Valvular Heart Disease

M Saugi Abduh

Valvular Heart Disease

Heart contains

Two atrioventricular valves

Mitral
Tricuspid

Two semilunar valves

Aortic
Pulmonic

Valvular Disease

Normal Structure
Mitral Valve

Cross sectional Area 4-6cm

Anterior and Posterior Leaflets
Chordae Tendineae Papillary Muscles

Mitral Stenosis
Etiology & Pathology

Rheumatic Fever- 99%

Other

Congenital
Carcinoid
Lupus
Amyloid
Infective Endocarditis
Mucopolysaccharide Disease

Stenotic Pathology

Etiology & Pathology

Commissural
Cuspal
Chordal
Mixed

30%
15%
10%
Remaining

Valve becomes funnel shaped or fish mouthed

Thickened immobile leaflets or chordal
structures

Fig. 37-9

Fish mouth

Pathophysiology

Mild MS- orifice <2 cm

Critical MS- <1 cm

A-V pressure gradient >20mmHg

Increased LA Pressure
Increase Pulmonary Venous + Capillary Pressures
Increase Pulmonary Artery Systolic Pressure
Decrease RV Function (when PAS>30-60mmHg)

History

Exertional Dyspnea
Cough/Wheezing
Orthopnea/PND/CHF
Hemoptysis-Rupture of Pulmonary VeinBronchial Vein Shunts

History

Chest Pain-Increase RV Pressures or

Unknown Etiology
Systemic Emboli (LA clots)

10

Increased LA size, Decreased C.O., Atrial Fib

Physical Exam

Auscultation

11

Diastolic Rumble
Assoc Murmur of MR
Loud S1-thickened leaflets
Increased P2-pulmonary hypertension

Decreased B/P if C.O. decreased

Prominent a wave if sinus rhythm present

Physical Exam

12

Mitral Facies-pink, purple facial patches

due to decrease CO and systemic
vasoconstriction
Hepatomegally
Edema
Ascites
Hydrothorax With Right Heart Failure

Diagnosis

ECG

Left Atrial Abnormality

13

P wave becomes bifid and greater than 0.12 sec in

duration in V1 and Lead II

RVH- right axis deviation

R wave > S wave in V1

Diagnosis

Chest X-ray

Echo- Cornerstone of Diagnosis

14

Dilated LA, RA, RV

Elevated Left Main stem Bronchus
Interstitial Edema
Thickened Calcified Leaflets
Doming of Leaflets on Opening

Natural History

15

Asymptomatic for 15-20yrs following

Rheumatic Fever
Additional 5-10 yrs for progression from mild to
severe stenosis
Stenosis progression approximately .09 cm/yr

Natural History

Presurgical Survival Rates

16

NYHA Class II 80%-10yrs

Class III 38%-10yrs, 62% 5yrs
Class IV 15%-5yrs

Percutaneous Balloon Angioplasty

18

Moderate-Severe MS
Mild MS- if Pulmonary Artery Pressures or
Wedge Pressure Elevate with Exercise

Valve Replacement

Indications

Mortality

19

Combined MS/MR
<1.5 cm-NYHA III or IV
<1 cm
Class II if Pulmonary Artery Pressure >70mmHg
3-8%

Valve Type-Prosthetic or Bioprosthetic

Mitral Regurgitation

Etiology

Rheumatic Heart Disease

Infective Endocarditis
Collagen Vascular Disease
Cardiomyopathy
Ischemic Heart Disease
Mitral Valve Prolapse-most common cause for valve
surgery in US

20

Pathophysiology

Decreased Impedance to Ventricular Emptying

Determinants of Regurgitant Flow

21

Instantaneous Size of MV Orifice

Dependent on Preload, After load, LV Contractility,
LV Size
LA-LV Pressure Gradient dependent on Systemic
Vascular Resistance, LV Pressure, & LV Size

Pathophysiology

LV Compensation

22

Increased End Diastolic Volume

Increased Wall Tension
Increased Preload
Increased LV Emptying
Normal Ejection Fraction should be Super Normal
>65% to maintain forward cardiac output and B/P

Pathophysiology

LV Decompensation

23

Increase End Systolic Volume

Increased End Diastolic Volume
Leads to Annulus Dilatation (MR begets MR)
Decreased Ejection Fraction and Stroke Volume

Pathophysiology

Ejection Fraction in Mitral Regurgitation

>65% normal in compensated MR
50-65% mild impairment
40-50% moderate-severe impairment
<35% advanced impairment
As ejection fraction decreases operative risk increases.

