Valvular Heart Disease

Valvular Heart Disease

Valves of the Heart

Learning Objectives • Identify the characteristics and positions of murmurs. • Describe the pathophysiology, etiology, signs and symptoms, natural history, and treatment

Aortic Valve • Aortic Stenosis • Aortic Regurgitation

Aortic Stenosis

Aortic Valve

Valvular Aortic Stenosis • Pathophysiology: Related to pressure changes, valve obstructed, LV >pressure, LV hypertrophy, LA enlarges, decreased cardiac output

Left Ventricular Hypertrophy

LVH Aortic Stenosis

Valvular Aortic Stenosis • Etiology

• Rheumatic Heart Disease • Congenital AV Disease • Stenotic from birth • Bicuspid Aortic Valve • Idiopathic Calcific Aortic Stenosis

Valvular Aortic Stenosis • Symptoms • Fatigue • Dyspnea on exertion (DOE) • Angina • Exertional Syncope • Heart Failure (HF) • Sudden Cardiac Death (SCD)

Mechanisms of Dyspnea in Aortic Stenosis ♥ LVH → diastolic dysfunction ♥ Progressive LV dilation and contractile failure → systolic dysfunction

Mechanisms of Anginal Chest Pain in Aortic Stenosis ♥ Increased wall stress → increased myocardial O2 demand, exceeds ability to coronary flow to meet demand ♥ Associated coronary artery disease

Mechanisms of Syncope in Aortic Stenosis ♥ Fixed cardiac output: Vasodilation (exercise, vagal stimulation, drug induced), inability to augment CO, drop in cerebral perfusion pressure. ♥ Heart block: Ca++ deposits in aortic ring encroach upon conduction tissue ♥ Ventricular arrhythmias (LVH, ischemia)

Aortic Stenosis • Vital Signs

• Narrow pulse pressure • PMI [point of maximum impact]

• Displaced • Ascultation

• S2 • Murmur crescendo-decrescendo harsh murmur which is best heard in the right upper sternal border (RUSB) and radiates to the neck

Aortic Stenosis • EcG • Hypertrophy • Estes criteria • CXR The chest xray (CXR) • Cardiomegaly 50% of the time • ECHO • Confirm, Severity • Gradient across aortic valve and aortic valve area can be estimated from increased flow velocity across aortic valve

• LHC Left heart catheterization • Severity, Coronary Artery Disease

Left Ventricular Hypertrophy

Severity of AS Severity

Mean gradient (mm Hg)

AV area (cm2)

Mild

<25

>1.5

Moderate

25-50

1-1.5

Severe

>50

<1.0

Critical

>80

<0.7

Natural History • Asymptomatic • For many years • Duration of symptoms until death • Angina - 3 years • Syncope - 2 years • CHF - 18 months

Natural History • Treated Aortic Stenosis • 40% survived for 5 years • 20% survived for 10 years • Sudden Cardiac Death • Decreased cerebral blood flow • Arrhythmias

AS Treatment • Strenuous Activity • Limit for symptomatic • Medical treatment of HF: ACC/AHA guidelines for preload/afterload reduction and fluid management

Treatment of Aortic Stenosis ♥ Mild to moderate asymptomatic aortic stenosis: Close follow up: History and physical exam, serial echocardiograms Endocarditis prophylaxis

♥ Severe, symptomatic aortic stenosis (1 year survival 57%) valvuloplasty or Aortic valve replacement with either mechanical or bioprosthetic valve - Ten year survival ~75% - Complications of prosthetic heart valves: infection, thromboembolism, mechanical failure

♥ Severe, symptomatic aortic stenosis NOT surgically treatable: Palliative option: aortic balloon valvuloplasty

AS Treatment • Surgical treatment • Indications, techniques, outcome depend on age/cause • Children/ adolescents • the most common cause of aortic stenosis (AS) is a bicuspid valve. These patients respond well to commissuratomy or valvuplasty

• Adults: valve replacement

Replacement Valves

Etiology of Aortic Insufficiency • Valvular Disease • Rheumatic Heart Disease • Infective Endocarditis • Trauma • Tear of the ascending aorta • Bicuspid valve

Aortic Insufficiency

Pathophysiology of Chronic Aortic Regurgitation ♥ Slowly progressive diastolic volume overload ♥ Augmented stroke volume with rapid runoff Increased systolic pressure with low diastolic pressure: wide pulse pressure ♥ Progressive left ventricular dilation, some hypertrophy ♥ Late systolic failure with reduced ejection fraction and CHF

Natural History of Chronic Aortic Regurgitation ♥ Long asymptomatic phase; may be decades long. ♥ Left ventricular systolic dysfunction ( decline in EF) LV dysfunction may occur in the symptoms

NOTE!! absence of

♥ Symptoms associated with LV dysfunction: - Exercise intolerance - Dyspnea on exertion ♥ Angina (rare) ♥ Sudden death (rare)

Aortic Insufficiency • Symptoms • Angina, Palpitations, CHF symptoms • Vital Signs • Wide pulse pressure • = elevates the systolic blood pressure (SBP)--decreases the diastolic blood pressure (DBP).

