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Valvular Heart Disease: Bekele T. (MD)

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Valvular Heart Disease

Bekele T. (MD)

1
Overview of Valves

2
Normal Valve Function
 Maintain forward flow and prevent reversal of flow
 Valves open and close in response to pressure differences (gradients)
between cardiac chambers.

3
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

4
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)

5
Adult valvular heart disease
 Mitral Valve
 Aortic Valve
 Tricuspid valve
 Pulmonic valve

6
Mitral Stenosis

Etiology

• Rheumatic (nearly all adult MS- 99.9%!!! )


Women >> Men

• Degenerative (calcification)

• Congenital (parachute MV)

• Others: post-inflammatory, metabolic syndromes etc

7
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

8
Mitral stenosis
 Clinical symptoms
 In temperate climate

- Latent period from the initial attack of rheumatic carditis to the


development of symptoms is generally 2 decades

- most experience disability in the 4th decade.


 In developing countries

- serious symptoms appear in patients less than 20 years of age

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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

 Base line investigations (CBC, RFT, electrolytes)

 Coagulation profile

12
Complications of MS
 Atrial fibrillation
 Systemic embolization
 Pulmonary hypertension
 Tricuspid regurgitation
 Pulmonary infarction
 Chest infections
 Infective endocarditis (rare)

13
MEDICAL MANAGEMENT OF MS
 Avoid strenous exercise and physical activity

 Diuretcs: in combination with salt restriction, is appropriate when


there are manifestations of pulmonary vascular congestion and right
sided HF

 Digoxin: indicated if and only if there is atrial fibrilation with fast


ventricular responce and right sided HF

 Secondary prevention of rheumatic fever

 Management of AF
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Surgical indication for severe MS
 Moderate or severe MS
 Valve area <1.5 cm2
 PAWP>25mmHg

15
Types of surgical interventions for MS
 Percutaneous mitral balloon valvotomy (PMBV)
 Closed commisurotomy
 Open commirotomy with valve repair
 Mitral valve replacement (MVR)

 Contraindications for PMBV


 Unfavorable valve morphology
 Thrombus in LA
 Grade 3 or grade 4 mitral regurgitation

16
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

20
Mitral Regurgitation…
 Acute severe MR
- Acute pulmonary edema
- Cardiovascular collapse
 Chronic MR
- Fatigue
-Orthopnea
- Exertional dyspnea
 Hemoptysis & Embolism Less frequent than in MS

21
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

23
MEDICAL MANAGEMENT OF MR
 Management of chronic severe MR depends to some degree on its cause

 In symptomatic patients with primary MR a beta blocker, diuretic,


hydralazine, or calcium channel blocker should be used.

 Diuretics may be needed for patients with post-MI papillary muscle


rupture or other forms of acute severe MR

 However, medical therapy is not a substitute for surgical intervention in


patients with chronic symptomatic MR.

24
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

26
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

Pressure Gradient Created Across the Valve

Chronic LV Pressure Overload

LV Hypertrophy
29
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

32
Medical treatment of AS
 In patients with severe AS (<1.0 cm2), strenuous physical activity should be avoided,
even in the asymptomatic stage

 Avoid dehydration and hypovolemia to protect against a significant reduction in CO


 Medications including beta blockers and ACE inhibitors, are generally safe for
asymptomatic patients with preserved left ventricular systolic function

 Diuretics reduce preload, on which the patient may depend for maintenance of
cardiac output.

33
SURGICAL MANAGEMENT OF AS

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Aortic Regulation
 75% are males
 Females predominate if there is associated mitral disease
 Causes

35
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 Symptoms

 Exertional dyspnea is usually the 1st symptom of decreased cardiac


reserve
 Physical findings

- Wide pulse pressure - Displaced apical beat

- Collapsing pulse - Diastolic thrill & murmur

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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.

38
Con----
 Apex beat: displaced laterally & downwards and is forceful
in quality.
 Auscultation:
 Diminished A2
 diastolic blowing murmur @ LSB

39
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

 Beta-blockers are also best avoided so as not to reduce the CO


further or slow the heart rate, which might allow proportionately
more time in diastole for regurgitation to occur

 Surgery is the treatment of choice

40
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
45
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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