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Aortic StenosisAortic RegurgitationMitral StenosisMitral Regurgitation
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Aims
• Causes• Symptoms• Murmur and signs• Treatment• Questions
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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
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Aortic Stenosis - Causes
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Pathophysiology
Reduced cardiac output
Left ventricular hypertrophy
SAD
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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
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Signs
1. Rheumatic fever2. Infective endocarditis
– Likes to sit on previously damaged valves
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Aortic Regurgitation - Causes
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Pathophysiology
Left ventricular failure
Asymptomatic until Left Ventricular Failure occurs•Dyspneoa•Fatigue•“pounding of the heart”•Angina, but less common than in AS
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Symptoms
Two murmurs to remember:
1.Early Diastolic: left sternal edge, high pitch2.Ejection systolic – from high flow of blood
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Murmur
1. Collapsing or Water-hammer pulse2. Deviated apex beat3. Lots of signs with weird names that we don’t
need to remember.
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Signs – Aortic Regurgitation
1. Rheumatic fever
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Mitral Stenosis - Causes
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Pathophysiology
Pulmonary hypertension
Atrial Fibrillation
Pulmonary Hypertension•Dyspnoea•Cough – frothy blood tinged sputumRight heart Failure•Raised JVP•Big liver•Ankle swelling
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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
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Signs
1. Rheumatic fever (50%)2. Prolapsing mitral valve3. Other:
– Ischaemic heart disease– Cardiomyopathies– Collagen abnormalities– Drugs
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Mitral Regurgitation- Causes
• Usually a benign and asymptomatic condition
• Common – 2-6% of population• May have atypical chest pain or
palpitations• “Mid- systolic click”
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Prolapsing “floppy” mitral valve
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Pathophysiology
Left ventricular failure
1. Pansystolic murmur – Heard best at the apex2. Deviated apex beat3. Left ventricular failure
– Dyspnoea– Orthopnoea
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Signs and symptoms
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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
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Treatment
• Need anticoagulation (warfarin)• Last longer - Younger people
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1. Mechanical valve
• Usually porcine• Doesn’t last as long – elderly people
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2. Bio-prosthetic valve
Rumbling Mid-diastolic murmur?
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Questions
Mitral Stenosis
Where is it heard best?
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Answer
Apex – with the patient on their left and using the bell
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Answer
Aortic Stenosis – what is the murmur?
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Questions
Ejection systolic heard best right sternal edge 2nd intercostal spaceWhere does it radiate?
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Questions
Carotids
Name three symptoms of Aortic stenosis?
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Questions
SyncopeAnginaDyspnoea
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Questions
Early diastolic murmur
Where is it heard best?
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Questions
Left sternal edge
What other murmur might you hear?
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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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.
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Previous exam 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.
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Question
Mitral valve prolapse
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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.
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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
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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.
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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
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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)
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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.
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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
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Which is most likely?
9. Senile calcific valve stenosis
The commonest cause of Aortic stenosis is:Calcific valve disease and mainly occurs in the elderly.
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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.
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Question 3
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
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Which is most likely?