Valvular Heart disease HVDValvular Heart disease HVD

ByBy

Dr. Ashraf Abdelfatah DeyabDr. Ashraf Abdelfatah Deyab

VHD- ObjectivesVHD- ObjectivesBy the end of this session, the student By the end of this session, the student should be able to:should be able to:

1.1. Define and classify valvular heart disease. Define and classify valvular heart disease.

2.2. Enlist the causes of acquired heart valve diseases.Enlist the causes of acquired heart valve diseases.

3.3. Identify the clinical consequences of valve dysfunction Identify the clinical consequences of valve dysfunction

and complications.and complications.

4.4. Describe different morphological features of valve Describe different morphological features of valve

dysfunction.dysfunction.

VValvular alvular HHeart eart DDisease(HVD)isease(HVD)Function of normal Valves Function of normal Valves – – Unidirectional blood flow, one-way flow of blood from the atria Unidirectional blood flow, one-way flow of blood from the atria to the ventricles to the arteries.to the ventricles to the arteries.

Name of heart valves Name of heart valves ––1.Two atrioventricular valves: 1.Two atrioventricular valves:

Mitral valve: Mitral valve: Left heart - “Bicuspid valve” .Left heart - “Bicuspid valve” . Tricuspid valve:Tricuspid valve:Right heart -“tricuspid” Right heart -“tricuspid”

2. Two semilunar valves:2. Two semilunar valves: Aortic valve: Aortic valve: Left heart .Left heart . Pulmonary valve: Pulmonary valve: Right heart.Right heart.

Valve competency depends on –Valve competency depends on –1. Annulus, 2. Leaflets, 3. Cords, 4. Papillary muscles, 1. Annulus, 2. Leaflets, 3. Cords, 4. Papillary muscles, 5.Ventricular wall layers 5.Ventricular wall layers

The aortic valveThe aortic valve

Bicuspid valve-thin delicate& leaflets Three thin and delicate cuspsBicuspid valve-thin delicate& leaflets Three thin and delicate cusps

The mitral valveThe mitral valve

Define HVD, and explain why its draw the Define HVD, and explain why its draw the clinical attention?clinical attention?

HVD is groups of critical clinical conditions involve heart valves, HVD is groups of critical clinical conditions involve heart valves, leading to different pattern of dysfunction.leading to different pattern of dysfunction.

HVD HVD come to clinical attention – because imposecome to clinical attention – because impose: :

1.1. HemodynamicHemodynamic instabilityinstability. .

2.2. Increase susceptibility to infection Increase susceptibility to infection ((infective endocarditis).infective endocarditis).

Why Why hemodynamichemodynamic burden precipitated? burden precipitated? 1 .Stenosis (Obstruction)

2 .Insufficiency (Regurgitation or incompetence).

3 .Both

Abnormal Valve FunctionAbnormal Valve Function1. Valve Stenosis1. Valve Stenosis– Obstruction to valve flow.Obstruction to valve flow.

2. Valve Regurgitation, 2. Valve Regurgitation, Insufficiency, IncompetenceInsufficiency, Incompetence– Inadequate valve closure---Inadequate valve closure--- back leakage. back leakage.

3. A single valve can be both stenotic and regurgitant; but 3. A single valve can be both stenotic and regurgitant; but both lesions cannot be severe!!both lesions cannot be severe!!

4. Combinations of valve lesions can coexist4. Combinations of valve lesions can coexist– Single disease processSingle disease process– Different disease processesDifferent disease processes– One valve lesion may cause another One valve lesion may cause another

Abnormal valve function Abnormal valve function Definition of Definition of Valvular Valvular stenosis stenosis ? ?

• Stenosis is the failure of a valve to open completely, which Stenosis is the failure of a valve to open completely, which obstructing forward flow.obstructing forward flow.

• Etiology Etiology   • Almost caused by chronic primary cuspal abnormalities- Almost caused by chronic primary cuspal abnormalities-

(1)(1)Calcification or (2)Valve scarring. Calcification or (2)Valve scarring. • Stenosis of the mitral valve is a common complication Stenosis of the mitral valve is a common complication

of of rheumatic fever.rheumatic fever.

Definition Definition of Valvular Regurgitation ? of Valvular Regurgitation ?

