Questions on mixed aortic valve disease
Mixed aortic valve disease
- What is your differential diagnosis? A
- Could it be purely AR without stenosis? A
- What do you think the likely cause in this case? a
- What is the predominant lesion and why? A
- What are the findings if AR is predominant? A, hs
- What are the differentiating features of predominant lesions? hs
- What investigations should be done? A, hs
- What is the cause of mixed aortic valve disease? a, hs
- Could it be syphilis? hs
- How will you treat your case? A, hs
Rimikri
SOLVES
Mixed aortic valve disease
What are the causes of mixed aortic valve disease?
The causes of mixed aortic valve disease are:
- Chronic rheumatic heart disease
- Biscuspid aortic valve
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 51
What are the differentiating features of predominant lesions?
Differentiating dominant lesion clinically:
| Clinical sign | Predominant aortic stenosis | Predominant aortic regurgitation |
| Pulse | Low volume slow-rising | Large volume collapsing |
| Apex beat | No or minimally displaced, heaving | Displaced, thrusting |
| Systolic thrill | Present | Not present |
| Systolic murmur | Long murmur, with late systolic peaking | Short, peaking early in systole |
| Blood pressure | Low systolic BP, normal diastolic and narrow pulse pressure | High systolic, low diastolic and wide pulse pressure |
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 51
What investigations should be done?
As follows:
- X-ray chest
- ECG (LVH)
- Echocardiogram, preferably color doppler
- Cardiac catheterization.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 198
How will you treat your case?
As follows:
- In mild to moderate case:
- Prophylaxis for infective endocarditis
- Penicillin prophylaxis if rheumatic in origin
- Follow-up.
- In severe case:
- Valve replacement.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 51
AS predominant
What are the examination findings of the precordium if AS is predominant?
- Pulse: 100/min, low volume and slow rising, normal in rhythm, pulsus Bisferiens is present (in carotid).
- JVP: Normal.
- BP: Low systolic and normal diastolic, narrow pulse pressure.
On inspection:
- Visible cardiac impulse (may or may not be).
On palpation:
- Apex beat in left … intercostal space, … cm from midline, heaving in nature.
- Systolic thrill: Present in aortic area, radiates to the right side of neck.
On auscultation:
- First heart sound: Normal in all the areas.
- Second heart sound: A2 is soft or absent and P2 is normal.
- There is an ejection systolic murmur in aortic area, which radiates to the right side of neck and also there is an EDM in the left lower parasternal area.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 87
What is the predominant lesion and why?
Predominant lesion is aortic stenosis, because:
- Pulse: Low volume and slow rising.
- Blood pressure: Low systolic and normal diastolic, narrow pulse pressure.
- Apex beat is heaving.
- Systolic thrill in aortic area.
- A2 : Absent.
Note
If AS is predominant, there may be history of more anginal pain and syncopal attack.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 197
What are the findings if AR is predominant?
If AR is predominant, there will be:
- Pulse: High volume and collapsing (water hammer type).
- Apex beat: Shifted and thrusting.
- Blood pressure: Increased systolic, fall of diastolic and wide pulse pressure.
Note:
If AR is predominant, in history, palpitation will be more and there will be less anginal pain and syncopal attack.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 198
What is your differential diagnosis?
There is combined systolic and diastolic murmur. So this may be confused with conditions that present with continuous murmur like:
- Patent ductus arteriosus (murmur is called machinery murmur or train in a tunnel)
- Pulmonary arteriovenous fistula
- Pulmonary stenosis with pulmonary regurgitation.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 197
What do you think the likely cause in this case?
Chronic rheumatic heart disease.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 197
Could it be syphilis?
No, syphilis never causes AS.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 51
AR predominant
What are the examination findings of the precordium if AR is predominant?
Presentation as in AS predominant, except:
- Pulse: High volume and collapsing in nature.
- BP: High systolic, low diastolic and wide pulse pressure.
- Apex beat: Shifted and thrusting in nature.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 87
Could it be purely AR without stenosis?
Yes, ESM here may be due to increased flow through aortic valve without AS.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 197
