valvular heart disease

Question 1

left untreated, what can valvular heart disease lead to?

Answer 1

Left uncorrected, valvular heart disease often leads to irreversible ventricular dysfunction and/or pulmonary hypertension.

Question 2

what are the classic symptoms of aortic stenosis?

Answer 2

angina

heart failure

syncope

(the classic triad)

also

decrease in exercise tolerance

dyspnoea on exertion

Question 3

what are the causes of aortic stenosis?

Answer 3

• age related (senile calcification, most common)
• congenital (bicuspid valve, williams syndrome)
• CKD
• previous rheumatic fever

Question 4

where is aortic stenosis best heard on auscultation?

Answer 4

2nd intercostal space right side

best described as ejection systolic, radiating to carotid/neck

Question 5

how is AS assessed initially?

Answer 5

by echocardiography

this allows quantification of the severity of stenosis and assessment of the rest of the heart

doppler echo can estimate the gradient across valves

Question 6

what are the indications for surgery in AS?

Answer 6

Symptoms caused by AS (regardless of severity). If symptomatic, prognosis is poor without surgery.

Asymptomatic severe AS with left ventricular systolic dysfunction.

Asymptomatic severe AS with abnormal exercise test (symptoms, drop in BP ST changes).

Asymptomatic severe AS at the time of other cardiac surgery (e.g. CABG)

Question 7

what should transcather aortic valve implantation be considered in AS?

Answer 7

In older patients, especially those with significant co-morbidities, transcatheter aortic valve implantation (TAVI) should be considered. This is implanted via the femoral artery.

usually the recommended treatment.

Question 8

how does aortic regurgitation lead to heart failure?

Answer 8

Patients with chronic aortic regurgitation (AR) may remain asymptomatic for many years despite significant regurgitation.

The increased volume load on the left ventricle leads to progressive LV dilatation and ultimately heart failure.

Question 9

what are the acute and chronic causes of aortic regurgitation?

Answer 9

Chronic

• Congenital
• CT disorders (Marfan’s syndrome, Ehlers–Danlos), - rheumatic fever
• RA, SLE

Acute

• infective endocarditis
• ascending aortic dissection
• chest trauma

Question 10

what are the symptoms of aortic regurg?

Answer 10

• exertion dyspnoea
• reduced exercise tolerance
• orthopnoea (SOB when lying flat)
• palpitations
• angina
• syncope

Question 11

where is an aortic regurgitation murmur best heard?

Answer 11

The murmur is best heard at the left sternal edge and is an early diastolic blowing murmur that is associated with a collapsing pulse and other synonyms such as De Musset’s sign (head bobbing).

murmur is also heard best in expiration with patient sat forward

Question 12

how can an ACEi be used to treat aortic regurgitation?

Answer 12

Afterload reduction (with ACEI) can slow the rate of left ventricular dilatation and is now standard therapy in patients with severe AR and LV dilatation.

Question 13

how are patients with aortic regurgitation assessed?

Answer 13

echocardiography is diagnostic. This allows quantification of the severity of the regurgitation and assessment of the rest of the heart.

CXR will show cardiomegaly.

Question 14

what are the indications for surgery in AR?

Answer 14

Symptomatic severe AR

Asymptomatic severe AR with evidence of early LV systolic dysfunction (EF < 50% or LV end-systolic diameter > 5 cm or LV end-diastolic diameter > 7·0 cm)

Asymptomatic AR of any severity with aortic root dilatation > 5·5 cm (or > 4·5 cm in Marfan syndrome or bicuspid aortic valve).

Question 15

what signs are seen in aortic regurgitation?

Answer 15

collapsing pule

De muse’s sign = head nods with each heart beat

Quincke’s sign = capillary pulsation in nail beds

Duroziez’s sign = in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal, it gives a diastolic murmur as blood flows backwards

Traube’s sign = ‘pistol shot’ sound over femoral arteries

Question 16

how is AR managed?

Answer 16

aim is to reduce systolic hypertension

ACE-i are helpful

echo every 6-12 months

Aim to replace valve before significant LV dysfunction

Question 17

what are the causes of mitral/tricuspid valve regurgitation?

Answer 17

Functional (RV dilatation; eg due to pulmonary hypertension induced by LV failure or PE)

rheumatic fever

infective endocarditis

congenital (eg Ebstein’s anomaly (downward displacement of the tricuspid valve)

Drugs

Question 18

what are the symptoms of mitral valve regurgitation?

Answer 18

Fatigue

hepatic pain on exertion (due to hepatic congestion)

ascites

oedema

symptoms of the causative condition.

Question 19

what are the signs of of MV regurgitation?

Answer 19

pansystolic murmur, heard best at lower sternal edge in inspiration

pulsatile hepatomegaly

jaundice

ascites.