• Insufficiency results from failure of a valve to close completely, Insufficiency results from failure of a valve to close completely, thereby allowing reversed flow.thereby allowing reversed flow.

• EtiologyEtiology• (1) Intrinsic disease of the valve cusps= destruction.(1) Intrinsic disease of the valve cusps= destruction.• (2) Distortion of supporting structure ((2) Distortion of supporting structure (papillary M, cords,etc.papillary M, cords,etc.))

ClassificationClassificationBased on etiology can be classified into:Based on etiology can be classified into:

1. Congenital heart disease1. Congenital heart disease

2. Acquired heart disease.2. Acquired heart disease.

Heart Valvular Disease- Etiology Heart Valvular Disease- Etiology

1.1.Congenital heart valve disease - Congenital heart valve disease -

e.g. Septal defect, Atresia, mal-position.e.g. Septal defect, Atresia, mal-position.

to be discussed in separate sessionto be discussed in separate session..

______________________________________________________________________________________________

2. Acquired heart valve disease :- (most frequent)2. Acquired heart valve disease :- (most frequent)

A.A. Endocarditis–Endocarditis– ( (MR & AR) most common is mitral valve.MR & AR) most common is mitral valve.

B.B. Post-inflammatory healed scar (Rheumatic heart disease) Post-inflammatory healed scar (Rheumatic heart disease) MS+MR & AS+AR MS+MR & AS+AR

C.C. Senile calcific aortic stenosis-Senile calcific aortic stenosis- ASAS

D.D. Myxomatous - Mitral valve Prolapse-Myxomatous - Mitral valve Prolapse- MR MR

E.E. Abnormalities of Leaflets and Commissures Abnormalities of Leaflets and Commissures

F.F. Abnormalities of Tensor Apparatus.Abnormalities of Tensor Apparatus.

G.G. Abnormalities of Left Ventricular Cavity and/or Annulus-Abnormalities of Left Ventricular Cavity and/or Annulus-

Valvular Heart Disease- Clinical consequences Valvular Heart Disease- Clinical consequences

The clinical consequences depend on :The clinical consequences depend on :

1.1. Type of valve involve.Type of valve involve.

2.2. Degree of impairment.Degree of impairment.

3.3. How fast it develops. (Acute form and chronic form)How fast it develops. (Acute form and chronic form)

4.4. Rate of compensatory mechanism.Rate of compensatory mechanism.

Clinical OutcomesClinical Outcomes::

1) 1) Stenosis leads Stenosis leads to to pressure overload pressure overload of the heart.of the heart.

22) Insufficiency leads ) Insufficiency leads to to volume overload volume overload of the heart.of the heart.

VALVULAR STENOSISVALVULAR STENOSIS

Pressure in upstream chamber Pressure in upstream chamber IS HIGHER thanIS HIGHER than Pressure in downstream chamber Pressure in downstream chamber during time of during time of flowflow (when valve is normally open). (when valve is normally open).

Hemodynamic abnormality = "Hemodynamic abnormality = "PRESSURE GRADIENTPRESSURE GRADIENT""    

  Upstream Down stream

High pressure low pressure

VALVULAR REGURGITATIONVALVULAR REGURGITATION

   

  

Upstream Down stream

Volume overload

Retrograde flow of blood "upstream" during time when valve is normally closed. Hemodynamic abnormality = "VOLUME OVERLOAD"  

Assessment for Valve DysfunctionAssessment for Valve Dysfunction– MurmursMurmurs– General malaiseGeneral malaise– Dyspnea on exertionDyspnea on exertion– DizzinessDizziness– Chest pain or discomfortChest pain or discomfort– Prior history of rheumatic Prior history of rheumatic

heart diseaseheart disease– OrthopneaOrthopnea– Dyspnea, ralesDyspnea, rales– Pink-tinged sputumPink-tinged sputum

Complications:Complications:–Hemodynamic instability Hemodynamic instability –Heart failureHeart failure–AnginaAngina–SyncopeSyncope–DeathDeath

DiagnosisDiagnosis::

ECGECG

Chest x-rayChest x-ray

Cardiac cathCardiac cath

Echocardiogram Echocardiogram

Heart Valvular Disease- Clinical OutcomesHeart Valvular Disease- Clinical Outcomes

ExampleExample::(1) Mitral stenosis: (comments type)(1) Mitral stenosis: (comments type)

Complication of Rheumatic heart diseaseComplication of Rheumatic heart disease fibrotic\scarring fibrotic\scarring

Chronic - Well tolerated over years.Chronic - Well tolerated over years.

