(K7) Valvular Heart Disease
(K7) Valvular Heart Disease
(K7) Valvular Heart Disease
Mitral Stenosis 2
Pathophysiology
• Normal MVA 4-6 cm2
– Mild MS 2-4 cm2
– Severe MS < 1.0 cm2
• Restriction of blood flow
from LA to LV during
diastole.
• As HR increases, diastole
shortens disproportionately
and MV gradient increases.
Mitral Stenosis 3
Hepatic Congestion Pulmonary Congestion
JVD Pulmonary HTN
LA Enlargement
Tricuspid Regurgitation Atrial Fib
RA Enlargement LA Thrombi
↑ LA Pressure
RV Pressure Overload
↓ LV Filling
RV Failure
↓ Cardiac output
Mitral Stenosis 4
Natural history
• Progressive, lifelong disease
• Usually slow & stable in the early years.
• Progressive acceleration in the later years.
• 20-40 year latency from rheumatic fever to symptom
onset.
• Additional 10 years before disabling symptoms.
Mitral Stenosis 5
Clinical features
• Fatigue • Atrial fibrillation
• Palpitations • Systemic embolism
• Cough • Pulmonary infection
• SOB • Hemoptysis (massive or frothy sputum)
• Left sided failure • Right sided failure
– Orthopnea – Hepatic Congestion
– PND – Edema
• Palpitation • Worsened by conditions that cardiac
output.
– Exertion,fever, anemia, tachycardia, Afib,
intercourse, pregnancy, thyrotoxicosis
Mitral Stenosis 6
Physical Examination
Tapping apex beat that is not displaced.
Loud S1.
Pulmonary hypertension
Loud P2 (pulmonary component of second heart sound)
Mitral Stenosis 7
Auscultation
1 2 3 4
S1 S2 OS S1
Mitral Stenosis 9
Mitral Stenosis 10
Chest Radiography
• LA enlargement
• Prominent pulmonal
segment
• Congestion
Mitral Stenosis 11
Management
Medical management
Diuretics for LHF/RHF.
Digoxin/β-blocker/CCB: rate control in AFib.
Anticoagulation (warfarin): in AFib.
Rheumatic fever prophylaxis
Endocarditis prophylaxis
Surgical
• Multiple severe valvular lesions or contraindications for BMV
– Mitral commissurotomy
– Mitral valve replacement (mechanical/bioprostethic)
Mitral Stenosis 12
Balloon Mitral Valvuloplasty
Contraindication:
Marked mitral regurgitation
Thrombus in LA
Calcified or thickened rigid
leaflets
Mitral Stenosis 13
Mitral Regurgitation
Mitral Regurgitation 14
Causes of MR
Site of pathology Pathology
Mitral Regurgitation 16
Pathophysiology
Hepatic Congestion Pulmonary Congestion
JVD Pulmonary HTN
↑ LA volume
LA dilatation
Regurgitant
flow
↑ LV inflow
RV failure LV volume overload
LV dilatation
LV failure
Mitral Regurgitation 17
Acute vs. Chronic MR
Acute MR (e.g. IE, RHD)
• Normal LA size
• Increased LA pressure
• Acute pulmonary edema
Mitral Regurgitation 18
Examination
Atrial fibrillation – irregularly irregular pulse
Mitral Regurgitation 19
Auscultation
S1 S2 S1
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
Mitral Regurgitation S1 S2 20S1
• ECG: • CXR:
– LA enlargement – LVH
– AFib – LAE
– LVH / RVH / – Congestion
biventricular
hypertrophy
Mitral Regurgitation 21
Management
Medical management
Diuretics and ACE inhibitors to treat the congestive cardiac failure.
Other drugs for the primary disease (e.g. ischemic heart disease, RHD,
IE)
Surgical management
Patients are considered for surgery if the MR is severe. It is important
to act before irreversible left ventricular damage has occurred.
• Mitral valve repair
• Mitral valve replacement (mechanic / bioprostethic)
Mitral Regurgitation 22
Aortic Stenosis
• Valvular AS most common form
– Senile calcification
– Bicuspid valve
– Rheumatic heart disease
• Subvalvular AS
– HCM
• Supravalvular AS
– Coarctation of aorta
Aortic Stenosis 23
Normal Bicuspid Calcified
Aortic Stenosis 24
Normal valves Aortic stenosis
Aortic Stenosis 25
Pathophysiology
Pulmonary Congestion
↑ LA pressure
↑ LV pressure
LVH Anginal symptoms
↑ LVEDP
LV dilatation
↑ Cardiac output
Aortic Stenosis 26
Natural History & Clinical Symptoms
• Asymptomatic for many years
• Symptoms develop when valve is critically narrowed
and LV function deteriorates
– Bicuspid AV 5th - 6th decade
– Senile AS 7th-8th decades
• Classic Symptoms:
– Angina pectoris
– CHF
– Syncope
– Sudden Death
Aortic Stenosis 27
Clinical features
Angina – due to the increased myocardial work and
reduced blood supply (the coronary arteries may be
normal).
Dyspnea – may lead to orthopnoea and paroxysmal
nocturnal dyspnoea as the left ventricle fails.
Dizziness and syncope – especially on exertion (fixed
cardiac output).
Sudden death.
Systemic emboli.
Aortic Stenosis 28
Examination
A slow rising, small volume pulse
A low blood pressure.
