Valvular heart diseases

VALVULARHEART DISEASE

د. محمد سعيد عبد الزهره

What Is Valvular Heart Disease?

Heart valve disease occurs when your heart's valves do not work the way they should.

How Do Heart Valves Work?

MAINTAIN ONE-WAY BLOOD FLOW THROUGH YOUR HEART

The four heart valves make sure that blood always flows freely in a forward direction and that there is no backward leakage.

Heart Valves

ANY DISEASE OF THESE VALVES ARE CALLED AS

VALVULAR HEART DISEASE!

Types of valve disease

Valvular Stenosis

THE VALVE OPENING NARROWS
the valve leaflets may become fused or thickened that the
valve cannot open freely  obstructs the normal flow of blood

EFFECTS:

the chamber behind the stenotic valve is subject to greater stress
 must generate more pressure (work hard) to force blood through the narrowed opening


initially, the compensates for the additional workload by
gradual hypertrophy and dilation of the myocardium
 heart failure

Valvular Regurgitation

LEAKAGE OR BACKFLOW OF BLOOD RESULTS FROM INCOMPLETE CLOSURE OF THE VALVE
due to:
• Scarring and retraction of valve leaflets
OR
• Weakening of supporting structures

EFFECTS:

causes the to pump the same blood twice
(as the blood comes back into the chamber)
the dilates to accommodate more blood
ventricular dilation and hypertrophy  eventually leads to
heart failure

Principal Causes

• Valve stenosis
• Valve regurgitation
• Congenital
• Rheumatic carditis
• Senile degeneration
• Congenital
• Rheumatic carditis (acute or chronic)
• Infective endocarditis
• Valve ring dilatation
(e.g. dilated cardiomyopathy)
• Syphilitic aortitis
• Traumatic valve rupture
• Damage to chordae and
• papillary muscle (e.g. MI)
• Senile degeneration

Valvular Heart Disease

• MITRAL STENOSIS
• MITRAL REGURGITATION
• AORTIC STENOSIS
• AORTIC REGURGITATION
• TRICUSPID STENOSIS
• TRICUSPID REGURGITATION
• PULMONARY STENOSIS
• PULMONARY REGURGITATION


1. MITRAL STENOSIS

Aetiology

Almost always rheumatic in origin

Older people: can be caused by heavy calcification of mitral valve congestion

Congenital (rare)

Pathophysiology

Normal mitral valve orifice is 5cm2 in diastole & may be reduced to 1cm2 in severe mitral stenosis

Pathophysiology

Atrial fibrillation due to
progressive dilatation
of the LA is very common.
Its onset often precipitates
pulmonary oedema
In contrast, a more gradual rise in left atrial pressure tends to cause an increase in pulmonary vascular resistance  pulmo. HTN  RVH, TR RHF

Atrial fibrillation due to

progressive dilatation
of the LA is very common.
Its onset often precipitates
pulmonary oedema
In contrast, a more gradual rise
In left atrial pressure tends to cause
an increase in pulmonary vascular
resistance  pulmo. HTN  RVH, TR RHF

Pathophysiology

Narrowing of mitral valve
 CO
O2/CO2 exchange
(fatigue, dyspnea, orthopnea)
Left ventricular atrophy
pulmonary congestion
 pulmonary pressure
 left atrial pressure
Hypertrophy left atrium
 blood flow to left ventricle
Right-sided failure

Fatigue

Clinical features

Symptoms
Breathlessness, cough (pulmonary congestion)

Chest pain (pulmonary hypertension)

Hemoptysis (pulmonary congestion or hypertension)

Fatigue (low cardiac output)

Oedema, ascites (right heart failure)

Palpitation (atrial fibrillation)

Thromboembolic complications

Clinical features

Signs
Atrial fibrillation
Mitral facies (abnormal flushing of the cheeks that occurs from cutaneous vasodilation in the setting of severe mitral valve stenosis)
Auscultation - Loud first heart sound, opening snap
(created by forceful opening of mitral valve)