24

History

25

Shortness of Breath
Exertional Dyspnea
Congestive Heart Failure
Right Heart Failure
Significant symptoms in chronic MR usually do
not develop until LV decompensation occurs.

History

Medical Treatment Survival

26

80% 5yr
60% 10yr
30-45% 5yr if MR severe

Diagnosis

Physical Exam

ECG

LA abnormality
LVH
RVH

Chest X-ray

27

Holosystolic Murmur
Increase Carotid Impulse

Increase LA, LV, RV, Interstitial Edema

Diagnosis

Echo

28

Transesophageal superior to transthoracic

Evaluation of Chamber Sizes, Regurgitant Jet,
Leaflets

Management of Acute MR

Medical

After load Reduction (Nitropresside & Intra

aortic balloon pump)

29

Decrease impedance to LV ejection

Decrease regurgitant volume into left atrium

Inotropic Support (Dobutamine)-if LV function

reduced

Management of Acute MR

Surgical Intervention

30

Progressive LV Failure or Hemodynamic

Deterioration
CHF
Hypertension
Valve Disruption

Management of Chronic MR

Medical

31

Digoxin
Diuretics*
After load Reduction
Anticoagulation in A-fib
Endocarditis Prophylaxis

Management of Chronic MR

Surgical

Indications

Asymptomatic Class I

Severe MR Class II, III, or IV

32

EF < 60% or LV Systolic Diameter >45mm

generally considered for surgery unless EF <30%

Valve Repair vs. Replacement

Aortic Valve
Normal Structure

33

Valve sits at the base of Aortic Root

Three Leaflets (cusps)-non coronary, right
coronary, left coronary
Normal cross-sectional area 3-4cm

Aortic Stenosis Etiology and

Pathology

34

Valvular
Supravalvular
Subvalvular
Hyperthrophic Cardiomyopathy

Congenital Aortic Stenosis

Unicuspid

Bicuspid

Adult Presentation
Chronic turbulent flow
Leads to fibrosis, rigidity, calcification

Tricuspid

35

Presents less than one year of age

Leaflets of unequal size

Acquired Aortic Stenosis

Rheumatic

Degenerative or Senile

36

Rare
Usually mitral valve also involved
Most common cause of adult AS
Most common cause of valve replacement
Inflammatory or Infectious component??
>age 65 30% Aortic Sclerosis

37

Hemodynamics

Critical (Surgical) AS

Moderate AS

38

1-1.5cm

Mild AS

Peak systolic pressure gradient > 50mmHg in the

presence of normal cardiac output
Valve area <0.7-0.8cm

1.5-2cm

Aortic Sclerosis

History

Long latent period of increasing

obstruction
Symptoms usually begin in 5th or 6th decade
Angina in 2/3 of patients

39

Hypertrophied myocardium
Increased ventricular systolic pressure
All of which increase myocardial oxygen
consumption
Oxygen supply-demand imbalance leads to
subendocardial ischemia

Diagnosis

Physical Examination

Systolic Murmur

Pulses Parvus

42

Diamond-Shaped, harsh, left sternal boarder to right

intercostal spaces, neck and apex
Late peak, obliteration of S2, Dx of Critical AS
Delayed and Prolonged Carotid Impulse

Diagnosis

ECG

Chest X-ray

Concentric LVH
Calcification of Aortic Valve

Echo

43

Classic LVH

calculation of LV-Aortic pressure gradient and

valve area

Diagnosis

44

Cardiac Catherization

Medical Management

45

Endocarditis Prophylaxis
Limit Physical Activity
Watch Beta Blockers and Diuretics
*Treatment of Critical AS in viable
candidates is surgery

