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Valvular heart disease flashcards

13 high-yield MRCP Part 1 cards from the Intellect Medicos Cardiology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.

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1. In mitral stenosis, what does a shorter interval between S2 and the opening snap suggest?

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   More severe stenosis.

   Why? Higher left atrial pressure forces the stiff mitral valve open sooner after the aortic valve closes, so the snap moves closer to S2.

2. A 79-year-old man has had two episodes of syncope on exertion. He has an ejection systolic murmur radiating to the carotids, a soft second heart sound and a slow-rising pulse. Echo: aortic valve area 0.8 cm², mean gradient 48 mmHg. What is the next step in management?

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   Refer for aortic valve intervention. Surgical valve replacement is first-line at low or intermediate surgical risk; TAVI (transcatheter aortic valve implantation) if surgical risk is high or surgery is unsuitable.

   Why? He has severe aortic stenosis (valve area ≤1.0 cm², mean gradient ≥40 mmHg) and symptoms. Symptomatic severe aortic stenosis is an indication for valve intervention because the outlook without it is poor.

3. In mitral stenosis, hoarseness from compression of the left recurrent laryngeal nerve by a large left atrium is called what?

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   Ortner's syndrome.

   Why? A dilated left atrium (and pulmonary artery) can stretch the left recurrent laryngeal nerve as it loops under the aortic arch.

4. Supravalvular aortic stenosis is associated with which genetic syndrome, and what is the chromosomal defect?

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   Williams syndrome — a microdeletion at 7q11.23 including the elastin gene.

   Why? Elastin deficiency narrows large arteries just above the aortic valve. Other features include elfin facies, hypercalcaemia and a very sociable personality.

5. Which form of S2 splitting occurs in severe aortic stenosis?

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   Reversed (paradoxical) splitting.

   Why? Prolonged left ventricular ejection delays aortic valve closure (A2) until after P2. The split then widens on expiration instead of inspiration.

6. In aortic regurgitation, what are Quincke's sign, de Musset's sign and Traube's sign?

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   Quincke's: capillary pulsation in the nail beds. De Musset's: head bobbing with each heartbeat. Traube's: "pistol-shot" sound over the femoral arteries.

   Why? All reflect the wide pulse pressure and bounding circulation of significant aortic regurgitation.

7. With a modern bileaflet mechanical valve and no extra risk factors, the target INR is typically ______ for the aortic position and 3.0 for the mitral position.

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   2.5

   Why? The mitral position has lower flow velocity and a higher thrombosis risk, so it needs more intense anticoagulation.

8. With a modern bileaflet mechanical valve and no extra risk factors, the target INR is typically 2.5 for the aortic position and ______ for the mitral position.

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   3.0

   Why? The mitral position has lower flow velocity and a higher thrombosis risk, so it needs more intense anticoagulation.

9. What is the first-line intervention for symptomatic severe rheumatic mitral stenosis when the valve anatomy is suitable?

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   Percutaneous (transcatheter) balloon mitral valvotomy.

   Why? The balloon splits the fused commissures without open surgery. Surgical mitral valve replacement is used if the valve is unsuitable for valvotomy.

10. In severe primary mitral regurgitation needing surgery, which operation is preferred if the valve is suitable?

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    Mitral valve repair, rather than replacement.

    Why? Repair keeps the subvalvular apparatus, preserves LV function and avoids lifelong anticoagulation. Replacement is used if repair is not feasible; transcatheter edge-to-edge repair is an option for symptomatic patients unfit for surgery.

11. NICE: consider intervention in ASYMPTOMATIC severe aortic stenosis if the peak aortic jet velocity is more than ______ or the LVEF is below 55%.

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    5 m/s

    Why? Other triggers: aortic valve area below 0.6 cm², BNP/NT-proBNP more than twice the upper limit of normal, or symptoms unmasked on exercise testing. Symptomatic severe AS is an indication for intervention in its own right.

12. NICE: consider intervention in ASYMPTOMATIC severe aortic stenosis if the peak aortic jet velocity is more than 5 m/s or the LVEF is below ______.

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    55%

    Why? Other triggers: aortic valve area below 0.6 cm², BNP/NT-proBNP more than twice the upper limit of normal, or symptoms unmasked on exercise testing. Symptomatic severe AS is an indication for intervention in its own right.

13. Carcinoid syndrome with liver metastases classically damages which heart valves?

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    The right-sided valves: tricuspid regurgitation (sometimes stenosis) and pulmonary stenosis.

    Why? Serotonin and other vasoactive substances cause fibrous plaques on the valves. They are inactivated in the lungs, so left-sided valves are usually spared unless there is a right-to-left shunt or lung metastases.