1. Valvular Heart Disease
Phase 2 Jonathan Evans
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2. Aims
Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation
Causes
Symptoms
Murmur and signs
Treatment
Questions
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3. Valves
Mitral Valve
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4. If in doubt - Rheumatic fever
Children aged 5-15
Common in Asia and south America
Pharyngeal infection with:
Streptococcus Pyogenes followed by the clinical syndrome of Rheumatic fever
It is an autoimmune reaction – not an infection
After years - valve disease
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5. Aortic Stenosis - Causes
Congenital – Bicuspid valve presents later in life
Acquired
Degenerative: Calcific valve disease
Rheumatic fever
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6. Pathophysiology Reduced cardiac output Left ventricular hypertrophy
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7. SAD Symptoms – severe AS Syncope – exercise induced
Angina – from LV hypertrophy
Dyspnoea – due to Heart failure
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8. Signs Ejection Systolic murmur radiating to the carotids
Slow rising pulse
Systolic thrill over aortic area
Other:
Systolic ejection click
Soft 2nd heart sound
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9. Aortic Regurgitation - Causes
Rheumatic fever
Infective endocarditis
Likes to sit on previously damaged valves
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10. Pathophysiology Left ventricular failure
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11. Symptoms Asymptomatic until Left Ventricular Failure occurs Dyspneoa
Fatigue
“pounding of the heart”
Angina, but less common than in AS
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12. Murmur Early Diastolic: left sternal edge, high pitch
Two murmurs to remember:
Early Diastolic: left sternal edge, high pitch
Ejection systolic – from high flow of blood
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13. Signs – Aortic Regurgitation
Collapsing or Water-hammer pulse
Deviated apex beat
Lots of signs with weird names that we don’t need to remember.
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14. Rheumatic fever Mitral Stenosis - Causes
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15. Pathophysiology Atrial Fibrillation Pulmonary hypertension
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16. Symptoms Pulmonary Hypertension Dyspnoea
Cough – frothy blood tinged sputum
Right heart Failure
Raised JVP
Big liver
Ankle swelling
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17. Signs
Rumbling Mid-diastolic murmur – heard best with the bell at the apex with the patient lying on the left side
Opening snap – at the start of the murmur
Pink cheeks – malar flush
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18. Mitral Regurgitation- Causes
Rheumatic fever (50%)
Prolapsing mitral valve
Other:
Ischaemic heart disease
Cardiomyopathies
Collagen abnormalities
Drugs
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19. Prolapsing “floppy” mitral valve
Usually a benign and asymptomatic condition
Common – 2-6% of population
May have atypical chest pain or palpitations
“Mid- systolic click”
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20. Pathophysiology Left ventricular failure
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21. Signs and symptoms Pansystolic murmur – Heard best at the apex
Deviated apex beat
Left ventricular failure
Dyspnoea
Orthopnoea
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22. Echocardiogram to see what’s going on:
Investigations
Echocardiogram to see what’s going on:
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23. Treatment Medical Treat Heart Failure if they have it Surgical
Valvoplasty – dilate the valve with a balloon for stenotic valves
Replace the valve
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24. 1. Mechanical valve Need anticoagulation (warfarin)
Last longer - Younger people
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25. 2. Bio-prosthetic valve Usually porcine
Doesn’t last as long – elderly people
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26. Questions Rumbling Mid-diastolic murmur?
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27. Answer Mitral Stenosis Where is it heard best?
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28. Answer Apex – with the patient on their left and using the bell
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29. Questions Aortic Stenosis – what is the murmur?
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30. Questions
Ejection systolic heard best right sternal edge 2nd intercostal space Where does it radiate?
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31. Questions Carotids Name three symptoms of Aortic stenosis?
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32. Questions Syncope Angina Dyspnoea
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33. Questions Early diastolic murmur Where is it heard best?
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34. Questions Left sternal edge What other murmur might you hear?
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35. Questions Ejection systolic – due to high flow
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36. Questions Ejection systolic – due to high flow
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37. Questions Ejection systolic – due to high flow
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38. Questions Ejection systolic – due to high flow
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39. Previous exam question
A 78 year old man presented with episodes of loss of consciousness on exertion. On examination, the carotid pulse is rising slowly. There is a loud ejection systolic murmur at the aortic area, radiating to both carotid arteries.
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40. Answer Aortic stenosis
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41. Question
A 32 year old lady presented with recurrent palpitation and exertional breathlessness. On examination, her height is 183 cm and her arms-span is 185 cm. The first heart sound is soft. There is a mid-systolic click, followed by a blowing late systolic murmur in the apex radiating to the axilla.
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42. Answer Mitral valve prolapse
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43. Question
A 45 year old lady, who moved to the UK from India 5 years ago, presented with increasing exertional dyspnoea and orthopnoea. On examination, the apex beat is tapping, with a loud first heart sound, and an apical mid-diastolic rumble.
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44. Answer Mitral Stenosis
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45. Question
47 year old chap presents with intermittent breathlessness. ECG is normal but 24 hr tape shows runs of AF. Paroxysmal AF is diagnosed. On auscultation he has a mid-diastolic murmur and is diagnosed with mitral stenosis. 1. Why is he presyncopal when he’s going into AF? 2. How is the mitral stenosis causing AF? 3. 2x imaging investigations for this patient + rationales for each
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46. Question
A 21 year old female intravenous drug abuser collapses following a 2 day history of rapidly increasing malaise, fever and a patchy rash. Although previously well, she now has a systolic cardiac murmur. Her urine shows both protein and blood on dipstick test.
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47. Which is most likely? Acute rheumatic fever Amyloid valve tissue
Congenital valve anatomy abnormality
Infective endocarditis
Metallic valve prosthesis
Mitral valve prolapse
Non-bacterial thrombotic endocarditis
Normal valve
Senile calcific valve stenosis
Xenograft valve
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48. Answer 4. Infective endocarditis Fever + new murmur = Endocarditis
Two main causes:
Streptococcus Viridans (dental problems)
Staphylococcus aureus (IVDU, Diabetes, Surgury)
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49. Question
A 71 year old male presents with anginal symptoms, shortness of breath and syncopal attacks when exercising. He has a harsh systolic flow murmur at the right sternal edge 2nd intercostal space.
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50. Which is most likely? Acute rheumatic fever Amyloid valve tissue
Congenital valve anatomy abnormality
Infective endocarditis
Metallic valve prosthesis
Mitral valve prolapse
Non-bacterial thrombotic endocarditis
Normal valve
Senile calcific valve stenosis
Xenograft valve
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51. Answer 9. Senile calcific valve stenosis
The commonest cause of Aortic stenosis is:
Calcific valve disease and mainly occurs in the elderly.
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52. Question 3
An 81 year old male patient with carcinoma of the bronchus collapses and dies. The autopsy shows irregular vegetations on the mitral valve. No septic event was identified prior to the patient’s death, and the clinicians did not detect an ante-mortem murmur.
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53. Which is most likely? Acute rheumatic fever Amyloid valve tissue
Congenital valve anatomy abnormality
Infective endocarditis
Metallic valve prosthesis
Mitral valve prolapse
Non-bacterial thrombotic endocarditis
Normal valve
Senile calcific valve stenosis
Xenograft valve
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54. Answer Non Bacterial Thrombotic Endocarditis
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