Valvular Heart Disease

Hakim Alkatiri

Mitral Stenosis

Mitral Stenosis Causes rheumatic fever congenital abnormality, calcification, myxoma Natural history RF age 12 murmur 1st heard 20 yrs later symptoms in 3-4th decade

Mitral Stenosis - Clinical features

Severity Mild Moderate Severe Very Severe MVA (cm) >2.0 1.1-2.0 <1.0 <0.8 LAP (mm Hg) <10-12 ~10-17 >18 >20-25 CO NL NL

Severity Mild Moderate Severe

Symptoms Asymptomatic or mild DOE Mild-mod DOE; orthopnea, PND, hemoptysis Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest; severe fatigue; cyanosis

Mitral Stenosis - Examination

Inspection Malar flush Peripheral cyanosis (severe MS) Jugular venous distension (right ventricular failure) Palpation Parasternal right ventricular impulse Palpable pulmonary arterial impulse Palpable S1, P2, and occasionally, the diastolic rumble Auscultation Increased intensity of the first heart sound Opening snap Low-pitched diastolic rumbling murmur

Mitral Stenosis - Treatment Medical Diuretic - pulmonary congestion

Prevent embolism - cause of 19% deaths, with LA size and age

anticoagulate all with PAF/AF, SR in older age Control atrial fibrillation

Mitral Stenosis - Treatment Balloon Mitral Valvuloplasty

Mitral Stenosis - Treatment Balloon Mitral Valvuloplasty 100% MVA, final area ~2cm2

Failure rate 1-15%

Mortality 0-3% Severe MR 2-10% Restenosis ~40% at 7years Contraindications - thrombus, MR, Ca++, other disease

Mitral Stenosis - Treatment Mitral Valve Replacement Open mitral valvotomy

Mitral valve replacement

Mitral Regurgitation - Aetiology

Primary Annulus Leaflet annular calcification myxomatous degeneration rheumatic deformity infectious perforation myxomatous degeneration spontaneous rupture rheumatic shortening infectious destruction infarction ischemic lengthening

Chordae

Papillary

Functional LV dilatation and PM displacement

CXR

Mitral Regurgitation - Pathophysiology

Mitral Regurgitation - Clinical findings

Acute dyspnoea, orthopnoea no cardiomegaly, short murmur, S3 Chronic variable symptoms cardiomegaly, murmur, P2 loud, S3 Quantification echocardiography, angiography

serial studies, LV function

Mitral Regurgitation - Outcome in Chronic MR Variable course - diagnosis to symptoms 16 years Symptomatic severe - survival 33% at 5 years mortality ~5% per year

LV dysfunction most important factor

Mitral Regurgitation - Treatment

Acute Diuretics LV filling P, p oedema

Vasodilators
IABP Chronic

forward SV

No known effective therapy Vasodilators - theoretical risks Treat complications

Mitral Regurgitation - Surgery

Options Valve repair MVR with chordal preservation MVR with destruction MV apparatus Outcome Mortality 80-94% v 40-60% at 5-10years

Valve function
Ventricular function

Mitral Regurgitation - Indications for surgery

No randomised trials!! 1. Symptomatic with normal LV function prognosis worse once NYHA class II symptoms

2. Symptomatic with abnormal LV function If severe LV impairment - poor outlook

EF < 30% ?medical Rx better

Mitral Regurgitation - Indications for surgery

3. Asymptomatic with abnormal LV function ? Asymptomatic Detection of LV dysfunction is the key EF<60%, LVESD > 45mm, LVESV>55ml/m2 4. Asymptomatic with normal LV function ?guaranteed repair PHT, recent AF

Mitral Regurgitation - Indications for surgery

Mitral Regurgitation - Prolapse

2-4% population

females:males 2:1
diagnosis from echocardiography subcategory according to leaflet abnormality SBE prophylaxis; normal + MR or abnormal leaflets

Aortic Stenosis - Aetiology

Congenital 1st-3rd decade Valve degeneration and calcification Rheumatic - 4th decade Bicuspid valve; 1%, males>females, 5-6th decades Tricuspid valve - 7-8th decades, 1-2% incidence

Aortic Stenosis - Pathophysiology

LV pressure overload LV hypertrophy diastolic LV dysfunction Systolic function usually preserved except late in disease

Systolic function improves with AVR

Outcome is dependent on symptoms

Aortic Stenosis - Clinical features Symptoms None

DOE, dizziness
HF, syncope, angina Examination Pulse - amplitude, delay Sustained apex S2- soft and single paradoxical splitting ESM - loud late peak soft

Aortic Stenosis - Severity Echocardiography

Mean Peak Ao AVA gradient velocity (cm2) (mmHg) 1.0-2.0 >2.5 <20 2.5-2.9 3.0-4.0 >4.0 >1.7 1.0-1.7 <1.0

Normal Mild

Moderate 20-40 Severe >40

Aortic Stenosis - Outcome Symptoms 2-year survival < 50%

Asymptomatic
Generally good prognosis Peak velocity >4.0m/s 2yr event-free survival 21% Progression of> 0.3m/s per year - worse

Aortic Stenosis - Treatment Medical None!!!

