This document discusses valvular heart disease, focusing on rheumatic heart disease, mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation. It covers the anatomy of heart valves, causes of valve diseases including rheumatic fever, clinical features, investigations, and treatment options such as medications, surgery, valve repair/replacement procedures. Key points are the involvement of heart valves in rheumatic fever, symptoms and complications of mitral stenosis, and surgical treatments for various valve diseases including valve repair/replacement and newer transcatheter procedures.

1. VALVULAR HEART
DISEASE

2. VALVES IN HUMAN HEART
MITRAL VALVE
AORTIC VALVE
TRICUSPID VALVE
PULMONARY VALVE

3. Valve Anatomy

4. Rheumatic Heart Disease
A condition in which the heart valves are damaged permanently due to
rheumatic fever, a inflammatory condition which occurs after under-
treated streptococcal infection.
Affected organs :-
1. Heart
2. Joints
3. CNS
4. Skin
5. Subcutaneous Tissues

5. Clinical Features Of RF
Migratory Polyarthritis
Fever
Carditis
Sydenham’s chorea
Subcutaneous nodules
Erythema marginatum
Importance of RF is in its involvement of the heart, it is
rarely fatal in its acute stage. But it may lead to
rheumatic valvular disease – a chronic and progressive
condition that causes disability or death many years
after the initial event.

6. Jones Criteria
For diagnosis of rheumatic fever
MAJOR CRITERIA
1. Carditis
2. Polyarthritis
3. Chorea
4. Erythema marginatum
5. Subcutaneous nodules
MINOR CRITERIA
CLINICAL FINDINGS
1. Arthralgia
2. Fever
LAB FINDINGS
1. Elevated CRP
2. Increased ESR
3. Prolonged PR interval

7. Pathology
PANCARDITIS Occurs
Pericarditis resolves - No
Sequelae
Myocarditis - Myocardial
cellular necrosis, Aschoff’s
nodules
Endocarditis – Responsible for
chronic rheumatic valvulitis.

8. Pathology
- verrucous vegetations 1-2 mm on valve surface
- edema and inflammation of valve leaflets
- healing
- granulations and fibrosis
- fusion of leaflets and chordae
- Valve STENOSIS or INCOMPETENCE

9. Mitral Stenosis
There is an obstruction to blood flow between the
LEFT ATRIUM and the LEFT VENTRICLE , caused by
abnormal mitral valve structure and function.
ETIOLOGY OF MS
1. Rheumatic fever
2. Mitral Annular Calcification
3. Left Atrial Myxoma, Cor Triatriatum
4. Congenital Mitral Stenosis

10. Pathophysiology of Mitral
stenosis
Decrease in mitral area -> increased LA pressure
LA ENLARGEMENT
ATRIAL ARRYTHMIA
↑ pul. Venous Pressure
Pulmonary Oedema

11. CLINICAL FEATURES
SYMPTOMS-on exertion
Dyspnea,wheezing,cough
Fatigue
Diminished activity / pace of
activity
Palpitations ,syncope
SYMPTOMS AT REST
Paroxysmal nocturnal dyspnea
Orthopnea
Hemoptysis
Hoarseness
SYMPTOMS – Complications
Embolism
Pedal edema, ascites

12. Clinical Features -MS
SIGNS
1. Irregular pulse
2. RV hypertrophy
3. Loud S1
4. Loud P2
5. Mid-diastolic murmur
with presystolic murmur
CXR
1. Increased LA size
2. Pulmonary edema
ECG
1. Atrial fibrillation
2. LA enlargement
3. RV hypertrophy.

13. Special Investigations
ECHOCARDIOGRAPHY
1. Mitral valve area
2. Thickening of leaflets
3. Calcification
4. Sub valvular deformity
5. RVH, LAH
6. LA thrombus.
CARDIAC
CATHETERISATION
1. MV area
2. LA pressure
3. PA pressure
4. Cardiac output
5. LV Ejection Fraction

14. INVESTIGATION
•Chest x-ray
•Echocardiogram
•An echocardiogram is a test that uses sound waves to create
pictures of the heart. The picture and information it produces
is more detailed than a standard x-ray image. An
echocardiogram does not expose you to radiation
•ECG (electrocardiogram)
•MRI or CT of the heart

15. Transesophageal
echocardiogram (TEE)
Transesophageal echocardiography (TEE) is a
test that produces pictures of your heart. TEE
uses high-frequency sound waves (ultrasound)
to make detailed pictures of your heart and the
arteries that lead to and from it.