Question 20

how is MV regurgitation assesed?

Answer 20

MR is best assessed by echocardiography. It is essential to assess LV function and size together with the severity of the jet of blood coming through the valve.

Question 21

how is MV regurgitation treated?

Answer 21

The surgical options in MR include mitral valve replacement or mitral valve repair. Surgical intervention is generally indicated in severe MR for:

• Symptomatic patients (with symptoms due to the MR).
• Asymptomatic patients with mild-moderate LV dysfunction (EF 30 - 60% and LVESD 4·5 - 5·5 cm).

Medical therapy of MR is restricted largely to the use of diuretics. In patients with functional or ischaemic MR (resulting from dilated or ischaemic cardiomyopathy), ACEI are beneficial.

If LV systolic dysfunction is present, treatment with drugs such as ACEI and β-blockers such as Bisoprolol or Carvedilol and CRT have all been shown to reduce the severity of MR.

Question 22

what cardiac conditions can predispose people to infective endocarditis?

Answer 22

mitral valve prolapse

presence of prosthetic material (e.g. valves and patches, but not coronary stents)

rheumatic heart disease,

degenerative and bicuspid aortic valve disease,

many forms of congenital heart disease

IE may also involve previously normal heart valves and may be associated with infection due to an intravascular device.

Question 23

what does a fever and a new murmur suggest?

Answer 23

Fever + new murmur = endocarditis until proven otherwise.

Any fever lasting >1wk in those known to be at risk must prompt blood cultures.

Question 24

what are the commonest causative organisms in IE?

Answer 24

viridans group of streptococci and Staphylococcus aureus

In IV drug users Staphylococcus aureus is commonest,

Enterococcal endocarditis may be a pointer to disease of the GU or lower GI tract.

Around 2 - 10% of cases are caused by fungi (mainly Candida or Aspergillus), particularly in patients with immunosuppression, IV drug use, cardiac surgery, prolonged exposure to antimicrobial drugs and IV feeding.

Question 25

how should IE be investigated?

Answer 25

Patients with suspected IE should be admitted to hospital. Routine initial investigations should include: ``` FBC ESR and CRP U&Es LFTs Urine dipstick analysis and MSU for microscopy/culture Chest X-ray ECG ``` However, the key diagnostic investigations are: BLOOD CULTURES & ECHOCARDIOGRAM. If echo inconclusive, can do TOE. take at least 3 (prefer 6) blood cultures from different sites over several hours. Try avoid using antibiotics till cultures taken if possible, as if patient on antibiotics will make it harder to identify causative organism. If samples negative, can do culture in special media = consult with microbiologist for details.

Question 26

what are the major diagnostic criteria for IE?

Answer 26

diagnostic criteria can be divided into major and minor. A diagnosis can be made on the basis of two major criteria or one major and three minor criteria or five minor criteria. Major criteria 1) Positive blood cultures - typical organism from 2 blood cultures - persistent positive blood cultures taken > 12 hours apart - > 3 positive blood cultures taken over more than 1 hour 2) Endocardial involvement 3) positive echo findings (vegetation, abscess) 4) new valvular regurgitation 5) dehiscence of prosthesis

Question 27

what are the minor diagnostic criteria for IE?

Answer 27

A diagnosis can be made on the basis of two major criteria or one major and three minor criteria or five minor criteria. Minor criteria 1) Predisposing valvular or cardiac abnormality 2) IV drug abuser 3) Pyrexia > 38°C 4) Embolic phenomenon 5) Vasculitic phenomenon 6) Blood cultures suggestive (organism grown but not achieving major criteria) 7) Suggestive echo findings (but not meeting major criteria)

Question 28

how IE managed?

Answer 28

- central venous line for prolonged course of IV antibiotics - if caused by streptococci = Benzylpenicillin, or vancomycin if allergic, and gentamicin low dose - enterococci = amoxicillin or vancomycin if allergic, and low dose gentamicin - staphylococci - flucloxacillin or vancomycin if allergic, and gentamicin

Question 29

how should response to therapy in IE be monitored?

Answer 29

regular bedside reviews of clinical status as well as - Echocardiogram (once weekly) to assess vegetation size and look for complications (e.g. valve destruction, intracardiac abscesses) - ECG (at least twice weekly) to detect conduction disturbances, which may indicate development of an aortic root abscess in aortic valve infection - Blood tests (twice weekly) - ESR, CRP, full blood count and U&Es

Question 30

when is surgery indicated in IE patients?

Answer 30

- Moderate to severe cardiac failure due to valve compromise - Valve dehiscence - Uncontrolled infection despite appropriate antimicrobial therapy - Relapse after optimal medical therapy - Threatened or actual systemic embolism - Coxiella burnetii and fungal infections - Paravalvar infection (e.g. aortic root abscess) - Valve obstruction