VALVULAR HEART DISEASES
[Link]. AM
Definition
• Valvular heart disease is characterized by damage
to or a defect in one of the four heart valves: The
Mitral, Tricuspid, Aortic, Pulmonary.
• Terms
-Stenosis(narrowing-obstrucion)
-Regurgitaion(backward flow-insufficiency)
-Valves
-Systole
-Diastole
Prevents efficient
blood flow through
the heart.
valves
Heart valves
Heart valves
MITRAL VALVES –b/w LA and LV
s1
TRICUSPID –B/w RA and RV closure of mitral and tricuspid
Closes duing systol and opens during diastole valves
SEMILUNAR VALVES
s2
Aortic valves-B/W LV and the aorta
closure of aortic and
Pulmonary valves-B/w RV and pulminary artery
pulmonary valves
-Opens duing Systole and closes during Diastol
SYSTOLE & DIASTOLE
• Normally functioning valves ensure that blood
flows with proper force in the proper direction
at the proper time.
• In valvular heart disease, the valves become
too narrow and hardened (stenotic) to open
fully, or are unable to close completely
(incompetent).
Valvular Heart Disease
1. Mitral Stenosis
2. Mitral Regurgitation
3. Aortic Stenosis
4. Aortic Regurgitation
5. Tricuspid Stenosis
6. Tricuspid Regurgitation
7. Pulmonary Stenosis
8. Pulmonary Regurgitation
Mitral Valve Stenosis
Anatomy
Location bB/W left atrium and left ventricle(apex)
• Function
-Closes during systole
-Opens during diastole
• Malfuntion
-narrow during diastole
Valvular Stenosis
The Valve Opening Narrows
the valve leaflets may become fused or
thickened that the valve cannot open freely
obstructs the normal flow of blood
EFFECTS:
the chamber behind the stenotic valve is
subject to greater stress
must generate more pressure (work hard)
to force blood through the narrowed opening
initially, the heart compensates for the
additional workload by
gradual hypertrophy and dilation of the
Valvular Regurgitation
• LEAKAGE OR BACKFLOW OF BLOOD RESULTS FROM INCOMPLETE
CLOSURE OF THE VALVE
due to:
- Scarring and retraction of valve leaflets OR Weakening of
supporting structures
EFFECTS:
causes the heart to pump the same blood twice (as
the blood comes back into the chamber)
the dilates to accommodate more blood
ventricular dilation and hypertrophy
eventually leads to heart failure
Principal Causes
•Valve stenosis •Valve regurgitation
• Congenital
• Rheumatic carditis
• Senile degeneration
• Congenital
• Rheumatic carditis (acute or chronic)
• Infective endocarditis
• Valve ring dilatation
(e.g. dilated cardiomyopathy)
• Syphilitic aortitis
• Traumatic valve rupture
• Damage to chordae and
papillary muscle (e.g. MI)
• Senile degeneration
Clinical features
Symptoms
• Breathlessness, cough (pulmonary congestion)
• Chest pain (pulmonary hypertension)
• Hemoptysis (pulmonary congestion or
hypertension)
• Fatigue (low cardiac output)
• Oedema, ascites (right heart failure)
• Palpitation (atrial fibrillation)
• Thromboembolic complications
Signs
• Atrial fibrillation
• Mitral facies (abnormal flushing of the cheeks that
occurs from cutaneous
vasodilation in the setting of severe mitral valve stenosis)
• Auscultation - Loud first heart sound, opening snap
(created by forceful opening of mitral valve)
- Mid-diastolic murmur (apex)
• Crepitations, pulmonary edema, effusions
(raised pulmonary capillary pressure)
• RV heave, loud P2 (pulmonary hypertension)
Investigations
• ECG: - right ventricular hypertrophy tall R waves
• Chest x-ray: - enlarged LA & appendage
- signs of pulmonary venous congestion
• ECHO: - thickened immobile cusps
- reduced valve area
- enlarged LA
- reduced rate of diastolic filling of LV
• Doppler: - pressure gradient across mitral valve
• Cardiac catheterization: - coronary artery disease
- pulmonary artery pressure
- mitral stenosis and regurgitation
Management
Surgically
• Mitral balloon
valvuloplasty***
• Mitral valvotomy
• Valve replacement
Medically
• Anticoagulant
To reduce the risk of systemic embolism
• Digoxin, beta blockers, or rate limiting calcium antagonists
To control ventricular rate in atrial fibrillation
• Diuretic To control pulmonary congestion
Aortic Stenosis-Narrowing of the Aortic valve
Clinical Manifestation-
Symptoms
Fatigue & weakness – due to CO –
predominant complaint
Exertional dyspnea & cough –
pulmonary congestion
Palpitations – due to atrial fibrillation
(occur in 75% of pts.)