16. Medical management
•Diuretics to reduce fluid buildup in lungs or elsewhere.
•Blood thinners (anticoagulants) to help prevent blood
clots.
•Beta blockers, calcium channel blockers or digitalis
glycosides to slow heart rate and allow heart to fill more
effectively.
•Anti-arrhythmics to treat atrial fibrillation or other irregular
heart rhythms associated with mitral valve stenosis.
•Antibiotics to prevent a return of rheumatic fever if that's
what caused mitral valve stenosis.

17. Surgery or other procedures
Valve need repair or replacement to treat mitral
valve stenosis, which may include surgical and
nonsurgical options.
Percutaneous balloon mitral valvuloplasty
Surgical commissurotomy.
Mitral valve replacement.

19. SURGICAL
COMMISSUROTOMY
If balloon valvuloplasty isn't an option, a heart
surgeon might perform this open-heart surgery
to remove calcium deposits and other scar
tissue to clear the valve passageway. Surgical
commissurotomy requires that to be put the
patient on a heart-lung bypass machine during
the surgery. The procedure may repeat if mitral
valve stenosis returns.

21. MITRAL VALVE REPLACEMENT
•If the mitral valve can't be repaired, surgery may be
recommended to replace the damaged valve with a
mechanical one or a valve made from cow, pig or
human heart tissue (biological tissue valve).
•Biological tissue valves break down over time and
may need to be replaced. If you have a mechanical
valve, you will need to take blood thinners for life to
prevent blood clots. Each type of valve is having
certain benefits and risks.

22. MITRAL VALVE REGURGITATION
Mitral valve regurgitation is a type of heart valve
disease in which the valve between the left heart
chambers doesn't close completely, allowing blood
to leak backward across the valve.
Other names for mitral valve regurgitation are:
•Mitral regurgitation (MR)
•Mitral insufficiency
•Mitral incompetence

23. CONT…
It is the most common type of heart valve disease
(valvular heart disease). If the leakage is severe,
not enough blood will move through the heart or to
the rest of the body. As a result, mitral valve
regurgitation can make you feel very tired
(fatigued) or short of breath.

24. ETIOLOGY
Mitral valve prolapse
Rheumatic fever
Heart attack
Heart problem present at birth (congenital heart defect)
Thickening of the heart muscle (cardiomyopathy).
Damaged tissue cords
Endocarditis.
Radiation therapy

25. RISK FACTORS
Several things can increase the risk of mitral valve regurgitation,
including:
•Certain infections that affect the heart
•Heart attack
•Heart problems present at birth (congenital heart defect)
•History of other heart valve diseases, including mitral valve prolapse
and mitral valve stenosis
•Older age
•Radiation to the chest

26. SIGNS AND SYMPTOMS
Fatigue is a common but nonspecific symptom of mitral
valve regurgitation.
Other signs and symptoms of mitral valve regurgitation
include:
•Sound of blood flow across the valve (heart murmur)
•Irregular heartbeat (arrhythmia)
•Shortness of breath (dyspnea), especially when lying down
•Sensation of a rapid, fluttering heartbeat (palpitations)
•Swollen feet or ankles (edema)

27. DIAGNOSIS
Common tests to diagnose mitral valve regurgitation include:
Echocardiogram :Sound waves are used to create pictures
of the heart in motion. An echocardiogram shows the
structure of the mitral valve and blood flow in the heart. A
standard echocardiogram, also called a transthoracic
echocardiogram (TTE), can confirm a diagnosis of mitral
valve regurgitation and determine its severity.

28. Investigations - MR
CXR
Increased LA size
Increased LV size
Pulmonary edema
ECG
LV hypertrophy
LA enlargement
Atrial fibrillation
Echocardiography
◦ Dilated annulus
◦ Flail leaflets
◦ Increased length of chordae
◦ Ruptured chordae
◦ Fibrosed papillary muscle

29. MANAGEMENT
Treatment of mitral valve regurgitation may
include:
•Healthy lifestyle changes
•Regular monitoring by a health care provider
•Medications to treat symptoms and prevent
complications, such as blood clots
•Surgery to repair or replace the mitral valve

30. CONT…
Types of medications that may be prescribed for mitral valve
regurgitation include:
•Diuretics: water pills, this type of medication reduces or
prevents fluid buildup in the lungs and other parts of the
body.
•Blood thinners (anticoagulants): blood-thinning drugs to
prevent blood clots. Atrial fibrillation increases the risk of
blood clots and strokes.
•Antihypertensive

