Valvular Heart Disease: Bekele T. (MD)
Valvular Heart Disease: Bekele T. (MD)
Valvular Heart Disease: Bekele T. (MD)
Bekele T. (MD)
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Overview of Valves
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Normal Valve Function
Maintain forward flow and prevent reversal of flow
Valves open and close in response to pressure differences (gradients)
between cardiac chambers.
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Abnormal Valve Function
Valve Stenosis
Obstruction to valve flow during that phase of the cardiac cycle
when the valve is normally open.
Valve Regurgitation, Insufficiency, Incompetence
Inadequate valve closure--- back leakage
Combinations of valve lesions can coexist
Single disease process
Different disease processes
One valve lesion may cause another
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Factors of flow across valvular lesion
Valve area
Square root of hydrostatic pressure gradient across the valve
Time duration of transvalvular flow (applies to both systole
and diastole)
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Adult valvular heart disease
Mitral Valve
Aortic Valve
Tricuspid valve
Pulmonic valve
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Mitral Stenosis
Etiology
• Degenerative (calcification)
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Mitral stenosis…
Hemodynamic features
abnormally elevated left atrioventricular pressure gradient
normal LV diastolic pressure
subnormal CO
pulmonary hypertension:
contributing factors
Backward transmission of LA pressure
Reactive pulmonary hypertension
Organic obliterative changes
Interstitial edema in the wall of vessels
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Mitral stenosis
Clinical symptoms
In temperate climate
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Mitral stenosis…
Mild MS
Physical signs may be present without symptoms
Symptomatic MS
Lesser stresses precipitates dyspnea
Orthopnea and PND
Pulmonary edema
Atrial arrhythmias
Hemoptysis
Recurrent
10 pulmonary emboli & pulmonary infarction
Mitral stenosis
Physical Signs
Inspection
- Mitral facies (malar rash)
Palpation
- Right ventricular tap - Palpable P2
- Palpable S1 - Diastolic thrill
Auscultation
S1
P2
Diastolic rumbling murmur
Graham Steel m. (PR)
Signs of RV failure
Functional TR
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OTHER INVESTIGATIONS IN MS
ECHO
Cardiac catheterization
MRI
Coagulation profile
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Complications of MS
Atrial fibrillation
Systemic embolization
Pulmonary hypertension
Tricuspid regurgitation
Pulmonary infarction
Chest infections
Infective endocarditis (rare)
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MEDICAL MANAGEMENT OF MS
Avoid strenous exercise and physical activity
Management of AF
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Surgical indication for severe MS
Moderate or severe MS
Valve area <1.5 cm2
PAWP>25mmHg
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Types of surgical interventions for MS
Percutaneous mitral balloon valvotomy (PMBV)
Closed commisurotomy
Open commirotomy with valve repair
Mitral valve replacement (MVR)
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SURGICAL MANAGEMENT OF MS
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Mitral Regurgitation
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Etiology of MR
Rheumatic heart disease is the cause of chronic MR in only about one-third of cases and
occurs more frequently in males.
The rheumatic process produces rigidity, deformity, and retraction of the valve cusps and
commissural fusion, as well as shortening, contraction, and fusion of the chordae tendineae
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Pathophysiology of MR
Acute severe MR
LA and pulmonary venous pressures are markedly elevated, and
pulmonary edema is common
Chronic severe MR
These patients usually complain of severe fatigue and exhaustion
secondary to a low CO, while symptoms resulting from pulmonary
congestion are less prominent initially
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Mitral Regurgitation…
Acute severe MR
- Acute pulmonary edema
- Cardiovascular collapse
Chronic MR
- Fatigue
-Orthopnea
- Exertional dyspnea
Hemoptysis & Embolism Less frequent than in MS
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Mitral Regurgitation…
Physical findings
Inspection
Pulse = sharp upstroke
Palpation
Apex beat = displaced laterally hyperdynamic
Heave on left sternal border
Auscultation
- S1 - S4 in acute MR
- S2 wide split - Pansystolic blowing murmur
- S3
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Investigations
ECG:
LA enlaregement,LVH and if they develop pulmonary hypertension LA
enlargement and RVH can be seen
CXR: cardiomegaly
ECHO:
Essential for establishing the etiology and hemodynamic consequences of
mitral regurgitation .
