the basic anatomy of cardiac valves and their disorders, managament auscultation sites

1. A N A T M Y
O F
T H E
C A R D I A C
V A L V E S

2. OBJECTIVES
To demonstrate :
• The basic anatomy of cardiac valves
• The cardiac valves disorders and their managements
• The knowledge of heart sounds

3. T H E
H E A RT
H A S 4
VA LV E S

4. between the right atrium
and the right ventricle
between the right ventricle
and the pulmonary trunk
between the left atrium
and the left ventricle
between the left ventricle
and the ascending aorta
Tricuspid
Pulmonary
Mitral
Aortic

5. ATRIOVENTRICULAR ORIFICES
Large oval aperture of communication
between the right atrium and ventricle.
Aperture of communication between
the left atrium and ventricle, it’s a little
smaller than right A-V orifice,
it is admitting only two fingers.
Right A-V orifice :
Left A-V orifice :

6. RIGHT AND LEFT FIBROUS TRIGONE
Is a thickened area of connective tissue between
the aortic ring and right atrioventricular ring
Is a thickened area of connective tissue between
the aortic ring and the left atrioventricular ring
• It surrounds and provides points of attachment
for the cusps
Right fibrous trigone :
Left fibrous trigone :
NOTE :

7. ATRIOVENTRICULAR VALVES
• Support by attachments to chordae tendineae to the free ridges of cusps
• In turn, Chordae tendineae arise from tips of papillary muscles in inner surface of ventricles
• They produce 1st heart sound
Tricuspid valve: Mitral valve:
Has 2 papillary musclesHas 3 papillary muscles

8. It guards the right atrioventricular orifice
Has 3 cusps :
based on their position in RightVentricle
There are continuous together near
the bases at commissures
• Normal valve area in adult 4-6 cm2
• Tricuspid annulus provides a firm support .
Anterior
Septal
Posterior
TRICUSPID VALVE
NOTE :

9. The largest, most constant papillary muscle,
and arises from the anterior wall of the ventricle.
May consist of 1 to 3 structures, with some chordae tendineae
arising directly from the ventricular wall
The most inconsistent papillary muscle, either small or absent,
with chordae tendineae from the septal wall
• Two papillary muscles attached to each cusp
• Prevent separation of the cusps during ventricular contraction
Anterior papillary muscle :
Posterior papillary muscle :
Septal papillary muscle :
NOTE :
TRICUSPID VALVE

10. It guards the left atrioventricular orifice
Has 2 cusps: based on their position in the left ventricle
The anterolateral and posteromedial commissures divided
them into :
Larger and intervenes between A-V and aortic orifices
Smaller with wider attachment to the annulus
• Normal valve area in adult 4-6 cm2
Posterior cusp :
Anterior cusp :
MITRAL VALVE (BICUSPID)
NOTE :

11. • Each papillary muscle attached to both cusps
• They are larger than those of the right ventricle
A fibrous ring that connects with the leaflets
It’s not a continuous ring around the mitral orifice
and appears to be more D-shaped functions as a sphincter
that contracts and reduces the surface area of the valve
during systole to ensure complete closure of the leaflets
Anterior papillary muscle
Posterior papillary muscle
Mitral annulus:
MITRAL VALVE (BICUSPID)

12. AORTIC VALVE ORIFICE
A circular aperture, in front and to the right of the mitral orifice,
which is leading to ascending aorta and separated from L.A-V
by the anterior cusp of the bicuspid valve
Is a fibrous ring at Aortic orifice and
it considers as the transition point between
the left ventricle and aortic root.
Aortic annulus :

13. Opening between the pulmonary
trunk and the right ventricle of the
heart at apex of the infundibulum
Similar to aortic annulus and has
three arches which surround
the pulmonary valve orifice
Pulmonary annulus :
PULMONARY ORIFICE

