Valvular heart disease
| AS | AR | MR | MS | TR | |
| Pulse | Slow rising | Collapsing, large volume | - | AF | - |
| JVP | - | - | - | - | ↑, large V waves |
| Apex | Not displaced, Pressure overloaded | Displaced, Volume overloaded | Displaced, volume overloaded | Tapping | - |
| Heart sounds | Soft S2 | - | Soft S1 | Loud S1 | - |
| Auscultation | ESM rad carotids | EDM at left sternal edge | PSM rad axilla | MDM, ?opening snap | PSM left sternal edge, louder inpiration |
| BP | Narrow pulse pressure | Wide pulse pressure | - | - | - |
| Other | - | Corrigan's, duroziez etc | - |
Malar flush Valvotomy scar Pul hypertension |
Pulsatile hepatomegaly |
| Causes |
Bicuspid valve Senile calcification Rheumatic |
IE Ank Spon Rheumatic Marfan’s Syphilis |
Prolapse Conn tissue IE Rheumatic |
Rheumatic |
Pul hypertension RV dilation |
| Incidental findings | Stigmata IE, Conn tissue disease |
| +ve signs | As above |
| Differential diagnosis | As above |
| Function | Dominant lesion, Pulmonary hypertension, L/R heart failure |
| Tests | CXR, ECG, Echo, ±ETT, ±Angio |
Extensions
AR: Look for IE, Marfan’s, Ankylosing spondylitis, Argyll-Robertson pupils
AR: Look for IE, Marfan’s, Ankylosing spondylitis, Argyll-Robertson pupils
Notes
- AS: Valve replacement indicated if symptoms or when gradient > 50mmHg, valve area < 0.6
- AS: Beta blockers slow rate of rise of systolic pressure, avoid vasodilators, ACE inhibitors
- AS: Impossible to have mod/severe with normal S2
- Austin flint mid diastolic murmur occurs in severe AR due to regurgitant jet interfering with mitral valve
- AR: Surgery when either (i) EF<50% (ii) decreased exercise capacity (iii) LV end systolic 55mm (iv) aortic root 50mm
- AR: Long term nifedipine reduces/delays the need for valve replacement in asymptomatic patients with severe AR, not recommended for mild AR as good outcome with no therapy
- Acute MR due to papillary rupture in MI, endocarditis
- MR Indications surgery: Either (i) mod/severe symptoms despite medical therapy or (ii) EF<60% / LV end systolic dimension >45mm in absence of symptoms
- MS: normal valve area 4-6 cm2 tight stenosis < 1
- MS indications intervention: symptoms / pul oedema / haemoptysis / pul hypertension
- MS indications percutaneous valvotomy: mobile valve, not calcified on TOE
- Graham steele: EDM of pulmonary regurg with pulmonary hypertension
- Tissue aortic valve can have just loud S2
- Metallic S1 = mech mitral, S2 = mech aortic, both = either double valve or ball and cage