VALVULAR HEART DISEASE!!

VALVULAR HEART DISEASE

 Mitral Stenosis
 Mitral Regurgitation
 Aortic Stenosis
 Aortic Regurgitation
Mitral Stenosis

What is MS?

Its Left Atrial Outflow Obstruction.

Women to men ratio is 4:1
MITRAL STENOSIS

Rheumatic Heart Disease causes

MS in 99.8% of cases

*although in Panova’s lecture it was written 60% of cases.

(?)
 Other causes:
• Congenital Mitral Stenosis may be associated with hypoplasia
of the left ventricular cavity and the aorta, and also with
endocardial fibroelastosis.
• Atherosclerotic changes of the aorta dt calcification of valve
and fibosis of valve & subvalvular apparatus
• Systemic diseases like SLE,RA. Treatment with steroids can
cause fibrosis of the cusp with commissural fusion~
 Pathogenesis

Normal mitral valve has a cross-sectional area of

approximately 5cm2
At rest, blood flow takes place only in the center of
the valve (2cm2
In exertion, whole valve area is used
So if valve area is 2.5-5cm2, no signs appear at rest…
EARLY SYMPTOMS PATHOGENESIS
SO…..
1. Pulmonary symptoms
1. Dyspnea
2. Cough
3. Hemoptysis
4. Frequent respiratory infections
5. Night asthma-like dyspnea paroxysms, pulmonary
edema
2. Fatigue
3. Objective Signs (LA enlargement, auscultation
signs)
FURTHER DISEASE PROGRESSION
Which means…….
1. Atrial Fibrillation
2. Right-sided CHF
3. LA dilatation
4. Changes in auscultation picture
5. Embolisms
To sum up…
Mitral Stenosis = Mitral orifice becomes smaller
Two circulatory changes
 To maintain LV filling across the narrowed valve,

LA pressure ↑
 Blood flow across mitral valve is ↓which leads to

↓ Cardiac output
X-RAY FINDINGS OF MS
 Usually normal or slightly enlarged heart
 Enlarged atria do not produce cardiac enlargement,
only enlarged ventricles
 Straightening of left-heart border
 Or, convexity along left heart border secondary to
enlarged atrial appendage
 Only in rheumatic heart disease~
 Small aortic knob from decreased CO
 Double density of LA enlargement (?)
 Rarely, right atrial enlargement from tricuspid
insufficiency
CALCIFICATIONS
 Calcification of valve –not annulus – is best seen
on lateral film
 Rarely, calcifications of left atrial wall, secondary
to fibrosis from long-standing disease
 Rarely, calcification of pulmonary arteries
PULMONARY FINDINGS
 Cephalization
 Elevation of left mainstem bronchus
 Enlargement of main pulmonary artery secondary
to PAH
 Multiple small hemorrhages in lung (pulmonary
hemosiderosis)
MITRAL REGURGITATION
Definition

Mitral regurgitation (mitral insufficiency) is a valve disease

with structural changes of the mitral valve as a whole or its
separate parts, causing blood regurgitation from left
ventricle to left atrium, appearing at every systole.
CLINICAL SIGNS
 Exertional dyspnea
 Atrial rhythm disorders (up to fibrillation or
flutter)
 Fatigue
 Right CHF (appears late in disease)
 Auscultative signs and signs during P/E
 Embolisms maybe present
OBJECTIVE SIGNS
 Displaced apex beat to the left, systolic thrill
 Soft S1, maybe buried in systolic murmur
 Systolic regurgitation murmur > intensive at
apex. It can be pansystolic or decrescendo
 Increased pulmonary component of S2 (split S2)
X-RAY FINDINGS
 In acute MR
 Pulmonary edema
 Heart size not enlarged
 In chronic MR
 LA & LV markedly enlarged (dt volume overload)
 Pulmonary vasculature is normal usually (because
increase is in LA volume, not pressure)
AORTIC STENOSIS
Aortic Stenosis is the consequence of a
fixed obstruction to left ventricular
ejection.
The obstruction is most commonly at the
level of the valve itself, but may also be
immediately above the sinuses or within
the left ventricle.
CAUSES
Cause Frequency
Fibrosis of congenitally bicuspid 38%
valve
Degenerative senile with 33%
calcinosis
Rheumatic 24%
Congenital 2%
Atherosclerosis-induced (II type <2%
hyperlipidemia)
Aortic stenosis can be classified according to
location:

1) Valvular

2) Supravalvular

3) Subvalvular
CONGENITAL VALVULAR AORTIC STENOSIS
 Bicuspid aortic valve is the most common
congenital anomaly
 0.5 – 2%
 It’s usually not stenotic in infancy
 It’s more prone to fibrosis and calcification
compared to normal valve!~
 Many malformations of aorta or LV are
associated with bicuspid valve
 50% with CoA
 Hypoplastic left heart syndrome
 Interruption of aortic arch
CALCIFICATION?
 Bicuspid aortic valve is prone to calcification
 It occurs early, in the 4th decade of life compared
to degenerative aortic valve calcification (>65yo)
 It can also occur with Rheumatic Heart Disease
ANGIOGRAPHY
 Non-calcified bicuspid valve  thickening &
doming of valve leaflets during systole
 A jet of non-opacified blood is visible through
stenotic bicuspid valve (x with acquired AS)
 Congenital bicuspid valve hv 2 aortic sinuses (3
in acquired AS)
 In rheumatic ds, the commisures usually fuse but
not with degenerative AS
DIFFERENTIATING FEATURES
Etiology Calcification Other clues
Congenital bicuspid 30’s Jet effect on
valve aortogram
Degeneration of >65yo Commissures don’t
tricuspid valve fuse
Coronary artery
calcification
Rheumatic disease in 30’s but in 3rd world MS or MR almost
tricuspid valve countries, teenagers always present
Commisures fuse
together
INVESTIGATIONS
 ECG : Left ventricle hypertrophy/overload
 X-ray
 Cardiomegaly in case of HF
 Calcinosis of aortic valve maybe revealed
 Post-stenotic aortic root dilatation
 Echo
SUBVALVULAR AORTIC STENOSIS
 Usually associated with
 Subaortic fibrous membrane
 Hypoplastic left heart syndrome
 Idiopathic hypertrophic subaortic stenosis
SUPRAVALVULAR
 Rare
 In 2/3 associated with Williams Syndrome
 Hypercalcemia
 Pulmonary stenosis
 Elfinfacies
 Hypoplasia of aorta
 Stenosis in renals, celiac,
 Clinical symptoms
 Angina
 SoB
 Syncope
AORTIC REGURGITATION
AR is a valve disease caused by
aortic valve affection or valve ring
dilatation causing incomplete cusps
closure in diastole and thus, blood
regurgitation from aorta to LV
ETIOLOGY
 Chronic (80%)
 Rheumatic heart disease
 Infective endocarditis
 Hypertension
 Aortic aneurysm
 Ankylosing spondylitis
 Marfan’s syndrome
 Syphillis
 Acute (20%)
 Rupture of the valve cusps
 Ascendant aortic dissection
IMAGING FINDINGS
 X-ray
 Left ventricular enlargement
 Enlargement of entire aorta
 Colour doppler is also diagnostic
CLINICAL SYMPTOMS
 Fatigue
 Brain ischemia
 Symptoms dt regurgitation (pulsation in head,
etc)
 Angina
SYMPTOMS OF ARTERIAL PULSATION
 DeMussets
 Carotid Sign
 Dressler’s Sign
 Muller’s sign
 Quinke’s sign
 Duroziez’s or Traube’s double sound
 Becker’s sign