14. They produce the second heart sounds.
Each one consists of 3 cusps with free edge
projecting upward into the lumen of vessel
and each cusp has the following features :
Pocket like – dilatations between cusps and the wall of vessel
A middle, thickened portion on free superior edge of each cusp
A thin lateral portion on both sides
Aortic valve
Lunule :
Nodule :
Sinus :
Pulmonary valve
SEMILUNAR VALVES

15. AORTIC VALVE
It guards the aortic orifice
Has 3 cusps and sinuses: relative to their fetal position
Origin for the right coronary artery
Origin for the Left coronary artery
(posterior relatively to the others)
Because there are no arteries originate from it
• Blood recoils after ventricular contraction
and fills the aortic sinuses, it is automatically
forced into the coronary arteries
Anterior (noncoronary) :
Left (coronary) :
Right (coronary) :
NOTE :

16. It guards the pulmonary orifice
At the apex of the infundibulum
Has 3 cusps and sinuses :
relative to their fetal position
• The recoil of blood fills these pulmonary sinuses
and forces the cusps to close
• Normal valve area 2-3cm2
Anterior
Right
Left
NOTE :
PULMONARY VALVE

17. SURFACE ANATOMY OF
THE CARDIAC VALVES :
• Midline of sternum opposite 4th I.C.S
•
• Behind Left half of the sternum opposite Left 4th I.C.S
• Behind medial end of 3rd
C.C with part joining the sternum
• Aortic :
• Behind Left margin of Sternum opposite Left 3rd
C.C.S
Tricuspid :
Mitral :
Pulmonary :
Aortic :
Midline of sternum opposite 4th I.C.S
Behind Left half of the sternum
opposite Left 4th I.C.S
Behind medial end of 3rd C.C
with part joining the sternum
Behind Left margin of Sternum opposite Left 3rd C.C.S

18. W H E R E
T O
L I S T E N ?

19. VALVULAR
DISEASES: The failure of a valve to close
completely which allows backflow of the blood
Atresia :
Regurgitation :
The complete lack of formation of a valve
Stenosis :
The failure of a valve to open completely which
is obstructing forward flow of the blood

20. TRICUSPID STENOSIS
Uncommon condition, usually associated with clinical evidence of regurgitation
• Rheumatic (most common cause)
• Carcinoid syndrome
• Congenital condition
• Infective Endocarditis
• Treat the cause if endocarditis.
• Surgical replacement
• Repair: Interventional catheterization or surgical
Causes :
Management :

21. TRICUSPID REGURGITATION
Common condition, either :
• Primary (Intrinsic abnormality of the valve apparatus)
• Secondary (R.V dilatation or dysfunction)
• Rheumatic
• Carcinoid syndrome
• Infective Endocarditis
• Congenital condition :
- Ebstein anomaly : apical displacement of the septal and
posterior tricuspid valve leaflets which is the most common
• Diuretics, Digoxin,ACEI for R.V dysfunction
• Repair: Interventional catheterization or surgical
Causes :
Management :

22. TRICUSPID ATRESIA
3rd most common form of cyanotic congenital heart disease
3 different types depends on position of great arteries :
With normal great arteries
With D-transported great arteries
With I-Transported great arteries
• Repair: Interventional catheterization or surgical
Type 1 :
Type 3 :
Type 2 :
Management :

23. Could lead to pulmonary venous congestion due to high Pr. In L.A
• Rheumatic
• Mitral annulus calcification
• Congenital defect
• Symptoms appears when valve area is 2-2.5 cm2
• Severe stenosis valve area of less than1 cm2
• Effort dyspnea is dominant symptom.
• diuretics for pulmonary congestion
• anticoagulants for prevention of thrombus
• B-blockers, Ca channel blockers..etc to Control HR
• Surgical replacement
• Repair: Interventional catheterization or surgical
Causes :
Management :
MITRAL STENOSIS
NOTE :

