VALVULAR HEART DISEASE

DR.LIU LIXIN
Department of cardiology
 Rheumatic Fever
 Definition: autoimmune disease
caused by streptococcal infection,
cross-react between streptococcal
antigens and structural glycoprotein
of heart, joints, central nerves
system and connective tissue.
 Pathology: exudation, proliferation
(Aschoff nodes), scarring
 Rheumatic Fever
 Clinical Manifestations:
fever, rheumatic carditis, arthritis,
chorea, deformity of skin
 Laboratory finding:
ASO>500U, ASK>80U,
ESR↑,Alb↓,γ+a2↑ CRP(+),
CPK-MB↑, GOT↑,TnT TnI↑, C3↑, IgA↑
 Rheumatic Fever
 Diagnosis: Jones standards, 1992 AHA
 Treatment:
1) rest
2) antibiotics :Penicillin
3) anti- inflammation: Aspirin
Corticosteroids
4) others
 Prevention
Overview of Valves
 Mitral Stenosis
 Etiology:
predominant cause: rheumatic fever
rare cause
 Pathology:
thickening, shortening, adhering, calcium
depositing, and scarring
four forms of fusion: (1) commissural, (2)
cuspal, (3)chordal, (4)combined
two types of shape: fish-mouth shaped,
funnel-shaped
 Mitral Stenosis
 Pathophysiology:
normal cross-sectional area:4-6 cm2
mild MS: <2 cm2, LAP↑→LAH
---compensated period
moderate MS: <1.5 cm2, PVP↑, PCWP↑,
→interstitial edema
severe MS: <1.0 cm2,PAP↑→RVoverload
→RV failure →TR →PR
 Mitral Stenosis
 Clinical Manifestations (MVA<1.5cm2)
1. Symptom: dyspnea, hemoptysis, cough,
hoarseness (ortner’s syndrome)
2. Signs:
-Mitral faces
-Diastolic thrill at apex
-S1↑(flexible), OS(Opening snap), Diastolic
rumbling murmur
at apex,
-P2↑, splitting, Graham-Steel murmur(PR),TR
 Mitral Stenosis
 Laboratory Examination
- ECG:
1) left atrial enlargement: P wave (II,V1)
2) Af; 3) right ventricular hypertrophy
- X-film: change in cardiac silhouette,
Kerley B lines
- Echocardiography: M-mode, Two-
dimensional, Doppler
正常二 尖瓣形 态
 风湿性 二尖瓣 狭窄
Rheumatic mitral stenosis
 风湿 性二尖 瓣狭 窄
Rheumatic mitral stenosis
 风湿性 二尖瓣 狭窄
Rheumatic mitral stenosis
 风湿性 二尖瓣 狭窄
Rheumatic mitral stenosis
 风湿性 二尖瓣 狭窄
Rheumatic mitral stenosis
 Mitral Stenosis
 Diagnosis & Differential diagnosis
- Diastolic rumbling murmur at apex
+ X-film + ECG + Echo
- relative MS; Austin-Flint murmur;
left atrial myxoma ; Graham steell
murmur
 Complication:
Atrial fibrillation; acute pulmonary
edema;
congestive heart failure;
thromboembolism;
infective endocarditis; pulmonary
 Mitral Stenosis
 Management:
- Medical treatment:
Antibiotics, Diuretics and Digitalis,
Antiarrhythmic drugs, Anticoagulant
- Percutaneous balloon mitral valvuloplasty
( PBMV)
- Surgical treatment:
Closed mitral valvotomy
Open valvotomy
Mitral valve replacement
 Balloon Mitral
Commissurotomy
 Mitral Regurgitation
 Etiology and Pathology
- Abnormalities of valve leaflets:
Rheumatic, infective
- Abnormalities of the mitral annulus:
dilatation, calcification
- Abnormalities of the chordae tendineae:
congenitally, infective, trauma,
Rheumatic
- Involvement of papillary muscle: CAD
 Mitral Regurgitation
 Pathophysiology
In systolic period, blood flow from LV
→ LA, LA filling pressure↑;
in diastolic period, LV accepts more
blood →LV dilation, hypertrophy
→LVEDP↑
→LAP↑→PCWP↑→PAP↑→RHF; CO↓
 Chronic
 Acute
 Mitral Regurgitation
 Clinical Manifestations
(1) Symptoms: asymptomatic( gradually,>20
years),
palpitation, fatigue, dyspnea, pulmonary
edema
(2) Signs:
- apical pulse→left,lower
- apical beat heavy
- cardiac dullness enlarged→left
- pansystolic murmur at apex, radiate to left
axilla, subscapular
- S1↓,P2↑
 Mitral Regurgitation
 Laboratory Examination:
- ECG: LA enlargement, Af, LV hypertrophy
- X- Film: chronic– cardiomegaly (LV, LA)
acute– interstitial edema (Kerley
B)
- Echocardiography: two-dimensional,
Doppler , color flow mapping
- Angiocardiography & Magnetic resonance
imaging
二尖 瓣脱垂 伴关闭 不全
二尖瓣 关闭不 全
 Mitral Regurgitation
 Diagnosis:
systolic murmur at apex + LA↑, LV↑+
Echo
 Differential Diagnosis:
relative MR, ventricular septal defect,
tricuspid regurgitation, aortic stenosis
 Management:
- Medical treatment
- Surgical treatment
 Aortic Stenosis
 Etiology & Pathology:
- Rheumatic AS, Congenital AS,
Degenerative calcific AS
 Pathophysiology:
- Obstruction to LVOT→ LVH→ LAH→
PVP↑→
Pulmonary edema;
- LVEF↓→ischemia of peripheral 、 brain 、
heart
 Aortic Stenosis
 Clinical Manifestations:
- Symptoms: heart failure (fatigue, dyspnea),
angina pectoris, syncope, sudden
death
- Signs: Apical impulse↑,to left
Systolic thrill in AV area,pulse↓
Cardiac dullness→left
Ejection sound & SM in AV area, radiate
to neck
A2↓ splitting paradoxically
 Aortic Stenosis
 Laboratory Examination:
ECG; X- film;
Echocardiography; Angiography
 Diagnosis & Differential Diagnosis:
- murmur + Echo
- MI, TI, VSD
- other murmurs of LVOT obstruction
风湿性 主动 脉瓣狭 窄伴 返
流 Rheumatic aortic stenosis
and regurgitation
风湿性 主动 脉瓣狭 窄伴 返
流 Rheumatic aortic stenosis
and regurgitation
风湿性 主动 脉瓣狭 窄伴 返
流 Rheumatic aortic stenosis
and regurgitation
风湿性 主动 脉瓣狭 窄伴 返
流 Rheumatic aortic stenosis
and regurgitation
 Aortic Stenosis
 Complications:
Sudden death, heart failure,
arrhythmia,
infective endocarditis, systemic
embolism
 Management:
- Medical treatment
- Surgical treatment
 Aortic Regurgitation
 Etiology & Pathology
- Valvular Disease:
rheumatic, congenital, infective

