Valvular Disease

Cindy Chan, MD

Normal heart

Disease of Aortic Valve

Aortic Stenosis (AS)

Etiology of AS
Congenital (bicuspid) Rheumatic Senile calcific

Aortic Stenosis

Diastole Systole

Aortic Stenosis

Rheumatic Congenital Senile Bicuspid Calcific

Rheumatic

Bicuspid

Fish mouth

Senile calcification

< age 65 = congenital

>age 65 = senile calcific

NORMAL
120 mmHg
120 mmHg
Aorta

LV

STENOSIS
120 mmHg
220 mmHg
Aorta

LV

What is the effect of increased pressure on the LV?

Aorta

Pressure

Aorta

220 mmHg
Left ventricular hypertrophy

LV

Systolic Pressure load

LVH ( increased stiffness)

LV end-diastolic pressure Demands

CHF

Angina

Clinical Triad of Aortic Stenosis

Heart Failure Angina

Syncope

Syncope
Inability to increase cardiac output with exercise

Ventricular arrhythmias

Aortic Stenosis Natural History

100 90

80
70

60
50

Average Death 3-4 Years 40

Age

50

60

70

Aortic Stenosis Natural History

100 90

80
70

Failure Syncope Angina

60
50

Physical findings of AS Murmur Sounds Carotid Apex

LV = Ao
Ao

Normal

LA

S1

S2

LV

Ao
LA

Aortic Stenosis
Stenosis is a pressure gradient across a valve

S1

S2

Aortic Stenosis
Ao
LV
Murmur must be crescendo-decrescendo in timing

Crescendodecrescendo

S1

S2

Aortic Stenosis
Timing Frequency Location Position = = = = Systole High R or L SB Leaning forward

Ejection click
Early systolic sound suggests bicuspid valve

Aortic Stenosis
Ao
LV Ejection Click Crescendodecrescendo

S1

S2

Carotid artery pulsation

Normal
Pulsus

Abnormal

parvus et tardus

This is a clue to help determine AORTIC STENOSIS

Summary of Physical Findings

Harsh crescendo - decrescendo murmur (often radiating into the neck) Ejection click (if pliable) Carotid - pulsus parvus et tardus Apical impulse - S4

Opening snap, early ejection systolic

S4 (atrial gallop)
Forceful left atrial contraction

May feel at apex

DI ASTOLIC ABNORMALITY OF LV

LV compliance)

S4

(atrial gallop)
Apical impulse
S4

DIASTOLIC ABNORMALITY OF LV

NORMAL
S1 S2

ABNORMAL
S4 S1
S2

S4

Laboratory tests in Aortic Stenosis

Chest x-ray - LV prominence EKG - LVH Echocardiogram -Etiology
Severity LV size & function

Major diagnostic test

Echocardiogram

Echocardiogram in AS
Anatomy
Detect calcification Evaluate opening of valve

Physiology
Quantitative obstructive gradient Allow calculation of valve area

The use of Doppler Echo

Aorta

120 mmHg
Gradient 220 mmHg LV

Velocity

5 M /sec

Doppler Echo in Aortic Stenosis

Pressure Gradient: 2 Pressure = 4 x Velocity
Example: Velocity = 5 Meters/ sec Pressure Gradient= 4 x 5 x 5 = 100 mmHg

Continuity Equation

LVOT
1.0 M/sec x 5 cm
2

Aortic Valve
= 5 M/sec x ? Aortic valve area = 1.0 cm 2

Velocity X Area = Velocity X Area

Aortic Valve Area

Normal 3 .0 cm2 Mild AS 1.5 - 2.0 Moderate AS 1.0 - 1.5 Severe AS <1.0

Catheterization
if
Non-invasive tests are equivocal Age > 50 (to detect CAD)

Catheterization in A.S.
Left Ventricle to Aorta Pressure Gradient
220 mmHg

LV

120 mm Hg Ao

S1

S2

S1

Antibiotic prophylaxis
Dental, GI or GU procedures

Amoxicillin

Indications for Surgery Symptoms Critical stenosis =

Gradient > 50mmHg or Aortic valve area < 0.8 cm2

Prosthetic valves
Mechanical
Ball valve Tilting disk Bileaflet (St.Jude)

Tissue
Porcine Homograft

Tissue valve

Starr- Edwards

Ball in a cage

Mechanical

Tissue

Advantages
Mechanical Tissue Long lasting

Disadvantages
Need anticoagulation Degenerates

No anticoagulation

Ross procedure
Aortic position = Pulmonic autograft Pulmonic position = Pulmonic homograft

Complications of Prosthetic heart valves

Thromboembolism o Bleeding 2 to anticoagulation Prosthetic valve dysfunction Periprosthetic regurgitation Endocarditis Serious - 5%/yr Death - 1-2%/yr

Aortic Regurgitation

Abnormalities of valve leaflets Congenital Rheumatic Endocarditis Abnormalities of aortic root Aortic dissection Marfans syndrome Syphilis