24. Most common valvular heart disease, Either:
No time for L.A to dilate = increased Diastolic Pr. may cause P.Edema
overload on both LA&LV (both dilate) = Decreased CO
• Rheumatic
• Mitral valve prolapse (most common cause)
• Infective endocarditis
• Annular calcification
• ACEI, Diuretics to reduce Afterload.
• Surgical Replacement.
• Repair: Interventional catheterization or surgical
Acute :
Chronic :
Causes :
Management :
MITRAL REGURGITATION

25. It is a rare congenital defect, association with larger ventricular
anomalies
Management :
• Staged surgeries after birth
MITRAL ATRESIA

26. The most common valvular disease
• Rheumatic (usually associated with M.V disease)
• Congenital (such as Bicuspid valve)
• Calcification of the valve
Initially, CO is normal by the time L.V is hypertrophied then
Diastolic dysfunction then systolic dysfunction eventually MI/Death
• Mild to moderate aortic stenosis is usually asymptomatic
• severe stenosis < 1.0 cm2
• Digitalis, Diuretics, ACEI to control HF and Reduce AfterLoad
• Surgical replacement
• Repair: Interventional catheterization or surgical
Causes :
Management :
AORTIC STENOSIS
NOTE :

27. • Rheumatic Marfan's syndrome Uncontrolled hypertension
• Endocarditis Aortic dissection Supravalvular aortic stenosis
• Degenerative
• Congenital
Overload but there is time for L.V&L.A to
dilate eventually lead to LV dysfunction.
No time for L.V&L.A to dilate so increased diastolic Pr.
in both L.V&L.A may lead to P.Edema
• Vasodilators to control ABP (ACEI)
• Surgical replacement
Causes :
Cusps abnormality : Others :
Chronic :
Acute :
Management :
AORTIC REGURGITATION
Aortic root :

28. It is relatively common condition
• Congenital
• Carcinoid syndrome
• Rheumatic
• Sub-valvular (narrowing of the infundibular)
• Supra-valvular(in main pulmonary artery)
• Balloon valvuloplasty
• Surgical valvotomy
Causes :
Management :
PULMONARY VALVE STENOSIS

29. The isolated P.Regurgitation is rare. However, it is usually
secondary to pulmonary artery dilatation due to P.Hypertension
• Pulmonary hypertension (most common)
• From surgical complication
• Congenital (tetralogy of fallot)
RV overload > hypertrophy > dysfunction
eventually could lead to tricuspid regurgitation
• Treat the cause (Pulmonary hypertension)
• Valve replacement (Rare)
Causes :
Management :
PULMONARY VALVE REGURGITATION

30. Congenital condition for unknown etiology.
Its associated with PDA
• Pulmonary atresia without ventricular septum defect
• Pulmonary atresia with ventricular septum defect
• Repair: Interventional catheterization or surgical
Management :
PULMONARY VALVE ATRESIA
Two types or conditions :

31. HEART
SOUNDS
It is inaudible by stethoscope
Audible in (pathological conidiations) :
Aortic regurgitation or HF, ......
1st Heart sound
Closure of A-V valve
Long, soft, low pitched sound
Closure of semilunar valve
Short, sharp, high pitched
It is inaudible - audible in (pathological conditions) :
Ventricular hypertrophy or aortic stenosis
2nd Heart sound
3rd Heart sound
4th Heart sound
Valvular factor : The vibrations in cusps and chordae tendineae that
results for closure of the valve .

32. THANKS

33. REFERENCES :
• Essentials of medical physiology 6th ed
• Snell clinical anatomy by regions 9th ed
• Grey’s anatomy for student’s 4th ed
• Davidson’s Essentials of Medicine 24th ed
• Escardio.org/Education/Practice-
Tools/EACVI-toolboxes/3D-Echo/anatomy-of-
tricuspid-valve
• Emedicine.medscape.com/article/1878301-
overview#a4
• Emedicine.medscape.com/article/1922899-
overview#a2
• Emedicine.medscape.com/article/158359-
clinical#b5