1. Phase 2 Jonathan Evans The Peer Teaching Society is not liable for false or misleading information…

2. Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation The Peer Teaching Society is not liable for false or misleading information… Aims Causes Symptoms Murmur and signs Treatment Questions

3. The Peer Teaching Society is not liable for false or misleading information… Valves Mitral Valve

4. The Peer Teaching Society is not liable for false or misleading information… 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 10-20 years - valve disease

5. Congenital – Bicuspid valve presents later in life Acquired 1.Degenerative: Calcific valve disease 2.Rheumatic fever The Peer Teaching Society is not liable for false or misleading information… Aortic Stenosis - Causes

6. The Peer Teaching Society is not liable for false or misleading information… Pathophysiology Reduced cardiac output Left ventricular hypertrophy

7. SAD The Peer Teaching Society is not liable for false or misleading information… Symptoms – severe AS Syncope – exercise induced Angina – from LV hypertrophy Dyspnoea – due to Heart failure

8. Ejection Systolic murmur radiating to the carotids Slow rising pulse Systolic thrill over aortic area Other: Systolic ejection click Soft 2 nd heart sound The Peer Teaching Society is not liable for false or misleading information… Signs

9. 1.Rheumatic fever 2.Infective endocarditis – Likes to sit on previously damaged valves The Peer Teaching Society is not liable for false or misleading information… Aortic Regurgitation - Causes

10. The Peer Teaching Society is not liable for false or misleading information… Pathophysiology Left ventricular failure

11. Asymptomatic until Left Ventricular Failure occurs Dyspneoa Fatigue “pounding of the heart” Angina, but less common than in AS The Peer Teaching Society is not liable for false or misleading information… Symptoms

12. Two murmurs to remember: 1.Early Diastolic : left sternal edge, high pitch 2.Ejection systolic – from high flow of blood The Peer Teaching Society is not liable for false or misleading information… Murmur

13. 1.Collapsing or Water-hammer pulse 2.Deviated apex beat 3.Lots of signs with weird names that we don’t need to remember. The Peer Teaching Society is not liable for false or misleading information… Signs – Aortic Regurgitation

14. 1.Rheumatic fever The Peer Teaching Society is not liable for false or misleading information… Mitral Stenosis - Causes

15. The Peer Teaching Society is not liable for false or misleading information… Pathophysiology Pulmonary hypertension Atrial Fibrillation

16. Pulmonary Hypertension Dyspnoea Cough – frothy blood tinged sputum Right heart Failure Raised JVP Big liver Ankle swelling The Peer Teaching Society is not liable for false or misleading information… Symptoms

17. 1.Rumbling Mid-diastolic murmur – heard best with the bell at the apex with the patient lying on the left side 2.Opening snap – at the start of the murmur 3.Pink cheeks – malar flush The Peer Teaching Society is not liable for false or misleading information… Signs

18. 1.Rheumatic fever (50%) 2.Prolapsing mitral valve 3.Other: – Ischaemic heart disease – Cardiomyopathies – Collagen abnormalities – Drugs The Peer Teaching Society is not liable for false or misleading information… Mitral Regurgitation- Causes

19. Usually a benign and asymptomatic condition Common – 2-6% of population May have atypical chest pain or palpitations “Mid- systolic click” The Peer Teaching Society is not liable for false or misleading information… Prolapsing “floppy” mitral valve

20. The Peer Teaching Society is not liable for false or misleading information… Pathophysiology Left ventricular failure

21. 1.Pansystolic murmur – Heard best at the apex 2.Deviated apex beat 3.Left ventricular failure – Dyspnoea – Orthopnoea The Peer Teaching Society is not liable for false or misleading information… Signs and symptoms

22. The Peer Teaching Society is not liable for false or misleading information… Investigations Echocardiogram to see what’s going on:

23. Medical – Treat Heart Failure if they have it Surgical – Valvoplasty – dilate the valve with a balloon for stenotic valves – Replace the valve The Peer Teaching Society is not liable for false or misleading information… Treatment

24. Need anticoagulation (warfarin) Last longer - Younger people The Peer Teaching Society is not liable for false or misleading information… 1. Mechanical valve

25. Usually porcine Doesn’t last as long – elderly people The Peer Teaching Society is not liable for false or misleading information… 2. Bio-prosthetic valve

