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VALVULAR HEART DISEASE (MITRAL STENOSIS (EPIDEMIOLOGY (2 per 100 000, peak…

- - - - Rheumatic heart disease (95%) - causes post-inflammatory changes to the mitral valve - can take many years to manifest
    - - ageing - degenerative calcification of the leaflets
      - congenital valve deformity - particularly in young adults with mitral stenosis
      - Carcinoid syndrome
      - amyloidosis - amyloid deposition on the mitral valves
      - rheumatological disorders - RA and SLE can both cause a valvulitis
  - - - Symptoms mimic those of LHF
        
        dyspnoea (pulmonary congestion and interstitial oedema)
        
        fatigue (Low CO state)
      - strong association with AF (47%)
      - Haemoptysis
      - Cor Pulmonale:
        
        this is RHF resulting from pulmonary HTN
        
        often presenting with abdo pain (hepatomegaly) and peripheral oedema
    - - mitral facies (flushed cheeks)
      - irregularly irregular pulse (AF)
      - Low-vol pulse (again as a result of decreased CO)
      - Tapping apex beat (strong and palpable first heart sound due to rigid mitral valve)
      - on auscultation:
        
        loud first heart sound
        
        due to inc in difference in press between LA and LV. often accompanied by an opening snap which is thought to occur due to tension of the chordae tendonae and the stenotic valve leaflets
        
        opening snap
        
        rumbling mid-diastolic murmur (Accentuated when the pt leans to their left - pathognomonic of mitral stenosis
        
        caused by turbulence across the valve as the LA contracts during diastole. severity of stenosis is directly related to the duration of the murmur. - longer time required for LA to empty
  - - - ECG
        
        AF common
        
        P-mitrale (bifid P waves) due to left atrial enlargement
        
        may present with right axis deviation if chronic disease
      - CXR
        
        left atrial enlargement: double shadow in right cardiac silhouette
      - ECHO transthoracic
        
        done to all pts regardless of symptoms
    - - trans-oesophageal echo - provides more complete assessment of the valve
  - - - warfarin should be given if in AF or previous embolic events
      - AF should be treated (covered elsewhere)
    - - onset of symptoms necessitates surgery. If not viable then medical therapy may be considered
      - diuretics: reduce dyspnoea and RHF
      - beta blockers: reduce heart rate and optimise CO. improve symptoms and exercise tolerance
    - - only method of altering natural hx of the disease and improving survival
      - indicated in:
        
        symptomatic severe mitral stenosis
        
        asymptomatic very severe mitral stenosis
        
        pulmonary HTN
      - several options include
        
        percutaneous mitral balloon commissurotomy (PMBC) is first line
        
        surgical repair, commisurotomy or valve replacement if PBMC fails or is unstable
- - - - acute rheumatic fever
      - infective endocarditis
      - ruptured chordae tendonae
      - trauma
      - papillary muscle infarct
    - - primary mitral regurg (valve problems)
        
        rheumatic heart disease - developing countriws
        
        mitral valve calcification
        
        mitral valve prolapse (Barlow's syndrome) -most common caused in developed countries
        
        congenital anomalies
        
        connective tissue disease (eg Ehlers-Danlos syndrome, Marfan's syndrome)
      - secondary mitral regurg
        
        coronary heart disease: ischaemc mitral regurgitation
        
        LV dilatation: cardiomyopathy
        
        LV remodelling or dilatation distorts the valvular apparatus
  - - - ACUTE MR
        
        Presents as an emergency
        
        hypotension and cardiogenic shock
        
        rapidly progressive pulmonary oedmea
        
        sudden onset severe dyspnoea
      - CHRONIC MR
        
        symptoms occur when left HF develops in severe MR
        
        dyspnoea on exertion
        
        fatigue
        
        AF
        
        asymptomatic if mild or moderate
        
        at risk of developing infective endocarditis
    - - AF
      - displaced apex beat
      - on auscultation
        
        third heart sound may be heard (due to inc vol in the LV)
        
        blowing pansystolic murmur radiating to axilla (best heard at the apex)
        
        the murmur starts as soon as the ventricles contracts.
        
        BF through the valve may continue even after the second heart sound as the pressure difference between the LA and LV continues
        
        there is radiation to the axilla as turbulent flow proceeds in that direction. this is also why dynamic movements help accentuate the murmur
  - - - ECG
        
        P-mitrale (bifid P waves) due to left atrial enlargement
        
        changes uncommon in acute MR
        
        AF common
      - CXR
        
        signs of congestive HF
        
        acute mitral regurg: heart size is usually normal but shows pulm oedema (alveolar oedema)
        
        cardiomegaly: enlarged LA and LV
      - ECHO AND DOPPLER
        
        regurgitant blood flow is diagnostic
        
        can determine left and right ventricular function and pulmonary artery pressures
        
        Trans-thoracic echo with doppler should be performed in all pts
    - - CARDIAC CATHETERISTATION
        
        check for coronary artery disease if severe chronic secondary MR
        
        if echo is inconclusive
  - - - priority is medical stabilisation
        
        inotropes and intra-aortic balloon pumps if life-threatening
        
        nitroprusside to reduce MR
      - med and surg emergency. requires prompt surgical intervention
      - surgery: mitral valve repair
        
