Valvular heart lesions

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Meant for MBBS students. Not for higher levels. For a 1 hour lecture.

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Valvular heart lesions

  1. 1. A S Y N O P S I S VALVULAR HEART LESIONS
  2. 2. MITRAL STENOSIS (MS) • Normal 4-6 cm2 • Stenosis <4 cm2 • Symptoms <2 cm2 • Severe stenosis <1 cm2 • Causes:- • Rheumatic heart disease • Calcification • Congenital • Lutembacher’s syndrome (acquired MS+ASD) • Carcinoid tumour metastases
  3. 3. MS • Pathophysiology:- • LA outlet obstruction • LA pressure ↑, LA dilatation • LV filling ↓, dependent on LA contraction • Symptoms:- • ↑ing DoE, haemoptysis, cough, chest pain(Pulm cong, PAH) • Fatigue, pedal edema, ascites (Rt sided HF) • Palpitation (AF) • Systemic embolism:- CVA, Renal, Mesenteric, Peripheral ischaemia
  4. 4. MS EXAMINATION • Signs:- • Malar flush (AV anastamoses, venous stasis) • JVP ↑ (RVH, TR, PAH) • Pulse – SR, low volume, AF • Apex – localized tapping • RV – heaving, sustained (PAH, RVH) • Loud palpable S1, opening snap, loud P2 (PAH) • Mid-diastolic, rough, rumbling apical murmur + presystolic accentuation • Graham Steele – EDM (func PR)
  5. 5. MS INVESTIGATIONS • CXR:- • Enlarged LA • PVH, PAH, pulm edema • Calcified mitral valve • ECG:- • Bifid P (P mitrale) • RVH – RAD, tall R V1 • ECHO:- • Mitral valve – area, severity, calcific, mobility • PR, TR • Atria – size, LA thrombus • Ventricles – size, function • CAG – prior to MVR
  6. 6. MS TREATMENT • Diuretics (HF) • Digoxin, β-blocker, CCB, anticoag (AF) • Rheumatic fever prophylaxis • IE prophylaxis • Surgery – medical fails/not feasible • Trans-septal balloon valvotomy • Closed valvotomy • Open valvotomy • MVR
  7. 7. MITRAL REGURGITATION (MR) • Abnormality of:- • Valve leaflets • Valve annulus • Chordae tendinae • Papillary muscles • Left ventricle • Pathophysiology:- • Part of stroke vol back to LA • LA overload • CO ↓
  8. 8. MR • Acute:- • Large vol back to LA, acute LA press ↑ • PVH, pulm edema • Next LV enlarges, maintain stroke vol & CO • Chronic:- • LA dilates, LA press N/slight ↑ • Less PVH & pulm edema
  9. 9. MR CAUSES • Myxomatous valvular degeneration • Ischaemic HD • Rheumatic HD • Infective endocarditis • DCM, HCM • Autoimmune – SLE • Collagen vascular – Marfan’s, Ehler Danlos • Congenital – 1o ASD • Drugs – Fenfluramine, cabergoline
  10. 10. MR SYMPTOMATOLOGY • Slow progress – No symp for years • Sense forceful heartbeat - ↑ stroke volume • Fatigue, lethargy, cardiac cachexia - ↓ CO • Dyspnoea, orthopnoea –PVH, a/c pulm edema • Later – dyspnoea, ascites, pedal edema, ↑ JVP, palpitation (RVH, PAH, AF) • Sub a/c IE – PUO
  11. 11. MR EXAMINATION • Pulse:- • AF • SR, N/low volume • Apex:- • Forceful • Systolic thrill • Auscultation:- • S1 soft, S3+ • Apical PSM. Radiating to axilla • JVP ↑ if RV failure
  12. 12. MR INVESTIGATION • CXR:- • Cardiomegaly, LA & LV enlarged, valve calcific • ECG:- • AF, SR, bifid P mitrale, LVH • ECHO:- • LA & LV dilated • Valve leaflet motion • Papillary muscle anatomy & function • Regurg jet direction, severity
  13. 13. MR TREATMENT • Mild MR – asymp – conservative • Vasodilators - ↓ pre & afterload • Diuretics – HF • Anticoag, antiarrhythmics – AF • β blockers – atrial arrhythmia • ICD – vent arrhythmia • Endocarditis prophylaxis • Symptomatic = Sx (prevent LVD) • MV repair – Sx, clip • MV replacement
