Valve disease

Aortic valve disease

Aortic stenosis

Causes

  1. Congenital bicuspid valve
  2. Senile calcification
  3. Rheumatic fever
  4. Prosthetic valve failure

Symptoms

  1. Asymptomatic
  2. Angina
  3. Syncope
  4. Dyspnoea
  5. Sudden death

Signs

  1. Pulse slow rising, low volume
  2. BP narrow pulse presure
  3. Heaving apex (pressure overload). Apex not displaced.
  4. Systolic thrill
  5. Soft A2
  6. Ejection systolic murmur radiating to neck
  7. LVF
Increasing severity sees in order: slow rising pulse, inaudible S2, low BP, heart failure.

Aortic regurgitation

Causes

Valvular causes:
  1. congenital bicuspid valve
  2. rheumatic fever
  3. subacute infective endocarditis
  4. collagen vascular disease (RhA, SLE)
  5. Prosthetic valve failure
Aortic root causes:
  1. type A aortic root dissection
  2. syphilis
  3. heritable connective tissue disorders (Marfan's, Ehlers-Danlos, adult polycystic kidney disease)
  4. seronegative arthopathies (ank spond, Reiter's)

Symptoms

  1. asymptomatic
  2. dyspnoea, fatigue
  3. angina
  4. syncope
  5. aortic dissection
  6. LVF

Signs

  1. water hammer pulse (Corrigan's sign), head nodding (de Musset's sign), nail bed pulsation (Quincke's sign), 'pistol shot' femoral pulses (Traube's sign), etc.
  2. BP pulse pressure wide
  3. apex thrusting (volume overload), displaced
  4. diastolic thrill
  5. soft S2, S3, S4
  6. early diastolic murmur
  7. systolic flow murmur
Increasing severity sees: ↓of murmur, LVF, displaced apex.

Mitral valve disease

Mitral stenosis

Causes

  1. Rheumatic Fever

Symptoms

  1. progressive exertional dyspnoea
  2. symptoms of pulmonary congestion: orthopnoea, paroxysmal nocturnal dyspnoea, cough, haemoptysis
  3. pulmonary oedema precipitated by exertion
  4. recurrent bronchitis
  5. RVF
  6. palpitations (AF)

Signs

  1. pulse, small volume, AF
  2. mitral facies
  3. central cyanosis
  4. apex tapping, not displaced
  5. loud S1, opening snap, mid-diastolic murmur with presystolic accentuation if in sinus rhythm
  6. basal crackles
  7. pulmonary hypertension–RV heave, loud P2, secondary TR, RVF
Increasing severity sees increasing duration of murmur.

Mitral regurgitation

Causes

  1. mitral prolapse
  2. rheumatic fever
  3. posterior infarct (papillary muscle rupture)
  4. SBE (cause or complication)
  5. LVF → dilated ventricle → stretching of AV ring
  6. carcinoid heart disease
  7. cardiomyopathy, dilated or hypertrophic
  8. ergotamine therapy
  9. Kawasaki disease
  10. chronic renal failure

Symptoms

  1. asymptomatic
  2. dyspnoea
  3. palpitations, AF
  4. non-specific chest pain
  5. fatigue
  6. cor pulmonale

Signs

  1. pulse, small volume, may be collapsing
  2. AF (atrial fibrillation)
  3. apex thrusting (volume overload), displaced
  4. systolic thrill
  5. MVP–midsystolic click, late systolic murmur
    MR–soft S1, pansystolic murmur radiating to axilla
  6. S3, S4
  7. diastolic flow murmur
  8. RV heave, loud P2 (pulmonary hypertension)

Tricuspid valve disease

Tricuspid regurgitation

Causes

  1. bacterial endocarditis (esp. IV drug users)
  2. pulmonary hypertension
  3. rheumatic fever
  4. RVF → AV ring stretched

Symptoms

Mitral stenosis often co-exists and predominates
  1. exertional dyspnoea
  2. GI upset

Signs

  1. ↑JVP with large v waves
  2. pulsatile hepatomegaly
  3. ascites
  4. dependent oedema
  5. pansystolic murmur over tricuspid area, louder on inspiration