What is a TAVI?
Transcathetic aortic valve implant
How does auscultation of AS change with increasing severity of the disease?
The more severe, the more widely it’s heard on the precordium
When is the valve replaced in AS?
Severe AS on echo + Symptoms
What types of hypersensitivity mediates rheumatic fever?
Type II
What causes MR?
Myxomatous degeneration (mitral valve prolapse)
Ruptured chordae tendinae
Infective endocarditis
MI - ruptured papillary muscle
When do you operate in AR?
Once the LV starts to increase in size (on echo)
What are some signs of MS?
Mitral facies
Tapping apex beat
How is rheumatic fever managed long term?
Long term antibiotic prophylaxis
Describe the murmur in MR?
Pansystolic
Rumbling
Mostly heard at the apex (occasionally at the base too)
What are the pros and cons of bioprosthetic valve?
Pros: Don’t need anticoagulants
Cons: Shorter life (10-15years)
What is a TOE best for?
Mitral valve
Thombus in the LV
Endocarditis on valves or pacemaker leads
What has happened to the LV at onset of symptoms in regurg?
Irreversibly damaged
How does the LV compensate for regurgitation? What happens at decompensation?
Increases EDV while ESV remains the same = an increase in SV and EF
Pump failure: EDV further increases
ESV increases
EF decreases
What causes aortic regurg?
Aortic leaflet damage - endocarditis, rheumatic fever
Aortic root dilated - Marfan’s syndrome, aortic dissection, syphilus
How does the LV change in AS?
Concentric hypertrophy
What are the pros and cons of mechanical valves?
Pros: they last forever
Cons: require anticoagulation with warfarin (INR 2-3)
How do you decide which type of valve to use?
Age
>70 - Bioprosthetic
What are some peripheral signs of AS?
Slow upstroke of carotid pulse
Heaving apex beat
Thrill over upper R sternal edge
What causes TR?
RVF - due to pulmonary hypertension
Endocarditis
Pacemaker leads
What are some signs of AR?
Collapsing pulse - fast up and down stroke
Wide pulse pressure
Early diastolic murmur
Various other signs
What are the symptoms of AS?
SOB
Chest pain
Syncope
What are the two major types of degenerative valvular disease?
Aortic calcification - Aortic stenosis
Mitral prolapse - Mitral regurg
Characterise the sound of AS
Ejection systolic - crescendo-decrescendo
Best heard at upper R sternal edge with diaphragm
Can also be heard elsewhere on precordium
What are some complications of MS?
Atrial dilatation and AF
Thrombo-embolism
Pulmonary hypertension
RHF
How does infective endocarditis present most commonly?
Fever and murmur
What are the clinical features of rheumatic fever?
Fever
Arthritis - migratory polyarthritis, large joints
Rash - erythema marginatum
Subcutaneous nodules - over bones, tendons
Murmur
Sydenham’s chorea
What are the causes of AS?
Age related calcification
Congenital - AS, bicuspid
Rheumatic fever
How is rheumatic fever diagnosed?
By clinical feature only, using the Jone’s criteria
What is the major cause of mitral stenosis?
Rheumatic fever
Describe the murmur in MS?
Pan-diasystolic
OS opening snap mitral opening
What is the pathophysiology of rheumatic fever?
Type II hypersensitivity response occurs 2-3 weeks post strept pyogenes infection - typically pharyngitis or scarlett fever
Which valvular pathologies are asymptomatic until the onset of HF?
AR
MR
What are some common agents of IE?
Strep viridans
Strep bovis
Staph aureas
Staph epidermidis
How do you treat IE? When do you do surgery?
Long term abx via PICC line
If HF or uncontrolled infection
What blood/urine results might you get with IE?
Anaemia
Leukocytosis
Elevated ESR or CRP
Microhaematuria