        high mortality rates (up to 50%)
    - - anticoagulation
        
        warfarin should be given if the pt has AF or a previous embolic event
        
        target INR 2.5
      - Surgical intervention
        
        indications
        
        symptomatic severe MR and LVEF <30%
        
        asymptomatic severe MR with pulm HTN or new onset AF or LV dysfunction
        
        mitral valve surgery options include valve repair or replacement
        
        pts need careful follow-up in clinic
- - - - myxomatous degeneration (accumulation of proteoglycans by an unknown mechanism)
    - - MI
      - associated with cardiomyopathies and Turner's syndrome
      - connective tissue disease (Eg marfan's syndrome, ehler-danlos syndrome, osteogenesis imperfecta)
  - - - asymptomatic
      - atypical chest pain
      - palpitations
      - rarely autonomic symptoms
    - - On auscultation, a mid-systolic 'click' and/or late systolic murmur may be heard
        
        click caused by sudden tension on the valve leaflet and attached chordae tendinae as it is yanked back into the atrium
- - - - calcific aortic stenosis (Age-related)
      - congenital bicuspid aortic vlave
      - rheumatic fever
  - - - angina
      - dyspnoea
      - syncope
    - - narrow pulse pressure (ie there is a small difference between systolic and diastolic pressures)
      - left ventricular heave on apex
      - slow rising and delayed pulse (pulsusparvus et tardus)
      - on auscultation
        
        crescendo-decrescendo ejection systolic murmur radiating to both carotids (best heard over aortic area)
        
        may have a fourth heart sound
        
        note that even asymptomatic pts have reduced exercise tolerance
  - - - ECHO AND DOPPLER
        
        narrow aortic valve area is diagnostic
        
        estimates mean pressure gradient and jet velocity across the valve
      - ECG
        
        left ventricular hypertrophy with strain pattern, may show left axis deviation
        
        P-mitrale
        
        LBBB/complete AV block
    - - cardiac MRI
      - Cardiac catheterisation: if echocardiography is inconclusive
  - - - No medical therapy for AS has been shown to improve outcome
      - CAD is common in AS pts and atherosclerotic RF modification is recommended
      - onset of symptoms requires early valvular intervention. medical therapy for symptoms is only a bridge for intervention or those unfit for surgery. ACEi, diuretics and digoxin may be considered
    - - Aortic valve replacement (AVR) is the definitive therapy for aortic stenosis
      - indications for surgery:
        
        asymptomatic severe AS and LVEF <50%
        
        Pts with severe AS undergoing cardiac surgery for other indications
        
        symptomatic severe AS
        
        reasonable in asymptomatic very severe AS
        
        reasonable in asymptomatic severe AS with decreased exercise tolerance
      - transcatheter aortic valve implantation (TAVI) is billed as an alternative to surgical valve replacement (SAVR) but SAVR is still first line, but TAVI considered in pts deemed inoperable or high surgical risk
- - - - ascending aorta dissection
      - chest trauma
      - infective endocarditis
    - - bicuspid valve disease
      - vasculitis
      - aortic dilatation
      - RA
      - connective tissue disease (marfan's, ehlers danlos syndrome)
      - SLE
      - congenital anomalies
      - rheumatic fever
      - Late stage syphilis (very rare)
  - - - prevalence inc with age
      - no gender preponderance
  - - - Acute aortic regurgitation
        
        dyspnoea and features of pulmonary oedema
      - chronic aortic regurgitation
        
        usually presents with symptoms of HF
    - - pulsus bisferiens
      - collapsing (water hammer) pulse
      - laterally displaced apex due to LV dilatation
      - wide pulse pressure
        
        blood regurg back into LV = SV and press of next contraction is inc (sys bp inc).
        
        over time ventric dilatation cause dec in diast bp
        
        therefore pulse pressure difference becomes greater
      - on auscultation - high pitch early diastolic murmur (heard best on expiration, pt siting forward, left lower sternal edge)
      - signs associated (relate to high SV)
        
        corrigan's sign - carotid pulsation
        
        de musset's - head nodding with each heart beat
        
        quincke's - capillary pulsation in nail beds
        
        duroziez's -diastolic femoral murmur
        
        traube's - pistol shot sound auscultated over femoral arteries
      - may have third heart sound
      - an austin flint murmur (mid diastolic) indicates severe AR
  - - - ECG
        
        LV hypertrophy
      - CXR
        
        dilating ascending aorta
        
        pulmonary oedema
        
        cardiomegaly characteristic of chronic aortic regurg
      - ECHO
        
        a regurgatant jet is diagnostic; LV dilatation is also seen
    - - cardiac catheterisation
  - - - IMMEDIATE SURGERY INDICATED
      - haemodynamic support may be necessary (inotropes and nitrates) before surgery
    - - MEDICAL :
        
        treat HTN, recommended in all
        
        symptomatic pts require surgery and medical therapy is not a substitute. therapy with ACEi and B-blockers may be considered in severe AR when surgery is contraindicated
      - SURGICAL
        
        the definitive treatment of chronic AR is with aortic valve replacement
        
        indications:
        
        asymptomatic severe AR and LVEF <50%
        
        pts with advanced LV dilatation
        
        pts with severe AR undergoing cardiac surgery for other indications
        
        symptomatic severe AR