Heart Valve Disease

Heart valve disease

Heart valve disease Liu Chao,MD

Anatomy of heart

Anatomy of heart valve 

The heart has two halves, a left and a right, each with two chambers - the atrium and the ventricle. Between the chambers are the heart valves which ensure the blood runs only in one direction.

Anatomy of heart 

There are also heart valves situated between the ventricles and the major arteries the aorta and pulmonary artery where they have the same function.

Classification of heart valve disease? 

Narrowed valves

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Leaking valves

Narrowed valves 

These may be due to: 

congenital abnormality

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degeneration through atherosclerosis (aortic stenosis only)

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damage from rheumatic fever

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excessive calcification in old age (aortic stenosis only).

Leaking valves 

These may be due to: 

bacterial infection or inflammation of a valve

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excessive floppiness of the leaflets (mitral valve prolapse)

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enlargement of the heart or aorta - the main blood vessel into which the left ventricle pumps.

Valve heart disease    

Mitral stenosis and insufficiency Aortic stenosis and insufficiency Tricuspid stenosis and insufficiency Pulmonary stenosis and insufficiency

Anatomy of mitral valve

Mitral stenosis

Mitral stenosis      

Etiology and pathology Pathophysiology Diagnostic considerations Natural history Complication Operative treatment

Etiology 

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Rheumatic fever is the known cause of mitral stenosis, although a difinite clinical history can be obtained in only about 50% of patients. Mitral stenosis may also be associated with aging and a buildup of calcium on the ring around the valve where the leaflet and heart muscle meet.

Etiology 

Rarely congenital

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Two-thirds of all patients with MS are female.

Pathology 

Rheumatic valvulitis produces at least three distinct pathologic changes, the degree varying widely among different patients: fusion and shortening of the chordae tendineae; and fibrosis of the leaflets with subsequent stiffening, contraction, and calcificaion. The most extensive changes usully are seen in patients with recurrent attacks of rheumatic fever.

Pathophysiology 

The cross-sectional area of the mitral valve is 4-6 square centimeter, varying with body size. Significant hemodynamic changes from mitral stenosis do not appear, however, until the cross-sectional area is reduced to less than 2 to 2.5cm

Mitral Stenosis: Pathophysiology

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Normal valve area: 46 cm2 Mild mitral stenosis:  

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Mod mitral stenosis 

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MVA 1.5-2.5 cm2 Minimal symptoms MVA 1.0-1.5 cm2 usually does not produce symptoms at rest

Severe mitral stenosis 

MVA < 1.0 cm2

Mitral Stenosis: Pathophysiology

Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement

RV Pressure Overload RVH RV Failure

↑ Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi ↑ LA Pressure

LV Filling

What are the symptoms? 

Most people with mitral stenosis have no symptoms. When symptoms do happen, they may get worse with exercise or any activity that increases your heart rate. These may include

What are the symptoms?        

Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea Coughing, hemoptsis, pinkish, blood-tinged sputum. Fatigue. Chest pain that gets worse with activity and goes away with rest. Frequent respiratory infections such as bronchitis. Heart palpitations (the feeling that the heart has skipped a beat). Swelling (edema) of the feet and ankles. A hoarse or husky-sounding voice.

What is the sign?   

Thin and frail Atrial fibrillation Apical diastolic rumble murmur, an increased first sound, an opening snap

Diagnostic consideration    

Clinical manifestation Chest radiography EKG Echocardiography

Chest X-ray    

Enlargement of the left atrium (double contour ) Kerley’s line (enlarged pulmonary lymphatics) Distention of the pulmonary arteries and viens “Straight” left border of the heart (the enlargement of atrium and pulmonary artery obliterates the normal concavity between the aorta and ventricle)

Mitral Stenosis: EKG    

LAE RVH Premature contractions Atrial flutter and/or fibrillation 

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↑ freq. in pts with mod-severe MS for several years A fib develops in ≈ 30% to 40% of pts w/symptoms

Mitral Stenosis: Role of Echocardiography Diagnosis of Mitral Stenosis  Assessment of hemodynamic severity  mean gradient, mitral valve area, pulmonary artery pressure  Assessment of right ventricular size and function.  Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty  Diagnosis and assessment of concomitant valvular lesions  Reevaluation of patients with known MS with changing symptoms or signs. 

Mitral Stenosis: Natural History   

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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: Complications  

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Atrial dysrrhythmias Systemic embolization (10-25%)  Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis  Massive: ruptured bronchial veins (pulm HTN)  Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections

Mitral Stenosis:Therapy 

Medical Diuretics for LHF/RHF  Digitalis/Beta blockers/CCB: Rate control in A Fib  Anticoagulation: In A Fib  Endocarditis prophylaxis 

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Balloon valvuloplasty 

Effective long term improvement

Mitral Stenosis:Therapy 

Surgical Mitral commissurotomy  Mitral Valve Replacement 

Mechanical  Bioprosthetic 

Cardiopulmonary bypass

Mitral commissurotomy

Mitral valve replacement 

FDA-approved mechanical mitral valves. (A) StarrEdwards ball-andcage. (B) Medtronic-Hall tilting-disk. (C) Omnicarbon tilting-disk. (D) St. Jude Medical bifleaflet.

Mitral valve replacement 

FDA-approved mechanical mitral valves. (E) Carbomedics bileaflet. (F) ATS bileaflet. (G) ONX bileaflet.

Mitral valve replacement 

FIGURE 38-3 FDAapproved bioprosthetic mitral valves. (A) Hancock II porcine heterograft. (B) Carpentier-Edwards standard porcine heterograft. (C) Mosaic porcine heterograft. (D) Carpentier-Edwards pericardial bovine heterograft.

Operative procedure

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(A) An ellipse is removed from the posterior leaflet, and a flap is cut form the central portion of the anterior leaflet. The anterior flap is flipped to the posterior annulus and tacked to the caudad edge of the posterior leaflet and the posterior annulus. Sutures anchoring the prosthesis include the annulus and anterior and posterior leaflet remnants to which chordae are attached. (B) The anterior leaflet is partially excised, and remnants are "furled" to the annulus by sutures used to insert the prosthesis.

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Suturing techniques for prosthetic mitral valve implantation. Subannular sutures placed from ventricle to atrium for bioprosthetic or Starr-Edwards valves. Everting (supraannular) sutures placed from atrium to ventricle for bileaflet or tiltingdisk valves.

Recommendations for Mitral Valve Repair for Mitral Stenosis 

ACC/AHA Class I 

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Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for replacement if percutaneous mitral balloon valvotomy is not available Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for replacement if a left atrial thrombus is present despite anticoagulation Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with the decision to proceed with either repair or replacement made at the time of the operation.

Recommendations for Mitral Valve Repair for Mitral Stenosis ACC/AHA Class IIB  Patients in NYHA functional Class I, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation. ACC/AHA Class III  Patients with NYHA functional Class I-IV symptoms and mild MS. 

*The committee recognizes that there may be a variability in the

measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.

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Fig. 1.1: Dr. C. Walton Lillehei (opposite page), working at the University of Minnesota, developed a novel technique of cardiopulmonary bypass called cross circulation, in which the circulation of one person is used to support that of another during an open-heart operation. It was used successfully in sick children.