Valvular Heart Disease

Songsak Kiatchoosakun, MD.Division of CardiologyDepartment of MedicineKhon Kaen University

Normal Heart

Mitral Valve Stenosis

Etiology• Rheumatic heart disease

– Most common cause • Calcified mitral annulus

– Elderly– Chronic renal failure

Pathology of Mitral Stenosis

• Fibrosis and adhesion of mitral valve apparatus– Fish mouth appearance– Subvalvular stenosis

• Calcification of MV

Mitral Stenosis

Pathophysiology

• Normal MV area is 4-6 cm2

• Severity of mitral stenosis– MV area 1.5-2 cm2 : Mild MS– MV area 1.0-1.5 cm2 : Moderate MS– MV area < 1 cm2 : Critical or severe MS

Pathophysiology of MS

LA pressure depends on heart rate and mitral valve area

Pathophysiology of MS

• Elevated LA pressure • Pulmonary congestion • LA enlargement• Atrial fibrillation • LA clot• Reduced cardiac output• Normal LV contraction

Pathophysiology of MS

• RA/ RV hypertrophy • Right heart failure• Tricuspid regurgitation• Hepatomegaly• Edema

Natural History of MS

2 years 10-20 years

Acute Rheumatic Fever

Mitral Stenosis

SymptomaticMitral Stenosis

Natural History and Prognosis of MS

Symptoms 10- year survival

None (class I) 84Mild-moderate (class II-III) 40Severe (class IV) 0

At 1 year 42At 5 year 10

Clinical Manifestations• Exertional dyspnea• Pulmonary edema• Hemoptysis• Chest pain• Edema• Hoarseness of voice or “Ortner syndrome”• Systemic embolism

Physical Examination

• Mitral facies • Normal or small volume of arterial pulse• Atrial fibrillation• RV heaving

Physical Examination

Auscultation• Augmentation of S1

• Diastolic rumbling murmur– Duration of murmur relates with the

severity of MS• Augmentation of P2

• Opening snap (OS)

Mitral stenosis

Mitral Stenosis

Mitral Stenosis

Mitral Stenosis

ECG

Chest X- ray

Left atrium

RA Double contour

Straightening ofLeft heart border

Widening ofCarinal angle

Left Atrial Enlargement in Mitral Stenosis

Echocardiography in MS

LA Thrombus

Management of Mitral Stenosis

Mitral Stenosis

MVA 1.5- 2.0 cm2 MVA 1.0-1.5 cm2 MVA < 1 cm2

Medical treatment

Follow up q 3 years

Medical treatment

Follow up q 1-3 years

Symptomatic

PTMCMVR

Medical Management• Antibiotic prophylaxis

– Rheumatic prophylaxis• Bezathine Penicillin 1.2 mu q 3 weeks• Penicillin V 250 mg oral bid

– Infective endocarditis prophylaxis• Restrict activities in moderate to severe MS

– Severe exercise• Prevent and control AF (Digitalis or Beta-

blocker)• Diuretics in pulmonary congestion

Systemic Embolism in MS

• Risk was increased by 17 times compared to normal population• Not related to mitral valve area• May be the first manifestation of MS

Anticoagulant Therapy in MS

• Warfarin • Indications

– Atrial fibrillation– Systemic embolism– LA thrombus

• Keep INR 2-3

Management

Percutaneous balloon mitral valvuloplasty– Indications

1. Symptomatic severe MS2. No LA clot3. Favorable MV morphology

Mitral valve replacement– Indications

1. Symptomatic severe MS2. LA thrombus3. Unfavorable or calcified mitral valve

Mitral Regurgitation

Mitral apparatus

• Mitral leaflet

• Papillary muscle

• Chordae

• Mitral annulus

Mitral Regurgitation

Etiology• Mitral valve leaflet

– Mitral valve prolapse, rheumatic, endocarditis• Mitral annulus

– LV dilatation, calcified annulus• Chordae tendinea

– Rupture, myocardial infarction• Papillary muscles

– Myocardial infarction, bacterial abscess

Rheumatic Mitral Regurgitation

Thickening of leaflet and chordae and the retraction of mitral tissue

Mitral Regurgitation due to Endocarditis

Vegetations of the anterior leaflet and the ruptured cord

Ruptured Posterior Papillary Muscle

Pathophysiology of MR

• Half of cardiac output is ejected into left atrium

• Effective or forward is depressed

• Eccentric hypertrophy of LV and dilatation of left atrium

• Left ventricular systolic function is normal until late stage of disease

Syndrome of Mitral Regurgitation

1. Acute MR (normal LA compliance)• Acute pulmonary edema• Hypotension• Edema is usually not present

2. Chronic MR (increased LA compliance)• Low cardiac output• Atrial fibrillation• Edema

Clinical Presentations

• Acute pulmonary edema• Fatigue• Atrial fibrillation• Chest pain• Infective endocarditis