prolapse, ankylosing spondylitis,

degenerative
- Aortic Root Disease:
syphilitic aoritis, Marfan syndrome,
ankylosing spondylitis, degenerative
- Acute AR: infective, trauma, aortic
 Aortic Regurgitation
 Pathophysiology:
- LV receives both blood from LA &
AO
→volume overload →LV dilation →
pulmonary edema →relative MI,MS;
- Diastolic pressure↓,pulse pressure↑
 Aortic Regurgitation
 Clinical Manifestations:
- Symptom: palpitation, angina
- Sign: apical impulse→ left, inferior
cardiac dullness →left, inferior
Boot-shaped shadow—cardiac waist↓
DM in AV2 area →apex
S1↓,A2↓
relative MI—SM at apex
relative MS—Austin Flint
 Aortic Regurgitation
 Sign: Peripheral vascular sign:
- pulse pressure↑, carotid pulsation↑
- Musset sign, water hammer pulse,
Traube sign, Duroziez murmur,
Muller sign, Quincke sign,
 Laboratory Examination:
ECG, X-Film, Echo, etc
 Aortic Regurgitation
 Diagnosis & Differential Diagnosis:
AI + peripheral vascular signs +
Echo
 Complication: infective endocarditis
ventricular arrthymia
heart failure
 Aortic Regurgitation
 Management:
Medical treatment
Surgical treatment