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Valvular heart disease

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.

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Jones criteria
Major manifestations
 Carditis
 Polyarthritis
 Chorea
 Erythema marginatum
 Subcutaneous nodules

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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

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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.

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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.

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Pathophysiology
 Orifice area <2 cm2:
 Diastolic filling of the LV is impaired.
 Increased LA pressures.

 Orifice area <1 cm2:


 LA pressure is > 25 mmHg.
 Symptoms of HF
 Tachycardia

 LV diastolic pressure is usually normal in


isolated MS.
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Signs and symptoms
 Dyspnea
 Orthopnea
 PND
 LL edema
 Pulmonary edema
 Mitral facies.
 Hemoptysis
 Embolic events: MI, stroke, renal emboli.

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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

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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.

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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.

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CXR
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CXR

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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.

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2D echocardiogram
 Estimates the severity of MS
 Measure the pressure gradient between LA to
LV.
 Define the etiology.

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Treatment
 BB and CCB for rate control
 Anticoagulation with warfarin if…
 Chronic A.fib
 Prior embolic events.

 Severe MS with LA >5.5 cm on echocardiogram.

 A.fib recurrence is 20-30% after the first


episode.

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Surgery
 Indications for intervention focus on:
 Episode of pulmonary edema,
 Decline in exercise capacity,

 Evidence for pulmonary hypertension.

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Surgery
 Percutaneous mitral balloon valvotomy:
 Mitral valve area <1.5 cm2

 MVR:
 Mitral valve area <1.0 cm2

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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.

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Prevalence
 20% of post Mi patients.

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Sign and symptoms
 Symptoms typical for the underlying cause.
 Exercise intolerance.
 DOE
 Pulmonary edema and CHF.
 Triggers for symptoms…
 Atrial fibrillation, pregnancy and infection.

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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.

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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.

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CXR

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2D echocardiogram
 Thickened mitral valve in rheumatic disease.
 Enlarged left ventricle with above-normal,
normal, or decreased function.
 Regurgitant flow mapped into left atrium.

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Management
 Acute MR:
 Emergency surgery.
 Stabilization with vasodilators (nitroprusside)

 Intra-aortic balloon counterpulsation.

 Chronic MR:
 Afterload reduction: ACEI
 Anticoagulation in case of atrial fibrillation.

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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.

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Questions?
Aortic stenosis
Etiology

 Bicuspid valve.
 Degenerative
 Congenital
 Rheumatic
 Infective endocarditis.

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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.

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Risk factors
 Hypertension,
 Hypercholesterolemia, and
 Smoking

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Signs and symptoms
 Cardiac output is maintained until the stenosis
is severe (with a valve area < 0.8 cm2).
 LV failure,
 Angina pectoris.

 Syncope exertional and a late finding.

 all occur with exertion.

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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.

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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.

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Tests
ECG
 Left axis deviation.
 Left ventricular hypertrophy.
 LBBB
 Repolarization changes.

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CXR
 Concentric left ventricular hypertrophy.
 Prominent ascending aorta, small knob.
 Calcified valve.

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2D echocardiogram
 Poststenotic dilation of the aorta,
 Restricted opening of the aortic leaflets,
 Bicuspid aortic valve in about 30%.
 Increased transvalvular flow velocity

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Management
 Medical management…
 No vasodilators.
 Indicated in asymptomatic patients only with
preserved LV function.

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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.

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Questions?
Aortic regurgitation
Etiology

1. Bicuspid aortic valve.


2. HTN
3. Rheumatic
4. Congenital
5. Aneurysm of the sinus of Valsalva.
6. Infective endocarditis.
7. Post aortic stenosis repair.
8. Osteogenesis imperfecta.
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Pathophysiology
 Increased preload and afterload to the LV.
 The response to these effects is to hypertrophy
by laying sarcomeres end to end.
 Increasing the LV chamber size greater than
the wall thickness (eccentric hypertrophy).
 The amount of hypertrophy is substantial and
greater than that seen in aortic stenosis or
mitral regurgitation.

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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.

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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).
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 The apical impulse is…
 prominent,
 laterally displaced,

 usually hyperdynamic, and

 may be sustained.

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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.

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Tests
ECG
 Left axis deviation.
 Left ventricular hypertrophy.

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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.

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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.

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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.
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Signs and symptoms
 RV failure
 hepatomegaly,
 edema, and

 ascites

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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.

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Management
 Elimination of the cause of the tricuspid
regurgitation.
 Intravenous diuretics should initially be used.
 Torsemide is better absorbed.

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Surgery, when?
 Symptoms and annular dilatation.
 Endocarditis.
 Ebstein’s anomaly.
 Bioprosthetic valve, and not a mechanical
valve, is used.

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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
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