Valvular Heart Disease

Hakim Alkatiri
Mitral Stenosis
 Mitral Stenosis

Causes
•rheumatic fever
•congenital abnormality, calcification, myxoma

Natural history
•RF age 12
•murmur 1st heard 20 yrs later
•symptoms in 3-4th decade
 Mitral Stenosis - Clinical features
Severity MVA (cm²) LAP (mm Hg) CO
Mild >2.0 <10-12 NL
Moderate 1.1-2.0 ~10-17 NL
Severe <1.0 >18 ↓
Very Severe <0.8 >20-25 ↓
↓

Severity Symptoms
Mild Asymptomatic or mild DOE
Moderate Mild-mod DOE; orthopnea, PND, hemoptysis

Severe Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest;

severe fatigue; cyanosis
 Mitral Stenosis - Examination

Inspection
Malar flush
Peripheral cyanosis (severe MS)
Jugular venous distension (right ventricular failure)

Palpation
Parasternal right ventricular impulse
Palpable pulmonary arterial impulse
Palpable S1, P2, and occasionally, the diastolic rumble

Auscultation
Increased intensity of the first heart sound
Opening snap
Low-pitched diastolic rumbling murmur
 Mitral Stenosis - Treatment
Medical
•Diuretic - pulmonary congestion
•Prevent embolism - cause of 19% deaths, ↑with
↑LA size and ↑age
anticoagulate all with PAF/AF, SR in older age
•Control atrial fibrillation
 Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
 Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
•100% ↑MVA, final area ~2cm2
•Failure rate 1-15%
•Mortality 0-3%
•Severe MR 2-10%
•Restenosis ~40% at 7years
•Contraindications - thrombus, MR, Ca++, other
disease
 Mitral Stenosis - Treatment
Mitral Valve Replacement
•Open mitral valvotomy
•Mitral valve replacement
Mitral Regurgitation - Aetiology
•Primary
Annulus annular calcification
Leaflet myxomatous degeneration
rheumatic deformity
infectious perforation
Chordae myxomatous degeneration
spontaneous rupture
rheumatic shortening
infectious destruction
Papillary infarction
ischemic lengthening
•Functional
LV dilatation and PM displacement
CXR
Mitral Regurgitation - Pathophysiology
 Mitral Regurgitation - Clinical findings
Acute dyspnoea, orthopnoea
no cardiomegaly, short murmur, S3
Chronic variable symptoms
cardiomegaly, murmur, P2 loud, S3
Quantification
•echocardiography, angiography
•serial studies, LV function
 Mitral Regurgitation - Outcome in
Chronic MR

Variable course - diagnosis to symptoms 16 years

Symptomatic severe - survival 33% at 5 years
mortality ~5% per year
LV dysfunction most important factor
 Mitral Regurgitation - Treatment

Acute
•Diuretics ↓LV filling P, ↓p oedema
•Vasodilators ↑forward SV
•IABP

Chronic
No known effective therapy
•Vasodilators - theoretical risks
•Treat complications
 Mitral Regurgitation - Surgery

Options
•Valve repair
•MVR with chordal preservation
•MVR with destruction MV apparatus
Outcome
•Mortality 80-94% v 40-60% at 5-10years
•Valve function
•Ventricular function
 Mitral Regurgitation - Indications for surgery

No randomised trials!!
1. Symptomatic with normal LV function
•prognosis worse once NYHA class II symptoms

2. Symptomatic with abnormal LV function

• If severe LV impairment - poor outlook
•EF < 30% ?medical Rx better
 Mitral Regurgitation - Indications for surgery

3. Asymptomatic with abnormal LV function

• ? Asymptomatic
•Detection of LV dysfunction is the key
EF<60%, LVESD > 45mm, LVESV>55ml/m2
4. Asymptomatic with normal LV function
•?guaranteed repair
•PHT, recent AF
Mitral Regurgitation - Indications for surgery
 Mitral Regurgitation - Prolapse

•2-4% population
•females:males 2:1
•diagnosis from echocardiography
•subcategory according to leaflet abnormality
•SBE prophylaxis; normal + MR or abnormal leaflets
 Aortic Stenosis - Aetiology

•Congenital 1st-3rd decade

Valve degeneration and calcification
•Rheumatic - 4th decade
•Bicuspid valve; 1%, males>females, 5-6th decades
•Tricuspid valve - 7-8th decades, 1-2% incidence
 Aortic Stenosis - Pathophysiology

LV pressure overload → LV hypertrophy → diastolic

LV dysfunction
Systolic function usually preserved except late in
disease
Systolic function improves with AVR
Outcome is dependent on symptoms
 Aortic Stenosis - Clinical features
Symptoms
•None
•DOE, dizziness
•HF, syncope, angina
Examination
•Pulse - ↓amplitude, delay
•Sustained apex
•S2- soft and single → paradoxical splitting
•ESM - loud → late peak → soft
 Aortic Stenosis - Severity
Echocardiography