Aorta

In diastole, aortic valve is not competent to hold up pressure or volume

Diastolic Volume load

LV dilatation
LV end-diastolic pressure Demands

CHF

Rarely,angina

AS

Systolic Pressure overload =

LV Hypertrophy

AR

Diastolic Volume overload

LV Dilatation

Aorta

In diastole, aortic valve is not competent to hold up pressure or volume

Low diastolic pressure = incompetent valve

High systolic pressure = large stroke volume

Therefore, wide pulse pressure

i.e. 200 / 40 mmHg

Physical findings of AR
Wide pulse pressure 200/40 Cardiomegaly Murmur Peripheral findings of wide pulse pressure

Aortic Regurgitation
Ao
LV
LA

S1

S2

Early diastolic high-pitched blowing murmur

Aortic Regurgitation
Timing Frequency Location Position = Early Diastole = High = R or L SB = Leaning forward

Wide pulse pressure signs

Head bob (deMussets) Uvula (Mullers) Finger capillaries (Quinckes) Brachial (Waterhammer) Femoral to & fro (Duroziezs)
Carotid double beating

(pulsus bisferiens)

Aortic Regurgitation
Treatment
Acute surgery Chronic afterload reduction with ACE-I Surgery if:
Symptomatic LV dysfunction (EF <55% or LV end-systolic dimension >5.0 cm) Aortic root diameter >4.5cm in Marfan or >5.0 in non-Marfan pt (avoid rapid expansion)

Often requires aortic root repair No percutaneous approaches (unlike AS)

Acute Aortic Regurgitation

Severe acute AR
Surgical emergency

Infective endocarditis

Acute versus Chronic

Massive pulmonary edema

Aorta

Aorta

LA

LV

LV Small stiff LV

ACUTE

CHRONIC

Acute vs Chronic

Cardiomegaly
Wide pulse pressure

No
No

Yes
Yes

Natural History AR 10 year survival

Mild Severe Heart failure >90% ~50% 90% <2 yrs

Follow-up
Regular clinical evaluation Periodic assessment of LV function Antibiotic prophylaxis Medical rx - diuretics afterload-lowering

BREAK

Disease of Mitral Valve

Cindy Chan, MD

Mitral Stenosis

Mitral Stenosis Normal Anatomy

Atrial fibrillation 50-80%

Mitral Stenosis
If mild-mod MS (valve area 1.8 cm2 1.3 cm2), asymptomatic or DOE
If severe MS (valve area < 1.0 cm2), pulm HTN, low CO, right HF

Mitral Stenosis

LA LV S1 S2 OS
Mid-diastolic Rumble Pre-systolic accentuation

Mitral Stenosis Timing Frequency Location Position decubitus = Mid Diastole = Low = Apex = Left lateral

Mid diastolic murmur

Blood Stasis in the Left Atrium

Transesophageal Echo

Left Atrial Appendage Clot

Transesophageal Echo

Mitral Stenosis
Treatment
If total valve score 8 or less, ballon valvuloplasty If >8 or with combined stenosis & regurg, valve replacement

Valve score
1-4 points for
Mitral leaflet thickening Mitral leafley mobility Submitral scarring Commissural calcium

Mitral Regurgitation

Mitral Valve Regurgitation

If acute, pulm edema

Atrial fibrillation

Mitral Regurgitation
LV
LA
Murmur should be holosystolic

S1 Systole S2

S1

Mitral Regurgitation
Timing Frequency Location Position Radiation = Pan Systolic = High = Apex = L lateral decubitus = Axilla

Holosystolic murmur

S3 (Ventricular gallop sound)

Timing- Early diastolic Frequency- Low Rarely palpable

S3

Diagnosis
EKG: there may be left atrial enlargement with chronic MR, atrial fibrillation or normal sinus rhythm Echo: accurate, non-invasive technique to assess cardiac chamber and valve anatomy and function. The etiology of MR may be diagnosed (i.e., ruptured chordae, valve prolapse, ischemia inducing a wall motion abnormality to name a few). Doppler echo detects the regurgitant flow and allows estimates of its severity. Cardiac catheterization: this allows for hemodynamic evaluation of the cardiac chambers and valves as well as determine the presence of coronary disease. Cardiac catheterization is done particularly when surgery is contemplated.