31. SURGICAL MANAGEMENT
Mitral valve repair
During mitral valve repair surgery, the surgeon might:
•Patch holes in a heart valve
•Reconnect the valve flaps
•Remove excess tissue from the valve so that the flaps can
close tightly
•Repair the structure of the mitral valve by replacing cords
that support it
•Separate valve leaflets that have fused

33. Cont…
Other mitral valve repair procedures include:
•Annuloplasty. A surgeon tightens or reinforces the ring around
the valve (annulus).
Valvuloplasty. This catheter procedure is used to repair a
mitral valve with a narrowed opening. Valvuloplasty might be
done even if you don't have symptoms. The surgeon inserts a
catheter with a balloon on the tip into an artery in the arm or
groin and guides the catheter to the mitral valve. The balloon is
inflated, widening the mitral valve opening. The balloon is
deflated, and the catheter and balloon are removed.

34. Cont….
Mitral valve clip. In this procedure, cardiologist
guides a catheter with a clip on its end to the mitral
valve through an artery in the groin. The clip is
used to improve the closure of the mitral valve
leaflets and to reduce the amount of regurgitation.
This procedure is an option for people who have
severe mitral valve regurgitation.
Mitral valve replacement

36. Aortic Stenosis
ETIOLOGY – Degenerative, Congenital , Rheumatic.
Pathophysiology
Decrease in valve area
Increased afterload
Compensatory mechanism - LVH
Diastolic Dysfunction
Congestive HEART FAILURE

37. CLINICAL FEATURES
SYMPTOMS
Syncope
Angina
Heart failure
Signs
Soft A2
ESM (ejection systolic murmur,)
in Aortic area
Low volume pulse
Forceful apex beat
ECG
Extreme LVH
ECHO
Thickened leaflets, stenotic
orifice.
Mild AS - Area >1.5 cm2
Moderate AS - 1-1.5 cm2
Severe AS - < 0.8 – 1 cm2
ANGIOGRAPHY

38. Treatment Of AS
MEDICAL
1. Antibiotic prophylaxis for IE and recurrent RF
2. Restriction of activities – competitive sports, severe
exercise
3. Prevent and control arrythmias
Followup – Mild AS every 2-3 years
Moderate AS – Every 6-12 months
Severe AS/ Symptomatic - immediate

39. SURGERY
Surgery options for aortic valve stenosis include:
•Aortic valve repair. To repair an aortic valve, surgeons
separate valve flaps (cusps) that have fused. However,
surgeons rarely repair an aortic valve to treat aortic valve
stenosis. Generally aortic valve stenosis requires aortic valve
replacement.
•Balloon valvuloplasty. This procedure can treat aortic valve
stenosis in infants and children. However, the valve tends to
narrow again in adults who've had the procedure, so it's
usually only done in adults who are too ill for surgery or who
are waiting for a valve replacement

40. Aortic valve replacement

41. Mechanical Valve Replacement

42. Transcatheter aortic
valve replacement (TAVR)

43. AORTIC REGURGITATION
It is a condition that occurs when your
heart's aortic valve doesn't close tightly.
As a result, some of the blood pumped
out of heart's main pumping chamber
(left ventricle) leaks backward.

44. ETIOLOGY
Causes of aortic valve regurgitation include:
•Congenital heart valve disease.
•Narrowing of the aortic valve (aortic stenosis).
•Inflammation of the lining of the heart's chambers and valves
(endocarditis).
•Rheumatic fever.
•Other diseases
•Including Marfan syndrome, a connective tissue disease. Some
autoimmune conditions, such as SLE.

45. SIGNS AND SYMPTOMS
As aortic valve regurgitation worsens, signs and symptoms may include:
•Shortness of breath with exercise or when you lie down
•Fatigue and weakness, especially when you increase your activity level
•Heart murmur
•Irregular pulse (arrhythmia)
•Lightheadedness or fainting
•Chest pain (angina), discomfort or tightness, often increasing during
exercise
•Sensations of a rapid, fluttering heartbeat (palpitations)
•Swollen ankles and feet

46. DIAGNOSTIC EVALUATIONS
1. Echocardiogram.
2. Electrocardiogram
3. Chest X-ray.
4. Exercise tests or stress tests.
5. Cardiac MRI.
6. Cardiac catheterization.

47. Treatment Of AR
MEDICAL
Antibiotic
Diuretics
ACE Inhibitors
Calcium Channel
Blockers
SURGERY
1. Aortic Valve repair
2. Aortic valve
replacement
3. Bentall Procedure
4. Ross Procedure.

49. Bentall procedure
The Bentall procedure is a type of cardiac surgery
involving composite graft replacement of the aortic valve,
aortic root, and ascending aorta, with re-implantation of
the coronary arteries into the graft.