Professional Documents
Culture Documents
M Chadi Alraies, MD
Chief Medical Resident
Tuesday, November 2, 2021
Valvular heart disease
Mitral regurgitation.
Mitral stenosis.
Aortic stenosis.
Aortic regurgitation.
Tricuspid regurgitation.
Tricuspid stenosis.
Pulmonary stenosis
Pulmonary regurgitation.
M Chadi Alraies 2
Jones criteria
Major manifestations
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
M Chadi Alraies 4
Minor manifestations
Clinical findings
Arthralgia
Fever
Laboratory findings
Elevated acute phase reactants (erythrocyte sedimentation
rate, C-reactive protein)
Prolonged PR interval
Evidence of preceding streptococcal infection:
Positive throat culture for group A beta-hemolytic
streptococci or positive rapid streptococcal antigen test.
antistreptolysin O
M Chadi Alraies 5
MITRAL STENOSIS
Prevalence
43% of all VHD in 1960
9% of all VHD in 1985
Rheumatic heart disease still affecting 21 out
of 1,000 school-age children in Asia.
2/3 of all patient with rheumatic MS are
women.
M Chadi Alraies 7
Causes
Rheumatic fever.
Congenital chordal fusion.
Congenital papillary muscle malposition.
Mitral annular calcification (e.g. ESRD, elderly)
Mitral valve repair.
Surgical valve replacement.
Obstruction by large vegetation.
Rheumatoid arthritis.
Carcinoid syndrome.
M Chadi Alraies 8
Pathophysiology
Orifice area <2 cm2:
Diastolic filling of the LV is impaired.
Increased LA pressures.
M Chadi Alraies 10
Signs and symptoms
Mild MS is asymptomatic at rest and mild exertion.
Symptoms triggered by factors that increase blood
flow across the mitral valve or shortening of the
diastolic period…
Stress
Exercise
Infection
Pregnancy
Atrial fibrillation with RVR
M Chadi Alraies 11
Physical exam
the murmur
"Tapping" sensation over area of expected PMI.
Accentuated S1
Opening snap.
Mid-diastolic murmur (rumble) low in pitch.
S2-OS interval of 70 msec is seen in severe MS.
Best heard after exercise, left lateral recumbency.
Bell chest piece lightly applied.
Pulmonary HTN and RVF occur later in MS.
M Chadi Alraies 12
ECG
Low sensitivity
P mitrale:
Lead II broad and bifid > 0.12 sec
Lead V1 broad and deep negative component of biphasic P
wave, longer than 0.04 sec and 1 mm in depth.
If pulmonary hypertension is present, tall peaked P
waves, right axis deviation, or right ventricular
hypertrophy appears.
Atrial fib.
Atrial flutter.
M Chadi Alraies 13
CXR
M Chadi Alraies 15
CXR
M Chadi Alraies 16
CXR
Straight left heart border.
Large left atrium.
Sharply indenting esophagus.
Elevation of left mainstem bronchus.
Large right ventricle and pulmonary artery if
pulmonary hypertension is present.
Calcification occasionally seen in mitral valve.
M Chadi Alraies 17
2D echocardiogram
Estimates the severity of MS
Measure the pressure gradient between LA to
LV.
Define the etiology.
M Chadi Alraies 18
Treatment
BB and CCB for rate control
Anticoagulation with warfarin if…
Chronic A.fib
Prior embolic events.
M Chadi Alraies 19
Surgery
Indications for intervention focus on:
Episode of pulmonary edema,
Decline in exercise capacity,
M Chadi Alraies 20
Surgery
Percutaneous mitral balloon valvotomy:
Mitral valve area <1.5 cm2
MVR:
Mitral valve area <1.0 cm2
M Chadi Alraies 21
Questions?
Mitral regurgitation
Etiology
Myxomatous degeneration: MVR, Marfan’s
Mitral annular calcification.
Rheumatic heart disease.