Mitral stenosis “fish mouth”show diffuse fibrous thickening &distortion, commissural fusion

Calcific aortic diseaseCalcific aortic diseaseMost common Most common acquiredacquired aortic stenosis in aortic stenosis in elderlyelderly..

Consequence of age-associated Consequence of age-associated “wear and tear“wear and tear” ” degenerationdegeneration , , fibrosis fibrosis and calcification.and calcification.

OccasionsOccasions: (1) Normal valves. (2) Congenitally bicuspid valves: (1) Normal valves. (2) Congenitally bicuspid valves

Pathological processes Pathological processes for calcificationfor calcification

(1) Disorder of elderly (2) Unknown.(1) Disorder of elderly (2) Unknown.

The major clinical features of SThe major clinical features of Stenosis tenosis ::

(1)(1) Left ventricular hypertrophy and (CHF) failure... Left ventricular hypertrophy and (CHF) failure...

(2) Angina.(2) Angina.

(3) Syncope (abrupt episodes of faintness) (hypoperfusion)(3) Syncope (abrupt episodes of faintness) (hypoperfusion)

Calcified aortic valve of old ageCalcified aortic valve of old ageMacroscopic 1)Heaped-up protruded calcified masses.

2) the cusps become fibrosed and thickened.

3) The free edges of the cusps are not involved.

Microscopic:large nodular calcific deposits.

MITRAL VALVE PROLAPSE MITRAL VALVE PROLAPSE (MPV)(MPV)

Definition:Definition:- Mitral valve leaflets (oMitral valve leaflets (one or both) are “floppy” and ne or both) are “floppy” and ProlapseProlapse, ,

or balloon back, into the left atrium during systole.or balloon back, into the left atrium during systole.- The histologic change in the tissue is called The histologic change in the tissue is called myxomatous myxomatous

degeneration.degeneration.

- MVP-MVP-Uncommon, affects approximately 3% of adults in USA.Uncommon, affects approximately 3% of adults in USA.- Women 7times more frequently > MaleWomen 7times more frequently > Male

- Pathogenesis of MVPPathogenesis of MVP: : - (1)Unknown, (1)Unknown, - (2) MVP is associated with heritable disorders of CT diseases (2) MVP is associated with heritable disorders of CT diseases

Marfan syndrome (fibrillin-1 mutation), Marfan syndrome (fibrillin-1 mutation), where there is where there is intrinsic defect of CT either in its intrinsic defect of CT either in its Synthesis or RemodelingSynthesis or Remodeling..

MPV-MORPHOLOGYMPV-MORPHOLOGY

Macroscopic appearanceMacroscopic appearance

1.1. The LeafletsThe Leaflets: Enlarged, : Enlarged, redundant, thick, rubbery, redundant, thick, rubbery, Ballooning .Ballooning .

2.2. The TendinousThe Tendinous : cords may : cords may be elongated, thinned, or be elongated, thinned, or even ruptured.even ruptured.

3.3. The The annulus:annulus: may be may be dilated.dilated.

4.4. The tricuspid, aortic, or The tricuspid, aortic, or pulmonary valves may also pulmonary valves may also be affected.be affected.

Left ventricle demonstrating prolapse of the posterior mitral leaflet into the left

atrium

Mitral Mitral valvevalve Pronounced hooding of MV with thrombotic plaques Pronounced hooding of MV with thrombotic plaques

MicroscopyMicroscopy: : * * ThinningThinning fibrosa layer of the valve. fibrosa layer of the valve.

* * MarkedMarked expansionexpansion of the spongiosa layer with of the spongiosa layer with deposition of mucoid (myxomatous) material. deposition of mucoid (myxomatous) material.

Valvular Heart DiseaseValvular Heart Disease

The endThe end??

1. Stenosis is the failure of a valve to close completely.1. Stenosis is the failure of a valve to close completely.

(T) OR (F)(T) OR (F)

2. Insufficiency is the failure of a valve to close completely.2. Insufficiency is the failure of a valve to close completely.

(T) OR (F)(T) OR (F)