Physical Findings in Severe Chronic Aortic Regurgitation ♥ deMusset’s sign: Head nod with each systolic pulsation ♥ Corrigans’s pulses: “Pistol shot” pulses over femoral artery ♥ Mueller’s sign: Pulsation of the uvula ♥ Duroziez’s sign: Systolic/diastolic bruit over femoral artery ♥ Quincke’s pulses: Capillary pulsations seen in the nailbeds

Aortic Insufficiency • Palpation • PMI, Thrill • Auscultation • S2 variable, A2 absent • Murmur • Diastolic: patient sitting, leaning forward, on expiration, • (3rd ICS LSB

• Austin Flint Murmur is a mid to late diastolic murmur seen in severe AI. It is created by the rapid flow of blood across the mitral valve into the LV that essentially has become non-distensible.

Aortic Insufficiency

The murmur of aortic insufficiency is described as a decrescendo diastolic murmur. This is because the blood flows back into the left ventricle during diastole creating a murmur. The pressure gradient is the highest right after the aortic valve shuts and then the pressure gradient decreases.

AI-Findings and Treatment • EcG • LVH • CXR • Marked enlargement if AI is chronic • ECHO • Confirms/severity • LHC • Severity/CAD

Management of Chronic Aortic Regurgitation ♥ Close follow up of left ventricular size and function with serial echocardiograms (Every few years with mild AR, every 6-12 months with severe AR) ♥ Endocarditis prophylaxis ♥ Medical therapy: Vasodilator therapy: reduces blood pressurereduces regurgitant volume Delays need for aortic valve replacement Digoxin (enhance systolic function) Diuretics (reduce LA pressure) Do NOT slow heart rate! ♥ Aortic valve replacement with mechanical or bioprosthetic valve

•Have a rest

Rheumatic Heart Disease

Friable Vegetations at Line of Closure

Mitral Stenosis with Diffuse Thickening

Rheumatic Heart Disease

Aschoff Body

Line of Closure Vegetations

Mitral Valve Stenosis • Etiology • Rheumatic heart disease • Female • Congenital • Rare • Carcinoid • SLE systemic lupus erythematosus • Rheumatoid Arthritis • Amyloid

Mitral Valve Stenosis • Pathophysiology • Minimum of 2 yrs for severe MS to develop after ARF(acute rheumatic fever )

• Pressure elevates in • Left atrium • Pulmonary tree • Right heart • Atrial fibrillation , CO

Normal mitral valve area/opening

>1.5cm2 1-1.5cm2 <1cm2

mild moderate severe

4-6cm2

Mitral Stenosis-Symptoms • • • • • • •

Dyspnea on exertion Hemoptysis Chest pain CHF symptoms Hoarseness Pulmonary Embolism Infective Endocarditis

MS-Physical Exam/Work up • Inspection • JVP(jugular venous pressure )rise

• Sternal lift • Palpation • Sternal heave • Auscultation • Accentuated S1, Opening snap, Diastolic murmur at apex

MS-Physical Exam/Work up • EcG • LAE • Pulmonary HTN (pulmonary hypertension)

• CXR • LAE • ECHO • Confirm/severity • LHC • Severity/CAD

MS-Treatment • Medical • SBE prophylaxis • Avoid strenuous exercise • Diuretics • Anticoagulants • Rheumatic heart disease • Atrial fibrillation • Treatment AF/AF • Digoxin [generic]

MS-Treatment • Surgical • Asymptomatic • Follow • Symptomatic • Balloon Valvuloplasty • Open commissurotomy • Valve replacement • Mechanical • Bio-prosthetic

Mitral Valve

Etiology of Mitral / Regurgitation Prolapse

• Valve leaflets: Do not close properly/Do not stay closed • Chronic RHD • SLE • Trauma • Endocarditis

Etiology of MR • Papillary muscles • Ischemia • Dysfunction • Scarring • Infarction • Necrosis • Rupture

Mitral Valve

Symtoms

• fatigue & weakness may represent early symptoms of chronic severe MR • Duration of apical impulse in chronic severe MR is related to LV systolic function • Posterior leaflet prolapse: murmur to aortic area

Clinical Findings • Auscultation • S1 • Diminished • S2 • Wide splitting • Murmur • Holosystolic • Loudest at apex

Mitral Regurgitation

Mitral regurgitation is described as a holosystolic murmur.

Evaluation of MR EKG LAE Atrial fibrillation supraventricular tachycardia (SVT). LVH Nonspecific ST-T changes

CXR LVE LAE (straightening left border, atrial double density, elevation of left main-stem bronchus) Pulmonary venous congestion

• ECHO • Confirm the diagnosis • other abnormalities

MR-Treatment • Low sodium diet • Preload reduction • Diuretics • Afterload reduction • Vasodilators • Nitroprusside [generic], ACE inhibitors, Hydralazine [generic] • Digoxin [generic] • SBE prophylaxis

MR-Treatment • Surgical • Symptomatic • Class II, III, IV • Asymptomatic • Monitor Symptoms • series Echo

• End • Thank you !!!