- Mid-diastolic murmur (apex)
Crepitations, pulmonary edema, effusions (raised pulmonary capillary pressure)

RV heave, loud P2 (pulmonary hypertension)

Mitral stenosis

…Lub Hoot…

Investigations
ECG: - right ventricular hypertrophy  tall R waves
Chest x-ray: - enlarged LA & appendage
- signs of pulmonary venous congestion

ECHO: - thickened immobile cusps

- reduced valve area
- enlarged LA
- reduced rate of diastolic filling of LV

Doppler: - pressure gradient across mitral valve


Cardiac catheterization: - coronary artery disease
- pulmonary artery pressure
- mitral stenosis and regurgitation

Management

Medically
Anticoagulant
• To reduce the risk of systemic embolism
Digoxin, beta blockers, or rate limiting calcium antagonists
• To control ventricular rate in atrial fibrillation
• To control pulmonary congestion
Surgically
Mitral balloon valvuloplasty***

Mitral valvotomy

Valve replacement

Balloon mitral valvuloplasty

2. MITRAL REGURGITATION

Mitral regurgitation

Incomplete closure of mitral valve

Aetiology
Rheumatic disease is the principal cause (in countries where disease is common)

Mitral valve prolapse

Dilatation of the LV and mitral valve ring (e.g. coronary artery disease, cardiomyopathy)

Damage to valve cusps and chordae (e.g. rheumatic heart disease, endocarditis)

Ischaemia or infarction of papillary muscle (MI)

Pathophysiology

Pathophysiology

Incomplete closure of mitral valve
 vol. of blood ejected by left ventricle
 Left atrial pressure
Right-sided heart failure
Left atrial hypertrophy
 CO
 Pulmonary pressure
Backflow of blood to the left atrium
 Right ventricular pressure

mitral valve prolapse

A.k.a ‘floppy’ mitral valve

One of the most common cause of mild mitral regurgitation

Caused by
congenital anomalies
degenerative myxomatous changes
feature of connective tissue disorders like Marfan’s syndrome

Mitral regurgitation

mitral valve prolapse
Mildest form:
Valve remains competent but bulges back into atrium during systole  mid-systolic click but no murmur

In the presence of regurgitant valve:

Click is followed by a late systolic murmur, which lengthens as the regurgitation becomes more severe

Severe form:

Progressive elongation of chordae tendinae increasing regurgitation Chordal rupture severe regurgitation
Mitral regurgitation








Clinical Manifestations
• Fatigue & weakness – due to  CO – predominant complaint
• Exertional dyspnea & cough – pulmonary congestion
• Palpitations – due to atrial fibrillation (occur in 75% of pts.)
• Edema, ascites – Right-sided heart failure
Symptoms

Clinical Manifestations

• Atrial fibrillation
• Cardiomegally
• Apical pansystolic murmur +/- thrill
• Soft S1, apical S3
• Signs of pulmonary venous congestion (crepitations, pulmonary edema, effusions)
• Signs of pulmonary hypertension & right heart failure
Signs

Mitral regurgitation

…Hoot Dub…

Investigations
ECG: - left atrial hypertrophy
• - left ventricular hypertrophy
Chest x-ray: - enlarged LA,LV
- pulmonary venous congestion
• - pulmonary oedema
ECHO: - dilated LA,LV
- structural abnormalities of mitral valve (e.g. prolapse)

Doppler: - detects and quantifies regurgitation

Cardiac catheterization: - dilated LA,LV
- mitral regurgitation
- pulmonary hypertension
- coexisting coronary artery disease

Management

Medically
Vasodilators (e.g. ACE inhibitors)

Diuretics

If atrial fibrillation presents,
Anticoagulant
Digoxin

Surgically
Mitral valve repair
OR
Mitral valve replacement
To treat
mitral valve
prolapse

