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

Phase 2

Jonathan Evans

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

Aortic StenosisAortic RegurgitationMitral StenosisMitral Regurgitation


Aims

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


Valves

Mitral Valve


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

• Congenital – Bicuspid valve presents later in life

• Acquired1. Degenerative: Calcific valve disease2. Rheumatic fever


Aortic Stenosis - Causes


Pathophysiology

Reduced cardiac output

Left ventricular hypertrophy

SAD


Symptoms – severe AS

Syncope – exercise inducedAngina – from LV hypertrophyDyspnoea – due to Heart failure

• Ejection Systolic murmur radiating to the carotids

• Slow rising pulse• Systolic thrill over aortic areaOther:• Systolic ejection click• Soft 2nd heart sound


Signs

1. Rheumatic fever2. Infective endocarditis

– Likes to sit on previously damaged valves


Aortic Regurgitation - Causes


Pathophysiology

Left ventricular failure

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


Symptoms

Two murmurs to remember:

1.Early Diastolic: left sternal edge, high pitch2.Ejection systolic – from high flow of blood


Murmur

1. Collapsing or Water-hammer pulse2. Deviated apex beat3. Lots of signs with weird names that we don’t

need to remember.


Signs – Aortic Regurgitation

1. Rheumatic fever


Mitral Stenosis - Causes


Pathophysiology

Pulmonary hypertension

Atrial Fibrillation

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


Symptoms

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 murmur3. Pink cheeks – malar flush


Signs

1. Rheumatic fever (50%)2. Prolapsing mitral valve3. Other:

– Ischaemic heart disease– Cardiomyopathies– Collagen abnormalities– Drugs


Mitral Regurgitation- Causes

• Usually a benign and asymptomatic condition

• Common – 2-6% of population• May have atypical chest pain or

palpitations• “Mid- systolic click”


Prolapsing “floppy” mitral valve


Pathophysiology

Left ventricular failure

1. Pansystolic murmur – Heard best at the apex2. Deviated apex beat3. Left ventricular failure

– Dyspnoea– Orthopnoea


Signs and symptoms


InvestigationsEchocardiogram to see what’s going on:

• Medical–Treat Heart Failure if they have it

• Surgical–Valvoplasty – dilate the valve with a

balloon for stenotic valves–Replace the valve


Treatment

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


1. Mechanical valve

• Usually porcine• Doesn’t last as long – elderly people


2. Bio-prosthetic valve

Rumbling Mid-diastolic murmur?


Questions

Mitral Stenosis

Where is it heard best?


Answer

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


Answer

Aortic Stenosis – what is the murmur?


Questions

Ejection systolic heard best right sternal edge 2nd intercostal spaceWhere does it radiate?


Questions

Carotids

Name three symptoms of Aortic stenosis?


Questions

SyncopeAnginaDyspnoea


Questions

Early diastolic murmur

Where is it heard best?


Questions

Left sternal edge

What other murmur might you hear?


Questions

Ejection systolic – due to high flow


Questions



Questions



Questions



Questions

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.


Previous exam question

Aortic stenosis


Answer

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.


Question

Mitral valve prolapse


Answer

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.


Question

Mitral Stenosis


Answer

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


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.


Question

1. Acute rheumatic fever2. Amyloid valve tissue 3. Congenital valve anatomy abnormality4. Infective endocarditis5. Metallic valve prosthesis 6. Mitral valve prolapse7. Non-bacterial thrombotic endocarditis8. Normal valve9. Senile calcific valve stenosis10. Xenograft valve


Which is most likely?

4. Infective endocarditis

Fever + new murmur = Endocarditis

Two main causes:1.Streptococcus Viridans (dental problems)2.Staphylococcus aureus (IVDU, Diabetes, Surgury)


Answer

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.


Question




9. Senile calcific valve stenosis

The commonest cause of Aortic stenosis is:Calcific valve disease and mainly occurs in the elderly.


Answer

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.


Question 3




Non Bacterial Thrombotic Endocarditis


Answer

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

Documents

asthe peer teaching

misleading informationif

high pitchejection systolic

systolic ejection clicksoft

left sideopening snap

aortic areaother

lv hypertrophydyspnoea

mitral valveother