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CR - Valvular Heart disease (ii) (aortic stenosis (complications (SCD…
CR - Valvular Heart disease (ii)
aortic stenosis
most common valvular lesion in elderly
1-2% @ 75-76 y/o
6% @ 86
severity according to size of valve area, velocity ratio + pressure gradient across valve
causes
degenerative calcification if tricuspid
congenital calcification if bicuspid
rheumatic heart disease
radiation
connective tissue disorders
risk factors
congenital valve abnormality
atherosclerosis
genetic factors
hypercholesterolaemia
end stage renal disease
symptoms
asymptomatic for a long period
exterional SAD...
presyncope/syncope
angina
dyspnoea
decreased exercise tolerance
HF @ end stage
Signs
pulsus parvus et tadus
sustained apex beat
indicates LVH or longstanding hypertension
impulse lifts your finger through all/almost all of sys
becomes displaced later
soft/split S2 (aortic closes slower than pul)
sometimes S4
ejection clicks in early disease
high pitched sounds occurring @ moment of max opening of aortic/pul valves (just after S1)
also occur due to dilated aorta/pul art, or pul art stenosis
murmur
grade it out of 6
2/3 auduble (dias v hard to to hear)
4 is palpable (thrill)
become softer as condition progresses due to LVF
loudest @ base of heart (2nd right ICS)
radiates to carotids + apex
find where it peaks
early peaking = early in sys
harsh quality
crescendo-decrescendo shape
mild/moderate stenosis
late peaking = late in sys
also harsh quality + crescendo-decrescendo shape
severe stenosis
nearly absent S2
accentuated by expiration (all left murmurs are, whereas right murmurs are accentuated by inspiration)
complications
SCD
arrhythmias
PVCs
non-sustained v tachy common
endocarditis
HF most common
A fib (uncommon in isolated aortic stenosis, usually secondary to the HF)
calcific CAD
aortic aneurysms
angiodysplasia (bleeding, incl @ GI, skin, mucosal sites)
also increased stress reduces quantity of von willebrand factor
Heyde's syndrome = GI bleeding from angiodysplasia due to the presence of aortic stenosis
mitral regurg
prevalence of mild MR + almost 20%
can arise from abnormalities if any part of mitral valve apparatus (cusps, annulus, chordae tendonae, papillary muscles)
causes
degenerative prolapse most common
infective endocarditis
LV dysfunction with annular dilatation
hypertrophic cardiomyopathy
rheumatic
symptoms
asymptomatic
LHF
preserved EF until late disease
dyspnoea, orthopnoea, PND
pul art hypertension
Atrial dilatation
A fib
palpitations
embolic phenomena
Signs
soft S1, split S2, S3 gallop
pansys murmur
heard best over apex
radiates to axilla
mid sys click + late sys murmur in mitral valve prolapse
mitral stenosis
causes
congenital (usually detected in infancy)
rheumatic heart disease
symptoms
asymptomatic
dyspnoea
haemoptysis (most commonly due to pul oedema)
A fib (embolic events)
pul hypertension
RHF
signs
low vol pulse
mitral faecies (malar flush)
raised JVP
S1 initially loud but later soft
loud P2 (pul valve closure; A2 + P2 = S2) - due to pul hypertension
dias decrescendo murmur occurring after an opening snap
right-sided valvular disease
mostly congenital
tricuspid stenosis
most commonly caused by rheumatic heart disease + carcinoid syndrome
fatigue, dyspnoea, ascites, fluid retention
tricuspid regurg
caused by endocarditis secondary to IVDU or right heart catheters, pul hypertension, right heart dilatation
pul stenosis
95% congenital, rarely carcinoid syndrome
pul regurg
rarely significant
caused by pulse valve intervention in childhood or endocarditis
Management
address risk factors
Tx complications
endocarditis prophylaxis (EU + USA guidelines differ, USA do it more, EU less due to MDR)
Tx symptoms + progressive deterioration
valve repair/replacement
mechanical last longer
tissue (pig)
e.g. TAVI (transcatheter aortic valve replacement - better in older pop as not an open sternotomy)