Surgery (Valve Replacement)

Indications

Symptomatic Patients -valve area 0.7-0.8cm or

less
Asymptomatic Patients-progressive LV
dysfunction (EF <35%) or hypotensive response
to mild exercise

46

Delaying surgery in asymptomatic patients with good

exercise tolerance is controversial

Aortic Regurgitation
Etiology and Pathology

Valvular

Rheumatic-Fibrotic Retraction of Leaflets

47

Ankylosing Spondylitis, Behcets, Psoriatic Arthritis,

Giant Cell Arteritis

Degenerative AS-75% w/AR

Infective Endocarditis-Leaflet Destruction
Trauma-ascending aortic tear
Bicuspid aortic valve-prolapse or incomplete
closure
Myxomatous Degeneration-like MVP
Appetite suppressant drugs-serotonin related
valve deposits

Etiology and Pathology

Aortic Root Disease-More common than primary

valvular. Root Dilatation leads to non-coaptation of leaflets.

48

Degenerative-Hypertensive Aortic Dilatation

Cystic Medial Necrosis-Classic Marfans
Syndrome
Aortic Dissection
Syphilitic Aortitis
Rheumatic Disease-same as valvular

History

Acute AR

Chronic AR

49

LV cannot accommodate acute regurgitant

volume
can lead to cardiovascular collapse
Gradual LV enlargement-eccentric hypertrophy
Exertional dyspnea, orthopnea, PND, CHF
Presents 4th or 5th Decade

50

Physical Examination

Diastolic Murmur

51

Left sternal boarder

Decrescendo, high pitched
Best heard Sitting Up, End Expiration
Longer murmur equals worse AR

Physical Examination

de Mussetts Sign (head bobbing)

Corrigans Pulse water hammer

Bisferiens-pulse

Pistol shot sounds over femoral pulse

Duroziezs Sign

52

2 peaks

Traubes Sign

Abrupt Distention with Quick Collapse

Murmur over femoral pulse with compression

Physical Examination

Quinckes Sign

Mullers Sign

Systolic pulsations of uvula

Hills Sign

53

Capillary pulsations

Popliteal pulse exceed brachial pulse by >

60mmHg

Physical Examination

Korotkoff Sounds

54

Can persist to 0mmHg

Wide Pulse pressure

Diagnosis

ECG

Chest X-ray

55

Cardiomegaly predominantly inferior and leftward

Echo

LVH

Can aid in detecting etiology, quantifying degree of

regurgitation, and assessing LV size and function

Cardiac Catheterization

Medical Treatment

Symptomatic Moderate-Severe AR

56

Limit exertional activity

Aggressively treat B/P
Diuretics
Salt Restriction
Digoxin
Vasodilators (Nifedipine?)

Surgical Treatment

Indications

57

Defer surgery for chronic severe AR if good

exercise tolerance, EF greater than 50%, end
systolic diameter < 50 mmHg, and end diastolic
diameter < 70 mmHg
Be aware that progressive decline in LV function or
size increases surgical morbidity and mortality

Surgical Treatment

Mortality

58

3-8% perioperative
5-10% late mortality with significant preop LV
dysfunction

Tricuspid and Pulmonic Valve Disorders

Uncommon

Both conditions cause an increase in blood

volume in R atrium and R ventricle

Result in Right sided heart failure

Diagnostic Tests

Echo- assess valve motion and chamber size

CXR
EKG
Cardiac cath- get pressures

Medications

Like Heart Failure

ACE inhibitors
Digoxin
Diuretics
Vasodilators
Beta blockers
Anticoagulants
*Prophylactic antibiotics

Medical/ Surgical Treatment

Percutaneous balloon valvuloplasty

Surgical therapy for valve repair or replacement:

Valve repair is typically the surgical procedure
of choice
Open commissurotomy- open stenotic
valves
Annuloplasty- can be used for both

Valve replacement may be required for certain

patients Heart valve surgery
Mechanical-need anticoagulant
Biologic-only last about 15 years
Ross Procedure
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