  14. 14. BARLOW’S SYNDROME (MVP) • Pathophysiology:- • Large leaflet/ annulus • Long chordae • Papillary muscle dysfunction • Seen max in young females • Associations:- • Marfan’s • Thyrotoxicosis • RHD, IHD, ASD, HCM • Findings – early systolic click, PSM +/-
  15. 15. AORTIC STENOSIS (AS) • LV outflow obstruction • Causes:- • Calcific degeneration – elderly, male, DM, HTN, DLP • Congenital bicuspid vlave • Rheumatic HD • Misc – • CKD • Paget’s of bone • Radiation • Familial hypercholesterolemia
  16. 16. AS PATHOPHYSIOLOGY • LV emptying obstructed • LV pressures ↑ • LV hypertrophy (press overload) • LV ischaemia – angina, arrhythmia, HF • Exertion – • CO rises very little • Worsens angina and fatigue • Syncope/presyncope • Later LA press ↑, PVH = dyspnoea
  17. 17. AS SYMPTOMS • When AV area <⅓ normal • Exertional symptoms • Angina = 4 years • Syncope = 3 years • Dyspnoea = 2 years • Heart failure = 1.5 years • Cachexia, fatigue = end-stage
  18. 18. AS EXAMINATION • Pulse – SR, low vol, slow rising (parvus et tardus) • Apex – undisplaced, heaving • Aortic area – systolic thrill • Auscultation:- • Ejection click • Soft A2, reversed split +/- • S4 • Systolic, low pitched, ejection (crescendo-decrescendo) murmur – aortic area, radiating to carotids
  19. 19. AS INVESTIGATION • CXR:- • Cardiac size N, HF = cardiomegaly • AV calcification • Dilated ascending aorta • ECG:- • SR, Vent arrhythmia • LVH + strain = ST ↓, T ↓, Left leads • ECHO:- • AV area, calcific, jet velocity, severity • LVH, dysfunction • Aorta dilatation • MRI/CT:- • Aortic aneurysm, dilatation, coarcation
  20. 20. AS TREATMENT • Asymptomatic:- • Regular follow-up ECHO • IE prophylaxis • Valvotomy:- • Buys time, improves LV temporarily • Childhood, adolescents mainly • Surgery:- • Symptomatic • Aorta gross/rapidly progressing dilatation • AV replacement – open, percutaneous
  21. 21. AORTIC REGURGITATION (AR) • Pathophysology:- • Blood ejected into aorta in systole • Leaks back into LV in diastole • DBP ↓ • LV volume overload • ↑ Stroke vol to maintain effective CO • LV dilatation, later dysfunction
  22. 22. AR CAUSES • Acute:- • Rheumatic fever • Infective endocarditis • Aortic dissection • Rupture sinus of valslva • Prosthetic valve failure • Chronic:- • Rheumatic heart disease, syphilis, HTN • Bicuspid valve, valve calcification, subvalvular VSD • Arthritides – reactive, ankylosing spondylitis, rheumatoid • Marfan’s, osteogenesis imperfecta
  23. 23. AR SYMPTOMS • Late in disease, when LV fails • Pounding of heart • ↑ Stroke volume & force of contraction • Angina • DoE • Arrhythmias +/-
  24. 24. AR EXAMINATION • Pulse:- • SR, large vol, collapsing • Water hammer/Corrigan’s pulse • BP:- • SBP ↑, DBP ↓ • Wide pulse pressure • Apex:- Displaced down & out (LV dilatation) • Sounds:- • High pitched EDM at Lt sternal border • ESM at aortic area, radiating to carotids • MDM at apex (Austin-Flint)
  25. 25. AR PERIPHERAL SIGNS • Light-house – Flushing & blanching forehead • Landolfi’s – Pupillary size alternation • Becker’s – Retinal artery pulsation • De Musset’s – Head nodding • Muller’s – Uvula pulsation • Corrigan’s – Dancing carotids • Quincke’s – Capillary pulsation in nails • Locomotor brachii • Rosenbach’s – Liver pulsations • Gerhardt’s – Spleen pulsations • Traube’s – Pistol shot sounds over femorals • Duroziez’s – Systolic & diastolic murmurs over femorals • Hill’s – SBP popliteal>brachial
