Topics: Valvular Heart Diseases, Rheumatic Heart Disease, Infective endocarditis, Prosthetic valves Subject: Pathology Course: ATOT IInd year Valvular Heart Diseases, Calcific Aortic Stenosis, Mitral Valve Prolapse, Rheumatic Fever, Rheumatic Heart Disease, Infective endocarditis, Prosthetic valves and complications

1. VALVULAR HEART
DISEASES
Dr. Salman Ansari
MBBS
28/02/23

2. Valvular heart diseases
● Types of valvular heart disease
● Calcific Aortic stenosis
● Mitral valve prolapse
● Rheumatic fever, Rheumatic heart disease
● Infective endocarditis
● Prosthetic valves and their complications

3. Anatomy

6. ● Systole: contraction
● Diastole: relaxation

7. Valvular heart disease
Definition: Various forms of congenital and acquired diseases which
cause valve deformities, and can result in heart failure
● Rheumatic heart disease is the most common acquired valvular disease
● Left side valves affected more commonly
● Most commonly affected valve: mitral valve, followed by aortic valve

8. Types of valvular heart disease
1. Stenosis
2. Insufficiency/regurgitation

9. 1. Stenosis:
Failure of a valve to open completely, and it obstructs forward flow of
blood
1. Regurgitation/insufficiency:
Failure of valve to close completely and it leads to backflow of blood

11. ● Tricuspid stenosis
● Tricuspid regurgitation
● Pulmonary stenosis
● Pulmonary regurgitation
● Mitral stenosis
● Mitral regurgitation(MR)
● Aortic stenosis(AS)
● Aortic regurgitation
Mnemonic for most common:
“ASMR”

14. Etiology of valvular heart disease
- Congenital:
- Congenital stenosis
- Acquired:
- Rheumatic heart disease
- Bacterial endocarditis
- Calcific degeneration
- Myxomatous degeneration
- Hypertension
- ageing

15. Calcific aortic stenosis
Definition: Narrowing of aortic valve orifice due to deposition of
calcium in the valve cusps and ring
Most common valve abnormality
Due to age-related wear and tear
Causes:
1. Senile calcific stenosis: in elderly, after 7th decade of life
2. Congenital bicuspid aortic stenosis: congenital condition - appears by
5th to 6th decades of life

16. Morphology:
Presence of calcified masses on base and lower half of aortic cusp

17. Pathological effects:
- Stenosed aortic valve
- Obstruction to outflow from left ventricle(LV)
- Concentric hypertrophy of LV
- Cardiac failure develops, leading to both dilatation and hypertrophy of
heart(“eccentric hypertrophy”)

18. Mitral valve prolapse/Myxomatous degeneration of mitral
valve
Also called floppy mitral valve syndrome
Valve leaflets become enlarged and floppy, and chorda tendineae
become elongated, leading to prolapse of leaflets of valve during systole
Most common cause of MR

19. Morphology:
● Gross: valve leaflets are deformed, enlarged, thick and rubbery,
with ballooning of mitral leaflets
● Microscopy: thickening with deposition of mucoid
material(myxomatous degeneration of mitral valve)

21. Clinical features:
● Asymptomatic in most cases
● Auscultation: mid-systolic click, mid to late systolic murmur
Diagnosis:
● by echocardiography
Treatment:
● Valve repair or replacement surgery

22. Complications:
● Infective endocarditis
● Mitral regurgitation
● Stroke
● Arrhythmia
● Sudden cardiac death

23. RHEUMATIC FEVER AND
RHEUMATIC HEART DISEASE

25. RF and RHD
● Definition
● Etiology
● Pathogenesis
● Morphology
● Clinical features, Jones criteria for RF
● Diagnosis + treatment
● Complications

26. RF and RHD
RF: acute post-streptococcal multisystem inflammatory disease
RHD: Longterm complication of rheumatic fever, due to damaged
heart valves
Etiology:
- children
- occurs few weeks after after a beta-hemolytic streptococcal infection
of the throat
- immune-mediated
- Due to single or repeated attacks of rheumatic fever

27. Pathogenesis
- In Acute rheumatic Fever:
- B-cell produces antibodies against antigen of streptococcus
- M-antigen of streptococcus is similar to self-antigens of
heart(called molecular mimicry)
- This antibody cross-reacts with heart and valves
- Leads to inflammation in heart(pancarditis)

28. - Multiple attacks of rheumatic fever
Progressive fibrosis of heart valves
Rheumatic valvular disease

29. Morphology:
● Cardiac and extra-cardiac lesions
Cardiac lesions:
● Acute rheumatic carditis which may progress to chronic rheumatic
heart disease
● Pancarditis - effects all three layers of the heart(endocardium,
myocardium and pericardium)
● Valves have small vegetations called “verrucae”, along lines of
closure of leaflet
● Aschoff body: areas of fibrinoid necrosis, with activated
macrophages(“Anitschkow cells”)
● Mitral valve stenosis or regurgitation

32. Vegetations(verrucae) along lines of closure of valves

34. Extra-cardiac lesions:
● Migratory polyarthritis: one joint becomes painful and swollen,
subsides, and then later another joint gets affected
● Erythema marginatum: reddish rashes
● Subcutaneous nodules: spherical painless nodules on wrists,
elbows, annkles, knees
● Sydenham chorea: rapid involuntary jerky movements
Mnemonic: M.E.S.Sy

