Increase peripheral artery pressure
Right heart dilation with tricuspid and pulmonary regurgitation

Question 5

The severity of mitral stenosis is dependent on

Answer 5

Trans-valvular pressure gradient and flow rate

Question 6

Trans-valvular flow rate is indicated by

Answer 6

Increased cardiac output and heart rate

Question 7

Clinical manifestations of mitral stenosis

Answer 7

Dyspnoea
Haemoptysis
Systemic embolism
Infective endocarditis
Chest pain
Hoarseness

Question 8

Clinical examination findings of mitral stenosis

Answer 8

Mitral facies (flushes red cheeks)
JVP - prominent a wave
Tapping apex beat and diastolic thrill
RV heave
Murmur between second and first heart sound

Question 9

Mitral stenosis echocardiograph

Answer 9

Thickening and scarring of the leaflets

Fusion of the commissures

Question 10

Mitral stenosis cardiac magnetic resonance

Answer 10

Enlarged right ventricle and very little opening of mitral valve

Question 11

Medical treatment of mitral stenosis

Answer 11

Diuretics and restriction of sodium intake
Atrial fibrillation - sinus rhythm restoration or ventricular rate control
Anticoagulation

Question 12

Mitral regurgitation

Answer 12

Leaky mitral valve

Question 13

Aetiology of mitral regurgitation

Answer 13

Rheumatic heart disease
Mitral valve prolapse
Infection
Degenerative
Left ventricle and annular dilation

Question 14

What causes annular enlargement of mitral valve in mitral regurgitation

Answer 14

Preload
Afterload
Left ventricular contractility

Question 15

Results of annular enlargement of mitral valve in mitral regurgitation

Answer 15

Increase in regurgitant volume

Question 16

Left ventricular compensation in acute mitral regurgitation

Answer 16

Decrease in end systolic pressure, end systolic volume and wall tension - ventricle contracts more

Question 17

Left ventricular compensation in chronic mitral regurgitation

Answer 17

Increased end diastolic volume, end systolic volume returns to normal, eccentric left ventricular hypertrophy develops

Question 18

Result of reduced left atrial compliance in mitral regurgitation

Answer 18

Pressure rise, thickening of atrial myocardium, increase in pulmonary vascular resistance, remodelling of pulmonary vasculature with pulmonary hypertension

Question 19

Result of increase left atrial compliance in mitral regurgitation

Answer 19

Volume enlargement, lesser changes in pulmonary vasculature, develop partial fibrillation

Question 20

Clinical manifestations of acute mitral regurgitation

Answer 20

Breathlessness
Pulmonary oedema
Cardiogenick shock

Question 21

Clinical manifestations of chronic mitral regurgitation

Answer 21

Fatigue
Exhaustion (low CO)
Right heart failure
Dyspnoea or palpitations due to partial fibrillation

Question 22

Clinical examination findings of mitral regurgitation

Answer 22

Pulse normal or reduced in heart failure
JVP prominence in right heart failure
Brisk and hyper dynamic apex beat
Right ventricular heave
Reduced S1, spilt S2 - early A2, loud P2
Murmur - holosystolic, blowing, loud at apex and radiation to axilla

Question 23

Mitral regurgitation echocardiography

Answer 23

Left ventricle contraction and dimension
Pulmonary artery pressure
Cause - leaflet dysfunction, chordae, papillary muscles, annular disease
Severity of MR

Question 24

Mitral regurgitation magnetic resonance imaging

Answer 24

Accurate cardiac volumes

Volumetric determination of regurgitation volume

Question 25

Medical treatment for acute mitral regurgitation

Answer 25

Preload and afterload reduction via sodium nitroprusside

Question 26

Medical treatment for chronic mitral regurgitation

Answer 26

Left ventricle function preservation

Question 27

Aortic stenosis

Answer 27

Narrowing of aortic valve opening

Question 28

Aetiology of aortic stenosis

Answer 28

Degenerative Rheumatic heart disease Bicuspid - 2 leaflets instead of 3 (congenital)

Question 29

Rheumatic aortic stenosis

Answer 29

Adhesion, fusion of the commissures | Retraction and stiffening of the free cusp margins

Question 30

Degenerative aortic stenosis

Answer 30

Atherosclerosis link | Slow inflammatory process resulting in thickening and calcification of the cusps from base to free margine

Question 31

Effects of aortic stenosis

Answer 31

``` Increase LV systolic pressure Severe concentric hypertrophy and left ventricular mass Increase end diastolic pressure Increase myocardial oxygen consumption Myocardial ischaemia Left venture failure ```

Question 32

Symptoms of aortic stenosis

Answer 32

``` Large asymptomatic phase Chest pain (angina) Syncope/dizziness (exertional pre-syncope) Breathlessness on exertion Heart failure ```

Question 33

Clinical examination findings of aortic stenosis

Answer 33

``` Pulse - small volume, rising JVP - prominent if RHF, low bp Vigorous and sustained apex beat Right ventricular heave Normal S1, less audible S2 Auscultation - late peaking, loud at base, harsh, radiation to the carotids ```

Question 34

ECG of aortic stenosis

Answer 34

Left ventricular hypertrophy voltage criteria | ST-T changes

Question 35

Chest x-ray of aortic stenosis

Answer 35

Calcification of aortic valve

Question 36

Aortic stenosis echocardiography

Answer 36

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

Question 37

Magnetic resonance of aortic stenosis

Answer 37

Identification of bicuspid valves

Question 38

Aortic regurgitation

Answer 38

Leaky aortic valve

Question 39

Aorta aetiology of aortic regurgitation

Answer 39

Dilated aorta - hypertension | Connective tissue disorders

Question 40

Leaflets aetiology of aortic regurgitation

Answer 40

Bicuspid aortic valve Rheumatic heart disease Endocarditis Myxomatous degeneration

Question 41

Effects of aortic regurgitation

Answer 41

LV accommodates both stroke volume and regurgitation volume Increase LV end-systolic volume and systolic pressure LV hypertrophy and dilation Increase myocardial oxygen consumption Myocardial ischameia LV failure

Question 42

Symptoms of acute aortic regurgitation

Answer 42

Emergency, poorly tolerated as wall tension cannot acutely adapt

Question 43

Symptoms of chronic aortic regurgitation

Answer 43

Long asymptomatic phase | Exertional breathlessness

Question 44

Clinical examination findings of aortic regurgitation

Answer 44

Pulse - large volume and collapsing High systolic bp, low diastolic bp (wide pulse pressure) Hyperdynamic displaced apex beat Norrmal S1 and S2, soft murmur and early diastolic

Question 45

ECG findings of aortic regurgitation

Answer 45

ST-T changes | Left axis deviation

Question 46

Chest X-ray of aortic regurgitation

Answer 46

Cardiomegaly (abnormal enlargement) in chronic aortic regurgitation

Question 47

Aortic regurgitation echocardiography

Answer 47

Demonstrates AV cusp anatomy (thickening, number, prolapsing, vegetations) LV function, dilation, hypertrophy Doppler haemodynamic assessment of regurgitant flow

Question 48

Medical treatment of aortic regurgitation

Answer 48

Vasodilator therapy delays the timing for surgical intervention

Question 49

Which valvular disease is the only one treated with medicine

Answer 49

Aortic regurgitation

Question 50

Mitral regurgitation ECG

Answer 50

LA enlargement | Right ventricular hypertrophy

Question 51

Mitral regurgitation chest x-ray

Answer 51

Cardiomegaly LA enlargement Calcification of mitral annulus

Question 52

Mitral stenosis ECG

Answer 52

Right ventricular hypertrophy | P wave>0.12sec