3. AORTIC STENOSIS

Aortic Stenosis

Narrowing of the aortic valve


Aetiology
INFANTS, CHILDREN, ADOLESCENTS
Congenital aortic stenosis
Congenital subvalvular aortic stenosis
Congenital subvalvular aortic stenosis

YOUNG ADULTS TO MIDDLE-AGED

Calcification and fibrosis of congenitally bicuspid aortic valve
Rheumatic aortic stenosis

MIDDLE-AGED TO ELDERLY

Senile degenerative aortic stenosis
Calcification of bicuspid valve
Rheumatic aortic stenosis

Pathophysiology

Pathophysiology

Stiffening/Narrowing of Aortic Valve
Incomplete emptying of left atrium
Left ventricular hypertrophy
Pulmonary congestion
Compression of coronary arteries
Right-sided heart failure
 CO
 Myocardial O2 needs
Myocardial ischemia
(chest pain)
 O2 supply


Clinical features
Symptoms
Mild or moderate stenosis: usually asymptomatic

Exertional dyspnea

Angina (due to demands of
hypertrophied LV)

Exertional syncope

Sudden death

Episodes o acute pulmonary oedema

CARDINAL
SYMPTOMS
CO fails to rise
to meet demand

Clinical features

Signs
Ejection systolic murmur


Slow-rising carotid pulse

Thrusting apex beat (LV pressure overload)

Narrow pulse pressure

Signs of pulmonary venous congestion (e.g. crepititions)

Investigations
ECG: - left ventricular hypertrophy
- left bundle branch block
Chest x-ray: - may be normal
- enlarged LV & dilated ascending aorta (PA view)
- calcified valve on lateral view

ECHO: - calcified valve with restricted opening, hypertrophied LV

Doppler: - measurement of severity of stenosis
- detection of associated aortic regurgitation

Cardiac catheterization: - to identify asst. coronary artery disease

- may be used to measure gradient
between LV and aorta


Management
Asymptomatic aortic stenosis  kept under review

Moderate/severe stenosis  evaluated every 1-2 years with Doppler echocardiography (to detect progression in severity)

Symptomatic severe aortic stenosis  valve replacement

Congenital aortic stenosis  aortic balloon valvuloplasty

Atrial fibrillation or post valve replacement with a mechanical prosthesis  anticoagulant
(as the development of angina, syncope,
symptoms of low CO or heart failure
has a poor prognosis and is an indication
for prompt surgery)

4. AORTIC REGURGITATION

Causes
Congenital:
Bicuspid valve or disproportionate cusps


Acquired:
Rheumatic disease
Infective endocarditis
Trauma
Aortic dilatation (marfan’s syndrome, aneurysm, dissection, syphilis)

Pathophysiology

Pathophysiology
Incomplete closure of the aortic valve
Backflow of blood to Left ventricle
Left ventricular hypertrophy & dilation
 Left atrial pressure
Left-sided heart failure
(late stage)
Left atrium hypertrophy
 CO
 Pulmonary pressure
Right-sided heart failure
 Right ventricular pressure


Clinical features
Symptoms
Mild or moderate aortic regurgitation:
Usually asymptomatic

Awareness of heartbeat, ‘palpitations’

Severe aortic regurgitation:
Breathlessness
Angina
particularly when lying on the left side,
which results from increased in stroke volume
(because compensatory ventricular
dilatation&hypertrophy occur)

Clinical features

Pulses:
Large volume or ‘collapsing’ pulse
Low diastolic and increased pulse pressure
Bounding peripheral pulse
Capillary pulsation in nail beds: Quincke’s sign
Femoral bruit(‘pistol shot’): Duroziez’s sign
Head nodding with pulse: de Musset’s sign


Murmurs:
Early diastolic murmur
Systolic murmur (increased stroke volume)
Austin Flint murmur (soft mid-diastolic)

Other signs:

Displaced, heaving apex beat (volume overload)
Pre-systolic impulse
4th heart sound
Crepitations (pulmonary venous congestion)