Mitral Regurgitation
Treatment
Acute emergent surgery Chronic surgery if symptomatic, EF <60%, or LV end-systolic diameter >4.5 cm

Mitral Valve Prolapse

Mitral Valve Prolapse

Epi
Found in up to 10% healthy young women (most commonly female) Associated with collagen diseases (Marfans, EhlersDanlos) Associated with skeletal deformities (pectus excavatum or scoliosis)

S/S
Usually asymptomatic Mid-systolic clicks (with late systolic murmur if leaflets fail to come together) CP, dyspnea, fatigue, palpitations

Myxomatous Mitral Valve with Mitral Valve Prolapse

Diagnosis
EKG: usually normal Echo: There are specific echo criteria that define mitral valve prolapse. The echo demonstrates the myxomatous nature and redundancy of the valve structure. It reveals the prolapsing motion of the valve in real-time. Doppler echo demonstrates associated mitral regurgitation. This along with clinical features makes the diagnosis of this disorder

Mitral Valve Prolapse

Treatment
BB to tx hyperadrenergic state Valve repair favored over replacement Include shortening of chordae, chordae trasfers, wedge resection of redundant valve tissue, mitral annular ring

Other valvular diseases

Tricuspid Stenosis
Etiology
Rheumatic Carcinoid syndrome

S/S
Diastolic rumble at lower left sternal border, opening snap, large a wave R heart failure (hepatomegaly, ascites, dependent edema)

Tricuspid Stenosis
Dx
Echo

Tx
Valvuloplasty ineffective (often with residual TR) Replacement (severe when mean diatolic pressure gradient >5 mmHg

Tricuspid Regurgitation
Etiology
RV dilatation from any cause (pulm HTN, severe PR, cardiomypathy, MI, L heart failure, Ebstein anomaly)

S/S
Holosystolic murmur at LSB, increases with inspiration, c-v wave in jugular venous pulsations, S3 RV failure

Tricuspid Regurgitation
Dx
Echo

Tx
Diuretics Tx L HF, pulm HTN If surgery for other reasons, tripcuspid annuloplasty

Pulmonic Stenosis
Etiology
Often assoc with other cardiac lesions Often with domed or dysplastic valve (eg Noonan syndrome) Increased resistance to RV outflow, then elevated RV pressure, the limited pulm blood flow

S/S
Asympotmatic if mild (PV-PA peak gradient < 30 mmHg) Moderate (30-50) to severe (>50) experience DOE, CP, syncope, and RV failure Loud, harsh systolic murmur, radiates to L shoulder, increases with inspiration, ejection click (which decreases with inspiration), parasternal lift (from RVH), thrill, S4, prominent a wave

Pulmonic Stenosis
Dx
Echo

Tx
Percutaneous balloon valvuloplasty if symptomatic or resting peak gradient >50 mmHg

Pulmonic Regurgitation
Classification
High-pressure causes (pulm HTN) Low-pressure causes (dilated pulm annulus, carcinoid plaque, post-surgical repair)

S/S
Diastolic murmur, widely split S2, S3

Pulmonic Regurgitation
Dx
Echo

Tx
Primary cause

One more thing about valve replacement

Bioprosthetic valves life expectancy 1015 years (less for younger pts & pts on HD)
No anticoagulation

Mechanical valves longer life expectancy

Mitral: INR 2.5-3.5 (greater risk of thrombosis) Aortic: INR 2.0-2.5

Some physical exam skills.

Description of Murmur

a. Loudness b. Pitch c. Timing d. Location - Radiation

Description of Murmur

Loudness: GRADE
I Soft - not heard initially II Soft- heard initially III Loud IV Loud with thrill - felt V Loud with one edge VI Loud- without steth

Abnormal

Location
Aortic Pulmonic

Tricuspid

Mitral

How do you tell systole from diastole?

Wiggers Diagram
Ao
LV LA

Lubb Dup

S1 Systole S2

Diastole

S1

Normal

S1 Systole S2

Diastole

S1

Tachycardia

S1Systole S2 Diastole S1

Must first tell systole from diastole

QRS of EKG
Carotid upstroke

Apical impulse

Heart sounds
S1 Systole S2

 SYSTOLIC

TIMING OF MURMURS
DIASTOLIC Mitral Stenosis Tricuspid Stenosis Aortic Regurgitation Pulmonic Regurg

Mitral Regurgitation Tricuspid Regurg Aortic Stenosis Pulmonic Stenosis ASD VSD HOCM (IHSS) Flow (innocent)

Ao
LV
LA

Diastolic sounds

S1

S2

OS

S3

S4 S1

LOW FREQUENCY

S3 S4
The murmur of Mitral Stenosis

Bell

Lubb Dup

S1 Systole S2

Diastole

S1

S4
Lubb Dup

S3

S1 Systole S2

Diastole

S1

LOW FREQUENCY
Timing Location
APEX

S3

EARLY DIASTOLE LATE DIASTOLE

S4

APEX

S4
a Stiff.Wall
S4,S1...

S2

S3
Slurp..ing in

S1S2,S3

S4
a Stiff Wall
S4,S1...

S3
Slurp ing in

S2

S1S2,S3

Maneuvers
Intervention Hypertrophic Obstructive Cardiomyopathy Up Aortic Stenosis Mitral Prolapse

Valsalva

Down

Up

Standing

Up

Down

Up (and earlier onset) Down

Handgrip or squatting

Down

Up

Thanks!