Congenital malformation.
Ruptured papillary muscles and cordae tindinea.
Infective endocarditis.
Tumors.
Functional:
Ischemia, DCM, infiltrative CMP and trauma.
M Chadi Alraies 24
Prevalence
20% of post Mi patients.
M Chadi Alraies 25
Sign and symptoms
Symptoms typical for the underlying cause.
Exercise intolerance.
DOE
Pulmonary edema and CHF.
Triggers for symptoms…
Atrial fibrillation, pregnancy and infection.
M Chadi Alraies 26
Physical exam
Forceful, brisk PMI; systolic thrill over PMI.
Pansystolic: begins with M1 and ends at or
after A2.
Loudest over PMI; transmitted to left axilla,
left infrascapular area.
After exercise; diaphragm chest piece.
M Chadi Alraies 27
Tests
ECG
Left axis deviation.
Left ventricular hypertrophy.
P waves broad, tall, or notched in standard
leads.
Broad negative phase of diphasic P in V1.
M Chadi Alraies 29
CXR
M Chadi Alraies 30
M Chadi Alraies 31
2D echocardiogram
Thickened mitral valve in rheumatic disease.
Enlarged left ventricle with above-normal,
normal, or decreased function.
Regurgitant flow mapped into left atrium.
M Chadi Alraies 32
Management
Acute MR:
Emergency surgery.
Stabilization with vasodilators (nitroprusside)
Chronic MR:
Afterload reduction: ACEI
Anticoagulation in case of atrial fibrillation.
M Chadi Alraies 33
When to refer for surgery?
1. Acute symptomatic MR
2. Severe MR, NYHA II-IV with EF >60%.
3. Severe MR, EF 50-60%, ESD 45-50 mm.
4. Severe MR, EF 30-50%, ESD 50-55 mm.
5. Severe MR, A. Fib with NL EF
6. Severe MR, severe pulmonary HTN, NL EF.
M Chadi Alraies 34
Questions?
Aortic stenosis
Etiology
Bicuspid valve.
Degenerative
Congenital
Rheumatic
Infective endocarditis.
M Chadi Alraies 37
Prevalence
25% of patients over age 65 years and
35% of those over age 70 years
The most common surgical valve lesion in
developed countries, and many patients are
elderly.
M Chadi Alraies 38
Risk factors
Hypertension,
Hypercholesterolemia, and
Smoking
M Chadi Alraies 39
M Chadi Alraies 40
Signs and symptoms
Cardiac output is maintained until the stenosis
is severe (with a valve area < 0.8 cm2).
LV failure,
Angina pectoris.
M Chadi Alraies 41
Physical exam
Powerful, heaving PMI to left and slightly
below MCL.
Small and slowly rising carotid pulse.
A2 normal, soft, or absent.
Paradoxic splitting of S2 if A2 is audible.
M Chadi Alraies 42
Physical exam
Prominent S4.
Midsystolic: begins after M1, ends before A2,
reaches maximum intensity in mid systole.
Right second ICS parasternally or at apex,
heard in carotids and occasionally in upper
interscapular area.
Patient resting, leaning forward, breath held in
full expiration.
M Chadi Alraies 43
Tests
ECG
Left axis deviation.
Left ventricular hypertrophy.
LBBB
Repolarization changes.
M Chadi Alraies 45
CXR
Concentric left ventricular hypertrophy.
Prominent ascending aorta, small knob.
Calcified valve.
M Chadi Alraies 46
2D echocardiogram
Poststenotic dilation of the aorta,
Restricted opening of the aortic leaflets,
Bicuspid aortic valve in about 30%.
Increased transvalvular flow velocity
M Chadi Alraies 47
Management
Medical management…
No vasodilators.
Indicated in asymptomatic patients only with
preserved LV function.
M Chadi Alraies 48
Surgery, when?
Symptomatic:
Improve survival in preserved and depressed LVF
Depressed LV function.