Signs

characteristic murmur is best heard
to the left sternum during held expiration

Investigations

ECG: initially normal,
later left ventricular hypertrophy & T-wave inversion
Chest x-ray: - cardiac dilatation, maybe aortic dilatation
• - features of left heart failure


ECHO: - dilated LV
- hyperdynamic LV
- fluttering anterior mitral leaflet

Doppler: - detects reflux

Cardiac catheterization: - dilated LV

• - aortic regurgitation
• - dilated aortic root

Management

Treatment may be required for underlying conditions, such as endocarditis or syphilis

Aortic regurgitation with symptoms aortic valve replacement (may be combined with aortic root replacement and coronary bypass surgery)

Asymptomatic patients  annually follow up with echocardiography for evidence of increasing ventricular size

Systolic BP should be controlled with vasodilating drugs, such as nifedipine or ACE inhibitors

5. TRICUSPID STENOSIS

Tricuspid Stenosis
usually occurs together with aortic or mitral stenosis

may be due to rheumatic heart disease (<5%)

 blood flow from right atrium to right ventricle
  right ventricular output
  left ventricular filling   co

 systemic pressure

Tricuspid Stenosis
Symptoms
symptoms of right-sided heart failure
- hepatomegaly
- ascites
- peripheral edema
- neck vein engorgement


 co – fatigue, hypotension

Signs

Raised JVP

Mid-diastolic murmur (best heard at lower left or right sternal edge)

Tricuspid Stenosis
Management

Valve replacement

Valvotomy
Balloon valvuloplasty

6. TRICUSPID REGURGITATION

Tricuspid Regurgitation
common, and is most frequently ‘functional’ as a result of enlargement of right ventricle

an insufficient tricuspid valve allows blood to flow back into the right atrium  venous congestion &  right ventricular output   blood flow towards the lungs

primary

Rheumatic heart disease

Endocarditis, particularly in injection drug-users

Ebstein’s congenital anomaly
secondary
Right ventricular dilatation due to chronic left heart failure (‘functional tricuspid regurgitation’)

Right ventricular infarction

Pulmonary hypertension (e.g. cor pulmonale)
Tricuspid Regurgitation

causes

Tricuspid Regurgitation
Symptoms
Usually non-specific

Tiredness (reduced forward flow)

Oedema

Hepatic enlargement (venous congestion)

Signs
Raised JVP

Pansystolic murmur (left sternal edge)

Pulsatile liver

Tricuspid Regurgitation

Management

Correction of the cause of right ventricular overload (if TR is due to right ventricular dilatation)
Use of diuretic and vasodilator treatment of CCF

Valve repair

Valve replacement

7. PULMONARY STENOSIS

Pulmonary Stenosis
Symptoms
Fatigue, dyspnea on exertion, cyanosis

Poor weight gain or failure to thrive in infants

Hepatomegaly, ascites, edema

Signs

Ejection systolic murmur (loudest at the left upper sternum & radiating towards the left shoulder)

Murmur often preceded by an ejection sound (click)

May be wide splitting of second heart sound (delay in ventricular ejection

May be a thrill (best felt when patient leans forward and breathes out)

Investigations
ECG: - right ventricular hypertrophy

Chest x-ray: - post-stenotic dilatation in the pulmonary artery

Doppler echocardiography is the definitive investigation

Management
Mild to modearate isolated pulmonary stenosis is relatively common and does not usually progress or require treatment

Severe pulmonary stenosis  percutaneous pulmonary balloon valvuloplasty

OR
surgical valvotomy

8. PULMONARY REGURGITATION

Pulmonary Regurgitation
A rare condition

Usually associated with pulmonary hypertension

which may be
• Secondary of the disease of left side of the heart
• Primary pulmonary vascular disease
• Eisenmenger’s syndrome


Blood flows back into right ventricle  right ventricle
and atrium hypertrophy  symptoms of right-sided
heart failure

• Trivial PR is a frequent finding in normal individuals and has no clinical significance