Heaving apex beat (rarely displaced)
Ejection systolic murmur (diamond-shape) at the aortic
area radiating to the carotids + palpable thrill
S1 S2
S2 single or paradoxically split
Signs of left ventricular failure
Aortic Stenosis 29
Investigations
Electrocardiography: LVH
Echocardiography
Cardiac catheterization
Aortic Stenosis 30
Management of Asymptomatic Patients
• Statin might be useful to delay calcification process
• Rheumatic fever prophylaxis
• Severe, asymptomatic AS surgery??
Aortic Stenosis 31
Aortic regurgitation
Aortic regurgitation (AR) may be due to an abnormality of
the valve cusps themselves or dilatation of the aortic root
and therefore the valve ring.
Pathophysiology
The regurgitation of blood back into LV
LV failure
Aortic Regurgitation 32
Causes of AR
Type of disease Cause
Valve disease Congenital
rheumatic fever
Infective endocarditis
Rheumatoid arthritis
SLE
Connective tissue disease (e.g.
Marfan syndrome,
pseudoxanthoma elasticum)
Aortic root disease Marfan syndrome
Osteogenesis imperfecta
Type A aortic dissection
Ankylosing spondylitis
Reiter’s syndrome
Aortic Regurgitation 33
Psoriatic arthritis
Aortic Regurgitation 34
Clinical features
A collapsing high-volume pulse (waterhammer pulse)
Aortic Regurgitation 35
Peripheral signs of Severe AR
• Quincke’s sign: capillary • Durosier’s sign: femoral
pulsation of nailbed retrograde bruits
• Corrigan’s sign: water • Traube’s sign: pistol shot
hammer pulse sound at femoral artery
• Bisferiens pulse (AS/AR >
• Hill’s sign:BP Lower
AR)
extremity > BP Upper
• De Musset’s sign: systolic
extremity by
head bobbing
– > 20 mm Hg – mild AR
• Mueller’s sign: systolic
– > 40 mm Hg – mod AR
pulsation of uvula
– > 60 mm Hg – severe AR
Aortic Regurgitation 36
Prognosis
Asymptomatic %/Y
• Normal LV function (~good prognosis)
– Progression to symptoms or LV dysfunction <6
– Progression to asymptomatic LV dysfunction < 3.5
– 75% 5-year survival
– Sudden death < 0.2
• Abnormal LV function
– Progression to cardiac symptoms 25
• Symptomatic (Poor prognosis)
– Mortality > 10
Aortic Regurgitation 38
Management
Medical management
Diuretics and ACE-I to treat cardiac failure
It is, however, important to make the diagnosis and
surgically treat this condition before the left ventricle
dilates and fails.
Surgical management
Aortic valve replacement is considered if the patients is
symptomatic or if there are signs of progressive left
ventricular dilatation. The aortic root may also need to
be replaced if it is grossly dilated.
Aortic Regurgitation 39
Tricuspid regurgitation
Causes
Mostly secondary to dilatation of the right ventricle. This
may be due to any cause of RV failure or pulmonary
hypertension.
Occasionally, tricuspid valve is affected by infective
endocarditis (usually in intravenous drug abusers).
Rarer causes include congenital malformations and the
carcinoid syndrome.
Tricuspid regurgitation 40
Clinical features
The symptoms and signs are due to the backpressure
effects of the regurgitant jet into the right atrium, which
are transmitted to the venous system causing a
prominent v wave in the jugular venous waveform.
Fatigue and discomfort due to ascites or hepatic
congestion are the commonest feature. Patients usually
present with symptoms of the disease causing the
underlying right ventricular failure;the TR is often an
incidental finding.
Management
The mainstay of management is medical with diuretics and
angiotensin-converting enzyme inhibitors to treat the
right ventricular failure and fluid overload. Tricuspid valve
replacement is considered in very severe cases.
Tricuspid regurgitation 41
Thank You
Features indicating severity of valve
disease
Valve disease Features
MS Proximity of opening snap to second heart sound and duration of murmur
Valve area assessed on echocardiography
Evidence of pulmonary hypertension on echocardiography and cardiac
catheterization
Pulmonary Dilatation of the valve RVF in severe cases, low- Treat underlying disease
ring secondary to pitched diastolic murmur in
regurgitation pulmonary pulmonary area, Graham
(PR) hypertension, infective Steel murmur- in severe PR
endocarditis the murmur is high pitched
due to the forceful parasternal
edge(i.e. similar to that in
aortic regurgitation but whith
signs of severe pulmonary
hypertension and RVF)
Normal Valve Function
• Integrated function of
several anatomic
elements
– Posterior LA wall
– Anterior & Posterior
valve leaflets
– Chordae tendineae
– Papillary muscles
– Left ventricular wall
where the papillary
muscles attach
Mitral Valve Disease: Etiology
The End
Mitral Valve Competence:
• Integrated function of
several anatomic
elements
– Posterior LA wall
– Anterior & Posterior
valve leaflets
– Chordae tendineae
– Papillary muscles
– Left ventricular wall
where the papillary
muscles attach
Case 1
• Pria 30 thn
• Mudah capai
• Apex 1 cm lateral LMCS
• Pansystolic murmur, thrill
• Ronki basah halus 1/3 lap paru,
Edema pretibial minimal
• EKG P mitral, LVH
• CXR: CTR 53%, apex lateral
downward
• Diagnosa??
Case 2
• Pria 35 tahun
• Riwayat syncope saat main bola
• Apex kuat angkat, 1 cm med LMCS
• Ejection systolic murmur, thrill
• EKG LVH
• CXR: CTR 47%
• Diagnosa??