26. Rumbling Mid-diastolic murmur? The Peer Teaching Society is not liable for false or misleading information… Questions

27. Mitral Stenosis Where is it heard best? The Peer Teaching Society is not liable for false or misleading information… Answer

28. Apex – with the patient on their left and using the bell The Peer Teaching Society is not liable for false or misleading information… Answer

29. Aortic Stenosis – what is the murmur? The Peer Teaching Society is not liable for false or misleading information… Questions

30. Ejection systolic heard best right sternal edge 2 nd intercostal space Where does it radiate? The Peer Teaching Society is not liable for false or misleading information… Questions

31. Carotids Name three symptoms of Aortic stenosis? The Peer Teaching Society is not liable for false or misleading information… Questions

32. Syncope Angina Dyspnoea The Peer Teaching Society is not liable for false or misleading information… Questions

33. Early diastolic murmur Where is it heard best? The Peer Teaching Society is not liable for false or misleading information… Questions

34. Left sternal edge What other murmur might you hear? The Peer Teaching Society is not liable for false or misleading information… Questions

35. Ejection systolic – due to high flow The Peer Teaching Society is not liable for false or misleading information… Questions

36. Ejection systolic – due to high flow The Peer Teaching Society is not liable for false or misleading information… Questions

37. Ejection systolic – due to high flow The Peer Teaching Society is not liable for false or misleading information… Questions

38. Ejection systolic – due to high flow The Peer Teaching Society is not liable for false or misleading information… Questions

39. 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. The Peer Teaching Society is not liable for false or misleading information… Previous exam question

40. Aortic stenosis The Peer Teaching Society is not liable for false or misleading information… Answer

41. 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. The Peer Teaching Society is not liable for false or misleading information… Question

42. Mitral valve prolapse The Peer Teaching Society is not liable for false or misleading information… Answer

43. 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. The Peer Teaching Society is not liable for false or misleading information… Question

44. Mitral Stenosis The Peer Teaching Society is not liable for false or misleading information… Answer

45. 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 The Peer Teaching Society is not liable for false or misleading information… Question

46. 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. The Peer Teaching Society is not liable for false or misleading information… Question

47. 1.Acute rheumatic fever 2.Amyloid valve tissue 3.Congenital valve anatomy abnormality 4.Infective endocarditis 5.Metallic valve prosthesis 6.Mitral valve prolapse 7.Non-bacterial thrombotic endocarditis 8.Normal valve 9.Senile calcific valve stenosis 10.Xenograft valve The Peer Teaching Society is not liable for false or misleading information… Which is most likely?

48. 4. Infective endocarditis Fever + new murmur = Endocarditis Two main causes: 1.Streptococcus Viridans (dental problems) 2.Staphylococcus aureus (IVDU, Diabetes, Surgury) The Peer Teaching Society is not liable for false or misleading information… Answer

49. 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 2 nd intercostal space. The Peer Teaching Society is not liable for false or misleading information… Question

50. 1.Acute rheumatic fever 2.Amyloid valve tissue 3.Congenital valve anatomy abnormality 4.Infective endocarditis 5.Metallic valve prosthesis 6.Mitral valve prolapse 7.Non-bacterial thrombotic endocarditis 8.Normal valve 9.Senile calcific valve stenosis 10.Xenograft valve The Peer Teaching Society is not liable for false or misleading information… Which is most likely?

51. 9. Senile calcific valve stenosis The commonest cause of Aortic stenosis is: Calcific valve disease and mainly occurs in the elderly. The Peer Teaching Society is not liable for false or misleading information… Answer

52. 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. The Peer Teaching Society is not liable for false or misleading information… Question 3

53. 1.Acute rheumatic fever 2.Amyloid valve tissue 3.Congenital valve anatomy abnormality 4.Infective endocarditis 5.Metallic valve prosthesis 6.Mitral valve prolapse 7.Non-bacterial thrombotic endocarditis 8.Normal valve 9.Senile calcific valve stenosis 10.Xenograft valve The Peer Teaching Society is not liable for false or misleading information… Which is most likely?

54. Non Bacterial Thrombotic Endocarditis The Peer Teaching Society is not liable for false or misleading information… Answer