VALVULAR HEART DISEASE - A SHORT REVIEW

1. Valvular Heart Disease

2. Classification of Heart Disease
Congenital
Coronary
Electrical
Endomyocardial
Pericardial
Valvular

3. The Cardiac Valves

4. Cardiac Valve Anatomy

5. Valvular Heart Disease
Acute and Chronic
are
Different Diseases

6. Aortic Stenosis

7. Aortic Stenosis
Types
Valvular
Subvalvular
Supravalvular

8. Aortic Valve Stenosis

9. Aortic Valve Stenosis
Bicuspid
Rheumatic
Degenerative

10. Aortic Valve Stenosis
Age Relationship

11. Bicuspid Aortic Stenosis

12. Rheumatic Aortic Stenosis

13. Degenerative Aortic Stenosis

14. Degenerative Aortic Stenosis
Risk Factors
Elevated LDL-cholesterol
Diabetes mellitus
Systemic arterial hypertension
Cigarette smoking

15. Aortic Valve Stenosis
Symptoms
Often Asymptomatic
Angina pectoris
Dyspnea
Fatigue
Syncope

16. Aortic Valve Stenosis
Signs
ARTERIAL PULSE, GEN – RISE, SLOW
ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED
ARTERIAL PULSE, GEN – DOWNSLOPE GRADUAL
ARTERIAL PULSE, GEN – PULSE PRESSURE, NARROW
ARTERIAL PULSE, GEN – SHUDDER
ARTERY, CAROTID – THRILL
HEART, LV APEX – IMPULSE, PRESYSTOLIC
HEART, LSB MID – MURMUR, DIASTOLIC
HEART, LSB MID – MURMUR, SYSTOLIC

17. Aortic Valve Stenosis
Signs (cont)
HEART, LV APEX – CLICK, SYSTOLIC
HEART, LV APEX – IMPULSE, SUSTAINED
HEART, RSB UPPER – MURMUR, SYSTOLIC
HEART, RSB UPPER – CLICK, SYSTOLIC
HEART, SOUND A2 – ABSENT OR REDUCED
HEART, SOUND S1 – SOFT
HEART, SOUND S2 – SINGLE
HEART, SOUND S2 – SPLIT REVERSED (PARADOXICAL)
NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

18. Aortic Valve Stenosis
Symptoms
FATIGUE
BREATHING – DIFFICULT WITH EFFORT (DYSPNEA)
CHEST, ANT – PAIN, NONPLEURITIC (ANGINA PECTORIS)
CHEST, ANT – PALPITATIONS
CONSCIOUSNESS – LOSS, SUDDEN (SYNCOPE)
CONSCIOUSNESS – LOSS, SUDDEN EFFORT (EFFORT SYNCOPE)
DIZZINESS – EFFORT

19. Aortic Valve Stenosis
Untreated Prognosis

20. Aortic Valve Stenosis
Chest X-Ray

21. Aortic Valve Stenosis
ECG

22. Aortic Valve Stenosis
Echo

23. Aortic Valve Stenosis
AV Pressure Gradient

24. Aortic Valve Stenosis
Medical RX
No drugs alter course – only valve repair/replacement
Antibiotic Prophylaxis
? Statins
For symptoms (if not candidate for valve replacement) – after-load reduction, i.e.,
nitroglycerine, used with caution to avoid BP fall

25. Aortic Valve Stenosis
Surgical Rx
Valvotomy
Replacement
Artificial
Bioprosthesis
Minimally-invasive transfemoral

26. Aortic Valve Replacement
Transfemoral

27. Aortic Valve Stenosis
Complications
Atrial fibrillation
Aortic Dissection
Heart failure
Infective endocarditis
Myocardial infarction
Sudden death

28. Aortic Regurgitation
(Insufficiency)

29. Aortic Regurgitation
Etiologies
Primary aortic valve disease
Aortic root abnormalities (Dissection, Syphilis)
Connective tissue disorders (Marfan’s)
Infective endocarditis
Inflammatory disorders (SLE)
Tumors

30. Aortic Regurgitation
Symptoms
BREATHING – DIFFICULT , NOCTURNAL
BREATHING – DIFFICULT WITH EFFORT
CHEST, ANT – PAIN, NONPLEURITIC (ANGINA)
CHEST, ANT – PALPITATIONS
HEAD, GEN – PAIN
SWEATING – NOCTURNAL

31. Signs
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED
ARTERIAL PULSE, GEN – DOUBLE
ARTERIAL PULSE, GEN – FALL, RAPID
ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE
ARTERIAL PULSE, GEN – RISE, RAPID
ARTERY, CAROTID – THRILL
ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING

32. Signs (cont)
HEAD – BOBBING
HEART, LSB MID – MURMUR, DIASTOLIC
HEART, LSB MID – THRILL, DIASTOLIC
HEART, LV APEX – IMPULSE, INF DISPLACEMENT
HEART, LV APEX – IMPULSE, LAT DISPLACEMENT
HEART, LV APEX – IMPULSE, DIFFUSE
HEART, LV APEX – MURMUR, DIASTOLIC
HEART, RSB UPPER – MURMUR , SYSTOLIC
HEART, RSB UPPER – MURMUR, DIASTOLIC