  26. 26. AR INVESTIGATIONS • CXR:- • LVH • Ascending aorta dilatation & calcification • AV calcific • ECG:- LVH • Tall R & deep T ↓ in left side leads • Deep S right side leads • ECHO:- • Dilated aortic arch • LV – dilatation, dysfunction • Severity of AR • TEE – Aortic valve & aortic root • MRI & CT – Assess thoracic aorta & root
  27. 27. AR TREATMENT • Rx for specific cause • A/c AR – vasodilators, inotropes • LV dysfunction – ACEi • Surgery:- • Before LVD sets in – not completely reversible • Before significant symptoms develop • A/c severe AR • Symptomatic c/c severe AR • LVD present • LV dilatation present • Along with other cardiac Sx
  28. 28. TRICUSPID STENOSIS (TS) • Uncommon • Women > men • Associated mitral & aortic valve disease • Causes:- • RHD • Carcinoid • Pathophysiology:- • RA emptying impaired, CO ↓ • RA press ↑ • Venous congestion (↑JVP, hepatomeg, ascites, pedal edema)
  29. 29. TS • Symptoms:- • Abd pain + swelling • Pedal edema • Left sided failure symptoms • Signs:- • ↑ JVP, pedal edema • Pulsatile liver, hepatomegaly • Rumbling MDM @ lower LSE, louder on inspiration • Tricuspid OS
  30. 30. TS INVESTIGATIONS • CXR:- • Prominent right atrial bulge • ECG:- • Peaked, tall P waves (>3 mm) in lead II (RAE) • ECHO:- • Thickened & immobile tricuspid valve
  31. 31. TS TREATMENT • Medical:- • Diuretic therapy • Salt restriction • Surgical:- • Tricuspid valvotomy • Tricuspid valve replacement is often necessary • Other valves usually also need replacement
  32. 32. TRICUSPID REGURGITATION (TR) • RA pressure overload • Causes:- • Functional- • RV dilatation • Cor pulmonale, MI, pulmonary HTN • Organic- • RHD • IE • Carcinoid syndrome • Congenital - Ebstein’s anomaly
  33. 33. TR • Symptoms:- • Right heart failure • Signs:- • Large jugular venous c & v waves • Hepatomegaly + pulsates in systole • Lt parasternal heave (RVH) • Blowing PSM @ LSE, best heard on inspiration • AF common • ECHO:- • Dilated RV • Thickened tricuspid valve
  34. 34. TR TREATMENT • Functional – Medical Rx • Severe organic:- • TV repair – plasty, plication • TV replacement
  35. 35. PULMONARY STENOSIS (PS) • Causes:- • Congenital – most common (isolated, ToF) • RHD • Carcinoid • Pathophysiology:- • RV press overload • RVH, then RAH • Rt heart failure
  36. 36. PS • Symptoms:- • Mild – asymptomatic • Moderate – fatigue, syncope, dyspnoea +/- • Severe – incompatible • Signs:- • JVP – prominent a wave • Lt parasternal heave • Delayed, soft P2 + pulmonary ejection click • Harsh midsystolic ejection murmur @ 2nd Lt ICS, best heard on inspiration, thrill + • RV S4
  37. 37. PS • Investigations:- • CXR:- • Prominent pulmonary artery • ECG:- • RAH – Tall P right leads • RVH – Tall R right leads • ECHO:- • Doppler – stenotic flow • RVH • RA hypertrophy/enlargement • Treatment:- • Pulmonary valvotomy (balloon,direct surgery)
  38. 38. PULMONARY REGURGITATION (PR) • Most common acquired pulm valve defect • Pulm HTN most common cause (annular dilatation) • Decrescendo diastolic murmur • No symptoms • Treatment rarely needed

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