Physical Examination

• Carotid pulse is normal • PMI shifts to the left• Pansystolic murmur at apex with

radiation to axilla

ECG

Chest- X ray

Medical Management

• Treat underlying disease• Digitalis in AF• Diuretics in pulmonary congestion• Vasodilators in acute MR and MR with LV

dysfunction• The effectiveness of vasodilator in chronic

valvular MR is not well demonstrated• Rheumatic prophylaxis• Bacterial endocarditis prophylaxis

Indications for Surgery

• Symptomatic MR (acute or chronic)• Asymptomatic MR with LV dysfunction

• LVEF 30- 60 %• Cardiac enlargement (LVESD 45-55 mm)

ACC/AHA guideline 1998

Aortic Stenosis

Etiology• Rheumatic • Degenerative• Bicuspid aortic valve

Aortic Stenosis

Pathophysiology of AS

Clinical Presentation of AS• Common symptoms

– Angina pectoris – Syncope – Heart failure

• Less common symptoms– Systemic emboli

Natural History of AS

Ross J. Circulation 1968

Physical Examination• Carotid pulse

– Pulsus parvus et tardus– Carotid shudder

• LV heaving• Auscultation

– Normal S1, decrease S2

– Systolic ejection murmur at right upper sternal border and radiate to carotid artery

Aortic Stenosis

ECG

Chest X-ray

Post-stenotic dilatation

Severity of AS

AS AVA (cm2)

Mild > 1.5

Moderate 1.1 - 1.5

Severe < 1.0

Management of AS• Antibiotic prophylaxis• Restriction of activities

– Severe exercise/ competitive sports• Arrhythmias: AF; restore sinus rhythm• Avoid negative inotropic drug, diuretic and

vasodilators• Follow up

– Asymptomatic; 2-5 years– Moderate; 6-12 months

Indication for Surgery

• All symptomatic severe AS patients• LV dysfunction

Aortic Regurgitation

Aortic Regurgitation

Etiology2. Aortic valve abnormality

– Infective endocarditis– Rheumatic disease

3. Aortic root abnormality– Dissection of aorta– Marfan syndrome– Aortitis

Aortic Regurgitation

Pathophysiolgy

Diastolic Regurgitation Heart murmur

Large Stroke Volume Peripheral signs

LV enlargement CardiomegalyFatigue

LV failure, Increased LVEDP: Dyspnea, chest pain

Clinical Presentations

• Asymptomatic• Nocturnal anginal pain

– Low diastolic blood pressure• Palpitation: heart contraction• Heart failure

Physical Examination

• Wide pulse pressure • Corrigan’s pulse, Water hammer’s pulse• Pulsus bisferiens• LV heaving• Diastolic blowing murmur at left lower sternal

border• Peripheral signs

– Muller’s sign– Quincke’s sign- Hill’s sign

Aortic Regurgitation

Aortic Regurgitation

Natural History of AR

Bonow, et al. JACC Nov 1988 2Aronow , et a. Am J Cardiol 1994; 74: 286.

• Normal LV function– Heart failure < 6 %/yr– Mortality < 1 %/yr

• LV dysfunction– Mortality rate > 10%/yr

ECG

Chest X-ray

Medical Management of Patient with AR

• Restriction of activities– Severe exercise/ competitive sports

• Vasodilator– Severe AR– LV dysfunction

• Diuretics• Digitalis in AF/ heart failure• Endocarditis prophylaxis

Surgical Therapy

• Indications for AVR (Severe AR)– Symptomatic (NYHA III-IV) regardless of LV

function– Symptomatic (NYHA II) with evidence of

progressive LV dysfunction

1 Bonow, et al. Circulation 1998;98:1949-84