Edema, ascites – Right-sided
heart failure
Signs
Atrial fibrillation
Cardiomegally
Apical pansystolic murmur +/- thrill
Soft S1, apical S3
Signs of pulmonary venous congestion
(crepitations, pulmonary
edema, effusions)
Signs of pulmonary hypertension &
right heart failure
Investigations
• ECG: - left atrial hypertrophy
- left ventricular hypertrophy
• Chest x-ray: - enlarged LA,LV
- pulmonary venous congestion
- pulmonary edema
• ECHO: - dilated LA,LV
- structural abnormalities of mitral valve (e.g. prolapse)
• Doppler: - detects and quantifies regurgitation
• Cardiac catheterization: - dilated LA,LV
- mitral regurgitation
- pulmonary hypertension
- coexisting coronary artery disease
Etiology
INFANTS, CHILDREN, ADOLESCENTS
Congenital aortic stenosis
Congenital subvalvular aortic stenosis
Congenital subvalvular aortic stenosis
YOUNG ADULTS TO MIDDLE AGED
Calcification and fibrosis of congenitally bicuspid aortic valve
Rheumatic aortic stenosis
• MIDDLE-AGED TO ELDERLY
• Senile degenerative aortic stenosis
• Calcification of bicuspid valve
• Rheumatic aortic stenosis
Clinical features
Symptoms
usually asymptomatic
• Exertional dyspnea
• Angina (due to demands of
hypertrophied LV)
• Exertional syncope
• Sudden death
• Episodes o acute pulmonary edema
Management
• Asymptomatic aortic stenosis kept under review
• Moderate/severe stenosis evaluated every 1-2
years with
Doppler echocardiography (to detect progression in severity)
• Symptomatic severe aortic stenosis valve
replacement
• Congenital aortic stenosis aortic balloon
valvuloplasty
• Atrial fibrillation or post valve replacement with a
mechanical prosthesis anticoagulant
Aortic Regurgitation-
Causes
• Congenital:
– Bicuspid valve
or disproportionate cusps
• Acquired:
– Rheumatic disease
– Infective endocarditis
– Trauma
– Aortic dilatation (marfan’s syndrome, aneurysm,
dissection, syphilis
Pathophysiology
Clinical features
Symptoms
• Mild or moderate aortic regurgitation:
– Usually asymptomatic
– Awareness of heartbeat, ‘palpitations’
• Severe aortic regurgitation:
– Breathlessness
– Angina
Clinical features
• Pulses:
– Large volume or ‘collapsing’ pulse
– Low diastolic and increased pulse pressure
– Bounding peripheral pulse
– Capillary pulsation in nail beds: Quincke’s
sign
– Femoral bruit(‘pistol shot’): Duroziez’s sign
– Head nodding with pulse: de Musset’s sign
• Murmurs:
– Early diastolic murmur
– Systolic murmur (increased stroke volume)
– Austin Flint murmur (soft mid-diastolic
Investigations
• ECG: initially normal,
later left ventricular hypertrophy & T-wave inversion
• Chest x-ray: - cardiac dilatation, maybe aortic dilatation
- features of left heart failure
• ECHO: - dilated LV
- hyperdynamic LV
- fluttering anterior mitral leaflet
• Doppler: - detects reflux
• Cardiac catheterization: - dilated LV
- aortic regurgitation
- dilated aortic root
Management
• Treatment may be required for underlying
conditions, such as
endocarditis or syphilis
• Aortic regurgitation with symptoms aortic valve
replacement (may
be combined with aortic root replacement and
coronary bypass
surgery)
• Asymptomatic patients annually follow up with
echocardiography
for evidence of increasing ventricular size
• Systolic BP should be controlled with vasodilating
drugs, such as
Tricuspid Regurgitation
Management
• Correction of the cause of right ventricular
overload (if TR is
due to right ventricular dilatation)
Use of diuretic and vasodilator treatment of
CCF
• Valve repair
• Valve replacement
Pulmonary Stenosis
Symptoms
• Fatigue, dyspnea on
exertion, cyanosis
• Poor weight gain or failure
to thrive in infants
– Hepatomegaly, ascites, edema
Signs
• Ejection systolic murmur
(loudest at the left upper sternum &
radiating towards the left shoulder)
• Murmur often preceded by an ejection
sound (click)
• May be wide splitting of second heart
sound (delay in ventricular ejection
• May be a thrill (best felt when patient
leans forward and breathes out)
Management
• Mild to modearate isolated pulmonary
stenosis is relatively
common and does not usually progress or
require treatment
• Severe pulmonary stenosis
• percutaneous pulmonary balloon valvuloplasty Or surgical
valvotomy
Pulmonary Regurgitation
A rare condition
Usually associated with pulmonary hypertension
which may be
• Secondary of the disease
• Primary pulmonary vascular disease
• Eisenmenger’s syndrome
Blood flows back into right ventricle
right ventricle and atrium hypertrophy
symptoms of right-sided
heart failure
PROSTHETIC VALVES
Bioprosthetic
Mechanical
Bioprosthetic valves
• Heterogeneous grafts made from animal tissue
• Low thrombogenic potential
• Do not need systemic anticoagulation
• Aspirin is recommended
Mechanical valves
• Longer lasting
• Need lifelong anticoagulation - Warfarin
therapy.
• Aspirin is usually combined with warfarin in
mechanical heart valves.
• Aspirin allergy – clopidogrel
Thank You…
