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CR - path of valvular heart disease (i) (intro (main problems (stenosis…
CR - path of valvular heart disease (i)
normal blood flow
right side
IVC (systemic circulation) -> right atrium -> tricuspid valve -> right ventricle -> pul valve -> pul art -> lungs
left side
pul vein -> left atrium -> mitral valve -> left ventricle -> aortic valve -> aorta (systemic circulation)
intro
most common areas with problems: aortic + mitral
main problems
stenosis
pressure buildup in left heart
back pressure to pul veins + capills
pul oedema (transudate in alveoli - cardiac origin)
narrower opening
failure of valve to open completely
impedes forward flow of blood
pressure overload tracks back in a reverse manner
congenital causes: primary valve or cusp abnormality
acquired causes: dystrophic calcification, postinflamm scarring
regurg
pump must work harder (LVH)
aka insufficiency or incompetency
failure of valve to close completely
reverse blood flow
vol overload
often age-related acquisition
intrinsic disease of cusps
damage to/distortion of supporting structures (e.g. papillary muscles)
combo of both
thrombi from valvular vegetations
valves maintain unidirectional blood flow
function depends on mobility, pliability/flexibility, structural integrity of cusps (leaflets)
pul + aortic valves require integrity + coordination of cusp attachment to close tightly (semilunar)
tricuspid + mitral valves have connections to ventricular papillary muscles
dilated left ventricle -> aortic incompetence
normal aortic valve - tricuspid
left coronary
right coronary
non coronary
bicuspid aortic valve = not a rare congenital condition (1-2% of pop)
normal mitral valve is bicuspid
VHD can be congenital or acquired
LHF = most common cause of RHF
any damage to valve predisposes to endocarditis
Aortic stenosis
causes
age-related wear + tear
dystrophic calcification (calcified masses prevent opening, also closing in regurg)
congenitally bicuspid
increased mechanical stress
younger onset age
most common type = right + left coronary cusp fusion with raphe
also rheumatic fever (but moreso in mitral)
LV pressure must rise to maintain CO -> concentric LVH
hypertrophied myocardium may be ischaemic
clinical feautures
exertional angina pectoris
no CAD
due to LVH
dyspnoea on exertion
presyncope / syncope (drop attacks) on exertion
weak pulse
if advanced
non-exertional symptoms
HF
arrhythmia - sudden death
haemoptysis uncommon but can occur with severe pul oedema
cardiogenic shock
Aortic regurg
increased cardiac workload (each contraction must expel normal stroke vol + regurgitated blood)
causes
cusp disease (e.g. infective endocarditis)
dilatation of aortic root (due to hypertension or arthritis, e.g. RA with aortitis)
consequences
if acute LVF
if chronic
may have little symptomatology
LVH + dilatation with eventual decompensation + LVF
mitral annular calcification
usually asymptomatic
can cause regurg or stenosis
annulus = peripheral fibrous ring of mitral valve
most common in older patients
mitral stenosis
caused by rheumatic fever mostly
consequences
dilated left atrium
can cause A fib
irregularly irregular pulse
prothrombotic
increased stroke risk (emboli)
mural thrombus
pul congestion
dyspnoea due to pul oedema
prolonged hydrostatic back pressure in pul veins
pul vasc + parenchyma changes
right ventricular hypertrophy + congestion
low CO
infective endocarditis (rare)
may need a balloon valvotomy (widens valve) or valve replacement
Mitral regurg
caused by
valve abnormalities
rheumatic/post inflamm scarring
infective endocarditis
prolapse
cusps are floppy + go back to atrium with each sys
frequently causes leakage
can be assymptomatic or severe
unknown cause, or due to Marfan's (fibrillin mutation)
other complications: infective endocarditis, leaflet thrombi (could embolise -> stroke risk)
abnormalities in tensor apparatus
rupture of papillary muscle or chordae tendinae
annular calcification
dilatation of left ventricle
cardiomyopathy
myocarditis