EM Notes – Valvular Heart Disease

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Aortic Valve Lesions

Aortic Stenosis

General

  1. Most common isolated affected valve, esp elderly
  2. 4M:1F
  3. Unrecognised can be important cause of anaesthetic & obstetric mortality

Causes

  1. Congenital bicuspid valves
  2. Degenerative calcified tricuspid valves
  3. Rheumatic fever ± regurg
  4. Asssoc with coarctation

Pathology

  1. Characterized by dev of concentric LVH. Valve – Norm area (grad) 3-4cm2 (2mmHg), compromise 40mmHg), critical <0.6cm2 (>70mmHg)

History

  1. May be asymptomatic even with severe stenosis
  2. Angina (only 50% have coronary disease, O2 demand from hypertrophied myocardium)
    1.1. Ave Survival = 5yrs untreated
  3. Syncope (fixed stroke vol limits CO in exercise) aka Stoke Adams attacks.
    1.1. Average survival = 3yrs if untreated
  4. Dyspnoea (late onset, high pulm pressures)
    1.1. Average survival = 2yrs if untreated

Exam

  1. Pulse – Slow-rising, plateau (narrow pulse pressure)
  2. Palp – sustained apex beat may be displaced
  3. JVP – prom a wave, sev AS -> RVF
  4. HS – harsh ESM RSE -> neck (later and longer murmur=more sev) & apex, S4

Inv

  1. ECG – LVH
  2. CXR – LVF ± calcification
  3. ECHO – confirmation + gradient determination

Management

  1. Treat Cx if possible
  2. Cautious use of nitrates in ischaemia
  3. Surgery if symptomatic or sev stenosis. Valvotomy (cong. bicuspid) or replacement

Cx

  1. Sudden death
  2. Calcific emboli
  3. Infective endocarditis
  4. Heart Failure
  5. Heyde’s syndrome = AS + GI angiodysplasia, vWF syndrome

Aortic Sclerosis

  1. Thickening of leaflets
  2. Minimal flow obstruction
  3. Similar murmur to AS without other features
  4. Common in >65y
  5. 15% progress to AS within 7yrs

Aortic Regurgitation

Causes

  1. Rheumatic fever ± regurg
  2. Congenital bicuspid valves
  3. Endocarditis
  4. Aortic dissection
  5. HT in elderly
  6. Seronegative arthropathies, SLE
  7. Congenital
  8. Other: Marfan’s, VSD, Congenital, Syphilis

History

  1. Asymptomatic
  2. Angina
  3. Syncope
  4. Dyspnoea, SOBOE

Exam

  1. Pulses – Collapsing, water hammer pulse (wide pulse pressure)
    1.1. Quinke’s sign – nailbed pulsations
    1.1. Corrigan’s sign – prom carotid pulsations
    1.1. Traube’s sign – pistol shot sounding fem pulses
    1.1. Duroziez’s sign – sys & dia murmurs over partly occluded femorals
  2. Palp – sustained apex beat may be diplaced
  3. JVP – prom a wave, sev AS -> RVF
  4. HS – decrescendo early diastolic murmur lower LSE (longer murmur=more sev) ± flow murmur, Austin Flint murmur, S3

Inv

  1. ECG – LVH & strain
  2. CXR – LVH ± calcification
  3. ECHO – confirmation + ejection fraction determination

Management

  1. Treat Sx & Cx if possible
  2. Arterial vasodilation will resistance to ventricular ejection e.g. ACEI, CCB, diuretics
  3. Surgery if symptomatic, decreasing ej. fraction

Mitral Valve Lesions

Mitral Stenosis

Valve

  1. Normal 6cm2, severe stenosis <1cm2

Causes

  1. Rheumatic fever
  2. Congenital (rare)
  3. Austin Flint murmur of AR

Features

  1. Malar flush
  2. Loud S1 opening snap
  3. Mid-diastolic rumble
  4. Tapping apex

Inv

  1. ECG – AF (common), P mitrale, RAD/RV strain (severe)
  2. CXR – MV calcification, LA enlargement (double shadow R heart border, displaced L bronchus), prom pulm arteries, peripheral paucity of markings, signs of HF
  3. ECHO

Surgery

  1. If SOB on minimal exercise, valve area<1cm2

Mitral Regurgitation

Causes

  1. Physiological (minor)
  2. MV prolapse, papillary muscle dysfn
  3. Rheumatic fever
  4. Cardiomyopathy (HOCM, dilated, ischaemic)
  5. Endocarditis
  6. LVF
  7. Connective tissue disease (Marfan, RA, Ank.Spond)
  8. Congenital (endocardial cushion defects)
  9. Trauma

Features

  1. Soft S1, pansystolic murmur at apex -> axilla
  2. Apex displaced
  3. S3 (sev)

Inv

  1. ECG – AF, P mitrale, RAD, LV strain
  2. CXR – MV calcified, LA enlarged (dble shadow R Ht border, displaced L bronchus), LVH
  3. ECHO

Management

  1. Treat Sx & Cx if possible
  2. Arterial vasodilation resistance to ventricular ejection e.g. ACEI, CCB, diuretics
  3. Surgery not usual unless MV prolapse

Mitral Valve Prolapse

Background

  1. Commonest heart lesion in community: 1-3%
  2. AD inheritance with less male penetrance
  3. Cause: Defective collagen synthesis

Definition

  1. Single or both leaflets >2mm beyond annular plane ± leaflet thickening
  2. Posterior prolapse more frequent than anterior

Exam

  1. Systolic click & late systolic murmur (earlier with Valsalva, delayed with squatting)

Assocs

  1. Marfan’s
  2. HOCM
  3. Mitral stenosis
  4. ASD secundum
  5. Anorexia nervosa
  6. Low wt & low BP
  7. Palpitations

Cx

  1. Sudden death
  2. Embolism
  3. Arrhythmias
  4. Endocarditis

Management

  1. No restrictions in activity in asymptomatic individuals
  2. Surgery for high risk

Pulmonary & Tricuspid Valve Lesions

Pulmonary Stenosis

Causes

  1. Congenital, Noonan’s, Carcinoid

Features

  1. Periph cyanosis
  2. Ejection systolic click & murmur, S4
  3. RV heave & pulmonary thrill
  4. JVP: giant a waves
  5. Presystolic pulsation of liver

Pulmonary Regurgitation

Causes

  1. Rare
  2. Pulm HT, Infective endocarditis, Pulmonary atresia

Features

  1. Descrescendo diastolic murmur at LSE, louder on insp. AKA Graham Steele murmur.

Tricuspid Stenosis

Causes

  1. Very rare
  2. Rheumatic fever (usually assoc with MV & AV disease)

Features

  1. Diastolic rumble murmur
  2. JVP: slow y descent, giant a waves if in SR
  3. Presystolic pulsation liver

Tricuspid Regurgitation

Causes

  1. Rheumatic fever
  2. RVF, Infective endocarditis (esp IVDU), Ebstein’s anomaly, Trauma & pap muscle dysfn

Features

  1. PSM LSE louder on insp
  2. RV heave
  3. JVP: large v waves and elevation if RVF
  4. Pulsatile tender liver, ascites, peripheral oedema, pleural effusions