Prophylactic AVR:
Patients going for CABG with severe AS
Patients going for other valvular surgery with
moderate AS.
M Chadi Alraies 49
Questions?
Aortic regurgitation
Etiology
M Chadi Alraies 53
Signs and symptoms
LV failure is a late event and may be sudden in
onset.
Exertional dyspnea and fatigue are the most
frequent symptoms.
Angina pectoris.
M Chadi Alraies 54
Physical exam
wide arterial pulse pressure.
water-hammer pulse or Corrigan's pulse.
Quincke's pulses (subungual capillary
pulsations)
Duroziez's sign (to and fro murmur over a
partially compressed peripheral artery,
commonly the femoral)
Musset's sign (head bob with each pulse).
M Chadi Alraies 55
The apical impulse is…
prominent,
laterally displaced,
may be sustained.
M Chadi Alraies 56
The murmur…
Aortic diastolic murmur is usually high-
pitched and decrescendo.
A mid or late diastolic low-pitched mitral
murmur (Austin Flint murmur) may be heard.
Patient leaning forward, breath held in
expiration.
M Chadi Alraies 57
Tests
ECG
Left axis deviation.
Left ventricular hypertrophy.
M Chadi Alraies 59
Management
Acute aortic regurgitation…
Treatment of the underlying infection.
Surgical management.
Chronic regurgitation…
vasodilators, such as hydralazine, nifedipine, and
ACE inhibitors, can reduce the severity of
regurgitation.
prescribe ACE inhibitors whenever the LV
diastolic size is increased > 5.0 cm.
M Chadi Alraies 60
Surgery, when?
LV dysfunction EF is < 55% or if the LV end-
systolic dimension is > 5.0 cm.
aortic root diameters of > 5.0 cm in Marfan or
> 5.5 cm in non-Marfan patients.
surgical risk is higher than in aortic stenosis
patients with a similar EF.
M Chadi Alraies 61
Questions?
Tricuspid
regurgitation
Etiology
1. RV geometry abnormality:
1. Pulmonary hypertension
2. Severe pulmonic regurgitation.
3. LVF
4. RV infarction.
5. Cor pulmonale.
6. Mitral stenosis.
2. Anatomic issues with the valve itself:
1. Infective endocarditis.
2. Ebstein's anomaly
3. Marfan’s syndrome
4. Carcinoid syndrome
5. TV prolapse.
M Chadi Alraies 64
Signs and symptoms
RV failure
hepatomegaly,
edema, and
ascites
M Chadi Alraies 65
Physical exam
Cyanosis may be present.
Occasionally systolic thrill at lower left sternal
edge.
Systolic pulsation of liver.
Blowing, coarse, or musical murmur.
Murmur usually becomes louder during
inspiration.
M Chadi Alraies 66
Management
Elimination of the cause of the tricuspid
regurgitation.
Intravenous diuretics should initially be used.
Torsemide is better absorbed.
M Chadi Alraies 67
Surgery, when?
Symptoms and annular dilatation.
Endocarditis.
Ebstein’s anomaly.
Bioprosthetic valve, and not a mechanical
valve, is used.
M Chadi Alraies 68
DD of systolic murmur
Intervention HOCM Aortic Stenosis Mitral Mitral Prolapse
Regurgitation
Valsalva Increased Decreased Decreased Inc or dec
or
or same
Standing Increased Increased Decreased Increased
Handgrip or Decreased Decreased Increased Decreased
squatting
Supine Decreased Increased No change Decreased
position with
legs elevated
Exercise Increased Increased Decreased Increased
Amyl nitrite Markedly Increased Decreased Increased
increased
Iso- Markedly Increased Decreased Increased
Proterenol
increased M Chadi Alraies 70
References
1. CMDT 2007
2. ACC/AHA 2006 Guidelines for the
management of patient with valvular
heart disease.
THANK YOU
M Chadi Alraies 71