33. Signs (cont)
HEART, RSB UPPER – THRILL, SYSTOLIC
HEART, SOUND A2 – ABSENT OR REDUCED
HEART, SOUND S1 – SOFT
HEART, SOUND S2 – SPLIT REVERSED
HEART, SOUND S3 LV
MOUTH, UVULA – PULSATIONS
NAILS – PULSATIONS
NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

34. Aortic Regurgitation – Chronic
Chest X-Ray

35. Aortic Regurgitation
Echo

36. Aortic Regurgitation
Medical Rx
Vasodilators to reduce systolic BP
Antibiotic prophylaxis

37. Aortic Regurgitation
Surgical Rx
Aortic valve replacement

38. Mitral Regurgitation
(Insufficiency)

39. Mitral Regurgitation
Etiologies
Congenital deformities
Degenerative, i.e., myxomatous
Endomyocardial fibroelastosis
Mitral annular calcification
Papillary muscle dysfunction – ischemic heart disease
Rheumatic

40. Mitral Regurgitation
Etiologies (cont)
Ergotamine toxicity
Carcinoid syndrome
Radiation Rx
SLE
Diet-drug therapy

41. Papillary Muscles

42. Leaflet Prolapse (MVP Syndrome)

43. Mitral Regurgitation
Calcified Annulus

44. Symptoms
BREATHING – DIFF, EFFORT
FATIGUE
SKIN, GEN – TEMPERATURE, COOL
SWEATING – EXCESSIVE

45. Signs
ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED
ARTERIAL PULSE, GEN - FALL, RAPID
ARTERIAL PULSE, GEN - RISE, RAPID
CHEST, ANT LEFT - BULGE
HEART, LV APEX - IMPULSE, FORCEFUL
HEART, LV APEX - IMPULSE, DIFFUSE

46. Signs (cont)
HEART, LV APEX - IMPULSE, SUSTAINED
HEART, LV APEX - MURMUR, DIASTOLIC
HEART, LV APEX - MURMUR, SYSTOLIC
HEART, SOUND P2 - LOUD
HEART, SOUND S3 LV
SKIN, GEN - TEMPERATURE, COOL

47. Mitral Regurgitation
2-D Echo

48. Doppler Echo

49. Complications
Atrial fibrillation
Pulmonary hypertension
LV dysfunction
Infective endocarditis

50. Medical Rx
Antibiotic prophylaxis
ACEIs (functional form of MR)
Beta-blockers (functional form of MR)

51. Surgical Rx
Mitral repair
Mitral valve replacement

52. Mitral Stenosis

53. Mitral Stenosis
Increased LA Pressure

54. Mitral Stenosis
Etiologies
Rheumatic
Rare:
Congenital
Chest radiation
Left atrial myxoma
Mucopolysaccharidosis
Severe mitral annular calcification

55. Mitral Stenosis
Symptoms
ABDOMEN, GEN – PAIN
BREATHING – DIFF, NOCTURNAL
BREATHING – DIFF, EFFORT
BREATHING – DIFF, RECLINING FLAT
BREATHING – DIFF, RESTING
BREATHING – RAPID
CHEST, ANT – PAIN, NONPLEURITIC
CHEST, ANT – PALPITATIONS
COUGH – CHRONIC, NONSPECIFIC
FATIGUE
SPUTUM – BLOODY

56. Mitral Stenosis
Signs
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN – LOW
ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW
ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED
BREATH SOUNDS, GEN – WHEEZES
EXTREMITIES, LOWER BILATERAL - EDEMA
HEART RATE – RAPID
HEART, LSB LOWER – IMPULSE, SYSTOLIC

57. Mitral Stenosis
Signs (cont)
HEART, LSB LOWER – MURMUR, DIASTOLIC
HEART, LSB MID – PERCUSSION, DULLNESS
HEART, LV APEX – MURMUR, DIASTOLIC
HEART, LV APEX – OPENING SNAP, MITRAL
HEART, LV APEX – THRILL, DIASTOLIC
HEART, RSB – SOUND, SYSTOLIC EJECTION
HEART, RSB UPPER – MURMUR, DIASTOLIC
HEART, SOUND P2 – LOUD

58. Mitral Stenosis
Signs (cont)
HEART, SOUND P2 – PALPABLE
HEART, SOUND S1 – SOFT
HEART, SOUND S1 – LOUD
LIVER – ENLARGED
SKIN, CHEEKS – COLOR, PINK PURPLE
SKIN, GEN – COLOR, BLUE
VENOUS PULSE, JUGULAR - A WAVE, LARGE
VENOUS PULSE, JUGULAR – ELEVATED

59. Chest X-ray

60. Echo

61. LA Thrombus

62. ECG

63. Complications
Atrial fibrillation
Infective Endocarditis
Peripheral embolism
Pulmonary hypertension

64. Medical RX
Antibiotic prophylaxis
Anticoagulation for
Atrial fibrillation
Prior embolic event
Documented LA thrombus
Arrhythmia control

65. Surgical RX
Invasive valvuloplasty
Percutaneous valvotomy
Valve replacement

66. Invasive Valvuloplasty

67. Surgical RX – Valvuloplasty with Balloon
Catheter

68. Valvular Heart Disease
Follow up
Antibiotic prophylaxis
New symptoms
Change in symptoms
Change in physical findings
Echocardiography/other imaging

69. THANK YOU