Evaluation of the left atrium, left ventricle, and pulmonary artery
pressures
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MEDICAL MANAGEMENT OF MR
Management of chronic severe MR depends to some degree on its cause
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SURGICAL MANAGENET OF CHRONIC
SEVERE MR
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Aortic Stenosis
Etiology
Congenital bicuspid valve
Acquired
Rheumatic heart disease
Almost always associated with rheumatic mitral valve disease
Associated AR favors rheumatic etiology
Idiopathic calcific aortic stenosis
Commoner in the elderly
Relatively mild obstruction
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Aortic Stenosis
A – Normal Valve
B – Congenital AS
C – Rheumatic AS
D – Bicuspid AS
E – Senile AS
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Degree of Aortic Stenosis
Normal AVA = 2.6 – 3.5 cm2
Mild AS
1.5 – 2.0 cm2
Moderate AS
1.0 – 1.4 cm2
Critical AS
AVA < 0.9 cm2
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Pathophysiology of Aortic Stenosis
Aortic Stenosis
Obstruction to LV Ejection
LV Hypertrophy
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Aortic Stenosis…
Symptoms
Rarely symptomatic until critical stenosis
Most are asymptomatic until 5th to 7th decade
Cardinal symptoms
Exertional dyspnea
Syncope
Angina pectoris
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Natural History of AS
May be a long asymptomatic period
Symptomatic
Usually have severe AS with AVA of 0.9 cm2 or less
Presenting symptoms:
Angina
Syncope
CHF
Average life span of Symptomatic patients without surgery:
Angina = 5 years
Syncope = 3 years
CHF = 2 years
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Aortic Stenosis…
Physical findings
BP - late and pulse pressure narrows
Slow rising pulse
Palpation
Forceful and sustained apex beat
Systolic thrill
Auscultation
A2 , S2 may be single or reversed splitting
Ejection systolic murmur
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Medical treatment of AS
In patients with severe AS (<1.0 cm2), strenuous physical activity should be avoided,
even in the asymptomatic stage
Diuretics reduce preload, on which the patient may depend for maintenance of
cardiac output.
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SURGICAL MANAGEMENT OF AS
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Aortic Regulation
75% are males
Females predominate if there is associated mitral disease
Causes
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Symptoms
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Chronic Aortic Regurgitation: Physical Findings
Pulse: bounding or collapsing.
Widened Pulse Pressure > 70mmHg
Low diastolic pressure < 60mmHg
Hyperdynamic LV –
DeMusset’s signs(head nodding with each heartbeat)
Corrigan’s pulse/Water Hammer Pulse/
Quincke's sign (capillary pulsation in the nail beds)
Durozier’s murmur (a to-and-fro murmur heard when the femoral
artery is auscultated with pressure applied distally-it is a sign of
severe aortic regurgitation)
pistol shot femorals.
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Con----
Apex beat: displaced laterally & downwards and is forceful
in quality.
Auscultation:
Diminished A2
diastolic blowing murmur @ LSB
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MEDICAL MANAGEMENT OF ACUTE
AR
Patients with acute severe AR may respond to intravenous
diuretics and vasodilators (such as sodium nitroprusside), but
stabilization is usually short-lived and operation is indicated
urgently
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Tricuspid stenosis
Most often rheumatic
Usually associated with mitral or aortic disease
Rare causes
carcinoid syndrome
Congenital valve abnormalities
Leaflet tumors
vegetations
Tricuspid Regurgitation
Most often secondary to dilation of the right ventricle and tricuspid annulus
Primary cause
Rheumatic
Endocarditis
Myxomatous (TVP)
Carcinoid
Radiation
Congenital (Ebstein's)
Trauma
Papillary muscle injury (post-MI)
Secondary causes
RV and tricuspid annular dilatation
Multiple causes of RV enlargement (e.g., long-standing pulmonary HTN)
Chronic RV apical pacing
Pulmonic stenosis
is most often congenital
Rheumatic deformity is rare
Pulmonic regurgitation
The result of dilation of the annulus secondary to pulmonary
hypertension
The murmur of pulmonic regurgitation early diastolic best heard
at the second left intercostal space (Graham Steell murmur)
Summary
Investigations of valvular heart disease
ECG: signs of chamber enlargement
X-ray: variable signs of congestion
Mitral stenosis
Straightening of left heart border
Prominent main pulmunary arteries
Echocardiography
Identify the hemodynamic lesion
Assess ventricular function
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Summary con….
Treatment of valvular heart disease
Prophylaxis for :
Sub acute bacterial endocarditis
Avoid strenuous exercise
Aortic stenosis
Hemoptysis: salt, diuretics
AF
Embolic events
Anticoagulation
Valve repair or replacement
CRHD
prophylaxisis for B-hemolytic streptococcal infection with
Benzathine penicillin
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THANK YOU !!!
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