Mean Peak Ao AVA

gradient velocity (cm2)
(mmHg)
Normal 1.0-2.0 >2.5
Mild <20 2.5-2.9 >1.7
Moderate 20-40 3.0-4.0 1.0-1.7
Severe >40 >4.0 <1.0
 Aortic Stenosis - Outcome
Symptoms
•2-year survival < 50%
Asymptomatic
•Generally good prognosis
•Peak velocity >4.0m/s → 2yr event-free survival 21%
•Progression of> 0.3m/s per year - worse
 Aortic Stenosis - Treatment
Medical
•None!!!
•Diuretics v LVF
•ACEI contraindicated
Balloon aortic valvuloplasty
•Average MVA improvement 0.8cm2 → 1.0cm2
•Restenosis <6/12 in 50%
•No improvement in mortality
•Procedural mortality 5%
 Aortic Stenosis - AVR

Indicated only if symptomatic

•Mortality 0.6-5%
•Survival 67-85% at 5 yrs, 70% at 10yrs
•2yr survival 4x greater than medical treatment
LV dysfunction
•?impairment from pressure overload or other cause
•DSE may be helpful
Aortic Stenosis - AVR
 Aortic Regurgitation - Aetiology

Root
Annuloaoroectasia
Marfans
Dissection
Syphillis
Ankylosing spondylitis
Leaflet
Endocarditis
Bicuspid valve
Rheumatic heart disease
Aortic Regurgitation - Pathophysiology

Normal
 Acute Aortic Regurgitation - Clinical features

No time for LV to enlarge

↑total SV, ↓fwd SV, ↑ ↑LVEDP
Quiet S1 (presystolic MV closure),
short murmur

Treatment
•Medical therapy ineffective
•AVR if symptoms/signs LVF
 Chronic Aortic Regurgitation - Clinical features

↑total SV, maintained fwd SV, RV runoff in diastole

→ ↑systolic BP, ↓diastolic BP
→Volume and pressure overload
Examination - hyperdynamic circulation, wide pulse
pressure, dilated LV, EDM duration important
Chronic Aortic Regurgitation - Clinical features
LV decompensation

Maybe asymptomatic, LVF, angina

 Chronic Aortic Regurgitation - Treatment

Medical - ↓afterload
Nifedipine 20mg bd delayed surgery by 2-3 yrs
Duplicated with small ACEI trials

Vasodilator therapy
ACC / AHA Practice Guidelines 2006
Indications for AVr/R

Class I
1. AVR is indicated for Symptomatic patients with
severe AR irrespective of LV systolic function.
2. AVR is indicated for asymptomatic patients with
chronic severe AR and LV systolic dysfunction ( EF
50 % or less) at rest.
3 AVR is indicated for patiens with chronic severe AR
while undergoing CABG or surgery on the aorta or
other heart valves.
 Diagnosis Auscultation Other P. E Radiograph ECG Therapy

Mirtal
- S1 loud
- Opening snap
Summary diuretic
- ↑LA, PA, RV - RAD, LAE anti coagulan
stenosis present followed RV lift - Normal LV - (±) RVH
by a mid-diastolic BMV
rumble surgery
- Holosystolic LV heave ↑ LA and LV - LAE diuretic
Mitral Regur- usually radiating - AF vasodilator
gitation to the axilla common
- S1 soft, S3 surgery
common
Aortic - Ejection type - LVH none !!
stenosis early systolic May have a - Aortic (medical)
(transmitted murmur thrill at the valve LAD and BAV
from base) - Also heard at right 2nd ICS calcification LVH surgery
right 2nd ICS with
radiation to the
carotids
Aortic diastolic
regurgitation murmur at left - RV lift Hypovascular vasodilator
base - Peripheral lung fields if - RAD surgery
- P2 loud if PR signs or AR pulmonary - RVH
secondary to absent hypertension
pulmonary present
hypertension
 Diagnosis Auscultation
Summary
Other P. E Radiograph ECG Therapy
- S1 loud
Tricuspid - Mid-diastolic
stenosis rumble ↑ a waves ↑ RA and SVC RAE
- increased by in JVP
inspiration
Holosystolic - ↑ V waves
Tricuspid murmur increases in JVP ↑ RA, ↑RV,
regurgitation with inspiration - Pulsating ↑ SVC RAD
(Carvallo's sign) liver
- RV failure
Ejection sistolic - RVH
Pulmonary with click ↑ A wave in - Poststenotic - RVH
stenosis - S2 split, P2 soft JVP dilatation of -RAD
or absent PA
Diastolic
Pulmonary murmur at left - RV lift hypovascular
regurgitation base - Peripheral lung fields if - RAD
- P2 loud if PR signs og AR pulmonary - RVH
secondary to absent hypertension
pulmonary present
hypertension