Phase 2

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Valvular Heart Disease

• Phase 2
• Jonathan Evans

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Aims

• Aortic Stenosis
• Aortic Regurgitation
• Mitral Stenosis
• Mitral Regurgitation

• Causes
• Symptoms
• Murmur and signs
• Treatment
• Questions

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Valves
Mitral Valve
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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

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Aortic Stenosis - Causes

• Congenital Bicuspid valve presents later in
  life
• Acquired
• Degenerative Calcific valve disease
• Rheumatic fever

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Pathophysiology
Reduced cardiac output
Left ventricular hypertrophy
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Symptoms severe AS

• SAD

Syncope exercise induced Angina from LV
hypertrophy Dyspnoea due to Heart failure
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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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Aortic Regurgitation - Causes

• Rheumatic fever
• Infective endocarditis
• Likes to sit on previously damaged valves

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Pathophysiology
Left ventricular failure
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Symptoms

• Asymptomatic until Left Ventricular Failure
  occurs
• Dyspneoa
• Fatigue
• pounding of the heart
• Angina, but less common than in AS

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Murmur

• Two murmurs to remember
• Early Diastolic left sternal edge, high pitch
• Ejection systolic from high flow of blood

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Signs Aortic Regurgitation

1. Collapsing or Water-hammer pulse
2. Deviated apex beat
3. Lots of signs with weird names that we dont need
   to remember.

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Mitral Stenosis - Causes

1. Rheumatic fever

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Pathophysiology
Atrial Fibrillation
Pulmonary hypertension
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Symptoms

• Pulmonary Hypertension
• Dyspnoea
• Cough frothy blood tinged sputum
• Right heart Failure
• Raised JVP
• Big liver
• Ankle swelling

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Signs

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

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Mitral Regurgitation- Causes

• Rheumatic fever (50)
• Prolapsing mitral valve
• Other
• Ischaemic heart disease
• Cardiomyopathies
• Collagen abnormalities
• Drugs

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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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Pathophysiology
Left ventricular failure
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Signs and symptoms

• Pansystolic murmur Heard best at the apex
• Deviated apex beat
• Left ventricular failure
• Dyspnoea
• Orthopnoea

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Echocardiogram to see whats going on
Investigations
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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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1. Mechanical valve

• Need anticoagulation (warfarin)
• Last longer - Younger people

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2. Bio-prosthetic valve

• Usually porcine
• Doesnt last as long elderly people

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Questions

• Rumbling Mid-diastolic murmur?

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Answer

• Mitral Stenosis
• Where is it heard best?

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Answer

• Apex with the patient on their left and using
  the bell

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Questions

• Aortic Stenosis what is the murmur?

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Questions

• Ejection systolic heard best right sternal edge
  2nd intercostal space
• Where does it radiate?

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Questions

• Carotids
• Name three symptoms of Aortic stenosis?

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Questions

• Syncope
• Angina
• Dyspnoea

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Questions

• Early diastolic murmur
• Where is it heard best?

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Questions

• Left sternal edge
• What other murmur might you hear?

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Questions

• Ejection systolic due to high flow

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Questions

• Ejection systolic due to high flow

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Questions

• Ejection systolic due to high flow

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Questions

• Ejection systolic due to high flow

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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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Answer

• Aortic stenosis

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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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Answer

• Mitral valve prolapse

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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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Answer

• Mitral Stenosis

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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 hes 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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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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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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Answer

• 4. Infective endocarditis
• Fever new murmur Endocarditis
• Two main causes
• Streptococcus Viridans (dental problems)
• Staphylococcus aureus (IVDU, Diabetes, Surgury)

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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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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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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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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
  patients death, and the clinicians did not
  detect an ante-mortem murmur.

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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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Answer

• Non Bacterial Thrombotic Endocarditis

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