Valvular Heart Disease Phase 2 Jonathan Evans The Peer Teaching Society is not liable for false or misleading information…

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

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

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

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

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

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

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

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

Symptoms 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…

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

Signs – Aortic Regurgitation Collapsing or Water-hammer pulse Deviated apex beat 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…

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

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

Symptoms 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…

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

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

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” The Peer Teaching Society is not liable for false or misleading information…

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

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

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

Treatment 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…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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 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…

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

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

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

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

Answer 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…

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 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…

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

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