Diuretics v LVF
ACEI contraindicated Balloon aortic valvuloplasty Average MVA improvement 0.8cm2 1.0cm2 Restenosis <6/12 in 50% No improvement in mortality Procedural mortality 5%

Aortic Stenosis - AVR

Indicated only if symptomatic Mortality 0.6-5% Survival 67-85% at 5 yrs, 70% at 10yrs 2yr survival 4x greater than medical treatment

LV dysfunction
?impairment from pressure overload or other cause

DSE may be helpful

Dimensionless index to be reported in all prosthetic AVR and if moderate + LV Aortic - AVR dysfunction is present. IndexStenosis <0.25 correlates to an AVA < 1.0cm2. Approach to symptomatic patients
Ao V max 4.0m/s 3.0-4.0 m/s 3.0m/s

Doppler AVA

1.0cm2

1.1 1.6 cm2 AI severity

1.7cm2

2-3+

0-1+

AVR recommended

AVR for AS not recommended

Aortic Regurgitation - Aetiology

Root Annuloaoroectasia Marfans Dissection Syphillis Ankylosing spondylitis Leaflet

Endocarditis
Bicuspid valve Rheumatic heart disease

Aortic Regurgitation - Pathophysiology

Normal

Acute Aortic Regurgitation - Clinical features

No time for LV to enlarge total SV, fwd SV, LVEDP Quiet S1 (presystolic MV closure), short murmur Treatment Medical therapy ineffective AVR if symptoms/signs LVF

Chronic Aortic Regurgitation - Clinical features

total SV, maintained fwd SV, RV runoff in diastole systolic BP, diastolic BP Volume and pressure overload Examination - hyperdynamic circulation, wide pulse pressure, dilated LV, EDM duration important

Chronic Aortic Regurgitation - Clinical features

LV decompensation

Maybe asymptomatic, LVF, angina

Chronic Aortic Regurgitation - Treatment Medical - afterload

Nifedipine 20mg bd delayed surgery by 2-3 yrs Duplicated with small ACEI trials

Vasodilator therapy

ACC / AHA Practice Guidelines 2006 Indications for AVr/R

Class I 1. AVR is indicated for Symptomatic patients with severe AR irrespective of LV systolic function. 2. AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction ( EF 50 % or less) at rest. 3 AVR is indicated for patiens with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves.

Auscultation - S1 loud Mirtal - Opening snap stenosis present followed by a mid-diastolic rumble - Holosystolic Mitral Regur- usually radiating gitation to the axilla - S1 soft, S 3 common Aortic - Ejection type stenosis early systolic (transmitted murmur from base) - Also heard at right 2nd ICS with radiation to the carotids Aortic diastolic regurgitation murmur at left base - P2 loud if PR secondary to pulmonary hypertension

Diagnosis

Summary
RV lift LV heave

Other P. E

Therapy diuretic - LA, PA, RV - RAD, LAE anti coagulan - Normal LV - () RVH BMV surgery LA and LV - LAE diuretic - AF vasodilator common surgery - LVH - Aortic valve calcification none !! (medical) BAV surgery

Radiograph

ECG

May have a thrill at the right 2nd ICS

LAD and LVH

- RV lift - Peripheral signs or AR absent

Hypovascular lung fields if - RAD pulmonary - RVH hypertension present

vasodilator surgery

Summary
Auscultation Other P. E - S1 loud Tricuspid - Mid-diastolic stenosis rumble a waves - increased by in JVP inspiration Holosystolic - V waves Tricuspid murmur increases in JVP regurgitation with inspiration - Pulsating (Carvallo's sign) liver - RV failure Ejection sistolic Pulmonary with click A wave in stenosis - S2 split, P 2 soft JVP or absent Diastolic Pulmonary murmur at left - RV lift regurgitation base - Peripheral - P2 loud if PR signs og AR secondary to absent pulmonary hypertension Diagnosis Radiograph ECG Therapy RA and SVC RAE

RA, RV, SVC

RAD

- RVH - Poststenotic - RVH dilatation of -RAD PA hypovascular lung fields if - RAD pulmonary - RVH hypertension present