38. Sydenham’s chorea
or St. Vitus’ Dance

39. Clinical features
● Fever
● Joint pain
● Rashes
● Nodules
● Jerky movements(chorea)

40. Jones criteria for RF
Major criteria Minor criteria
● Heart
involvement(pancarditis,
valve involvement)
● Migratory polyarthritis
● Erythema marginatum
● Subcutaneous nodules
● Sydenham’s chorea
● CRP increased
● Arthralgia
● Fever
● ESR increased

42. Diagnosis
For RF:
- Jones criteria for RF: 2 major, or 1 major + 2 minor criteria
- Throat culture
- Blood: antistreptolysin-O(ASO) titer, ESR, CRP
For RHD:
- Echocardiography of heart: for valve damage
- ECG: abnormal rhythms

43. Treatment:
● Prevention by early antibiotic treatment in acute rheumatic
fever
● Surgery to repair valves in rheumatic heart disease

44. Complications
- Can lead to Infective endocarditis: as valves are damaged
and bacteria can get deposited on the valve
- Mural thrombus: clot stuck to wall of blood vessel or heart
chamber)
- Thrombo-embolism
- Congestive cardiac failure: due to mitral and aortic valve
stenosis
- Pericarditis
- Arrhythmia

45. INFECTIVE ENDOCARDITIS

46. IE
● Definition
● Types
● Etiology
● Pathogenesis
● Morphology
● Clinical features
● Complications

47. Infective Endocarditis
- Infective endocarditis also called Bacterial Endocarditis
- Endo card itis
- Inside heart inflammation
- Definition: Infection of endocardium by microbial agents

48. Types
Depending on severity, there are 2 types
1. Acute Bacterial Endocarditis(ABE)
2. Subacute Bacterial Endocarditis(SABE)
- Acute BE: destruction of endocardium by highly virulent bacteria in a
previously normal heart, usually rapidly fatal in a period of 2-6
weeks
- Subacute BE: less virulent bacteria in a previously diseased heart,
gradual course over a period of 6 weeks to few months

49. Incidence
- Usually over 50 years of age
- Males affected more than females

50. Etiology
Causes: Infection with microorganisms
+
Predisposing factors

51. 1. Infective agents:
- Causative organism: 90% of cases by streptococci and staphylococci
- In ABE: most common is Staphylococcus Aureus - through injection
by intravenous drug users(IVDU)
- In SABE: most common is Streptococcus viridans - oral route
- HACEK organisms (Haemophilus, Aggregatibacter, Cardiobacterium,
Eikenella, Kingella)
1. Predisposing factors: 3 factors
-Conditions with bacteremia, septicemia, pyemia(any infection)
-Underlying heart disease: chronic rheumatic heart disease,
congenital heart disease
-Weakened immunity: diabetes, leukemia

52. Pathogenesis
- Damage to valves/endothelium
- Bacteria stick to damaged valves/endocardium
- Bacteria multiplies
- Formation of “vegetation”

53. Morphology
Presence of vegetations on valves or endocardium
Gross:
- Vegetations on mitral or aortic valve
- Friable
- Bulky
- Single or multiple

54. Microscopy:
1. CAP
2. BACTERIA
3. WBCs
Vegetation has:
● Cap
● Zone of bacteria
● Deep zone with WBCs

56. Clinical features
● Fever, chills, weakness
● Murmur may be heard on auscultation
Complications:
1. In heart(cardiac complications)
2. Can spread beyond heart to other organs(extracardiac complications)

57. 1. Cardiac complications
- Valvular stenosis(thickening of valve)
- Perforation, rupture or aneurysm of
Valves
- Abscess around valve(ring abscess)
- Myocardial abscess
- Suppurative pericarditis

58. 2. Extracardiac complications:
- Vegetations are friable and can break
- Emboli from left heart can go to other organs like spleen, kidney and
brain
- Septic emboli can lead to septic infarct
- Osler nodes in fingers
- Roth spots in eyes
- Splinter hemorrhage in nails

61. Diagnosis:
● Modified Duke criteria
● Blood culture
● Echocardiography
Treatment:
i.v antibiotics for upto 6 weeks

62. PROSTHETIC VALVES

63. Prosthetic valves
Replacement of damaged cardiac valves with prosthetic valve
Types:
● Mechanical valves
● Tissue valves(bioprosthesis): using porcine or bovine valves

65. Complications:
● Thromboembolism
● Anticoagulant-related hemorrhage
● Infective prosthetic valve endocarditis
● Structural deterioration: calcification, tearing
● Obstruction: due to fibrosis

66. Summary of valvular heart disease
● 2 Types?
● Most common cause?
● Most common valves affected?
● Right side or left side?
● Which valves?
● Calcific aortic stenosis
● Mitral valve prolapse

67. RF, RHD
● RF
● RHD
● Causative organism?
● Pathogenesis
● Morphology in heart?
● Extracardiac?
● MESSy
● Jones criteria
● Major and minor
● ♡ MESSy CAFE
● diagnosis

68. Infective endocarditis
● Definition
● Types
● ABE
● SABE
● Causative organism?
● Pathogenesis
● Morphology?
● Diagnosis: Modified ____ criteria
● Blood culture, echo

69. Prosthetic valves
● Types?
● complications

70. References:
● Ramadas Nayak - Textbook of Pathology for Allied
Health Sciences
● Harsh Mohan - Textbook of Pathology
Questions:
salman.s.ansari92@gmail.com
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