PENYAKIT KATUP JANTUNG

dr. Tjatur Winarsanto SpPD

RS Ciremai
Spectrum of VHD
Aortic Valve

Mitral Valve

Tricuspid Valve

Pulmonic Valve
Spectrum of VHD
Regurg Acute
Aortic Valve Chronic
Stenosis Acute
Chronic
Regurg Acute
Mitral Valve Chronic
Stenosis Acute
Chronic
Regurg Acute
Tricuspid Valve Chronic
Stenosis Acute
Chronic
Regurg Acute
Pulmonic Valve Chronic
Stenosis Acute
Chronic
Cardiac Physiology
Systole AV/PV opens
S1-S2 MV/TV closes
Diastole AV/PV closes
S2-S1 MV/TV opens
 Cardiac Physiology 101

Regurg/ Insuff leaking (backflow) of blood across a closed valve

Stenosis Obstruction of (forward) flow across an opened valve

Systole AV/PV opens-------Aortic Stenosis

S1-S2 MV/TV closes------Mitral Regurg
Diastole AV/PV closes------Aortic Regurg
S2-S1 MV/TV opens-------Mitral Stenosis

These concepts are set in stone, it cant occur any other way,
It would be anatomically impossible
STENOSIS MITRALIS

Mitral Stenosis
Etiology
Symptoms
Physical Exam
Severity
Natural history
Timing of Surgery
Mitral Stenosis: Etiology

Primarily a result of rheumatic fever

(~ 99% of MVs @ surgery show rheumatic damage )
Scarring & fusion of valve apparatus
Rarely congenital
Pure or predominant MS occurs in
approximately 40% of all patients with
rheumatic heart disease
Two-thirds of all patients with MS are female.
 Mitral Stenosis:
Pathophysiology

Normal valve area: 4-6 cm2

Mild mitral stenosis:
MVA 1.5-2.5 cm2
Minimal symptoms
Mod mitral stenosis
MVA 1.0-1.5 cm2 usually does not produce
symptoms at rest
Severe mitral stenosis
MVA < 1.0 cm2
 Symptoms

Fatigue Afib
Systemic embolism
Palpitations
Pulmonary infection
Cough Hemoptysis
Left sided failure Right sided failure
Orthopnea Hepatic Congestion
Edema
PND
Worsened by conditions
Palpitation that cardiac output.
Exertion,fever, anemia,
tachycardia, Afib,
intercourse, pregnancy,
thyrotoxicosis
Mitral Stenosis : Physical Exam

S1 S2 OS S1

First heart sound (S1) is accentuated

and snapping
Opening snap (OS) after aortic valve
closure
Low pitch diastolic rumble at the apex
Pre-systolic accentuation (esp. if in
 Murmur
Systolic Murmurs
Aortic stenosis

Mitral insufficiency

Mitral valve prolapse

Tricuspid insufficiency

Diastolic Murmurs
Aortic insufficiency

Mitral stenosis

S1 S2 S1
Mitral Stenosis: Natural
History
Progressive, lifelong disease,
Usually slow & stable in the early years.
Progressive acceleration in the later years
20-40 year latency from rheumatic fever
to symptom onset.
Additional 10 years before disabling
symptoms
 Complications
Atrial dysrrhythmias
Systemic embolization (10-25%)
Risk of embolization is related to, age,
presence of atrial fibrillation, previous
embolic events
Congestive heart failure
Pulmonary infarcts (result of severe CHF)
Hemoptysis
Massive: 20 to ruptured bronchial veins
(pulm HTN)
Streaking/pink froth: pulmonary edema, or
infection

 Mitral Stenosis :ECG

LAE
RVH
Premature contractions
Atrial flutter and/or fibrillation
freq. in pts with mod-severe MS for
several years
A fib develops in 30% to 40% of pts
w/symptoms
 Mitral Stenosis
There is atrial fibrillation. No P waves are visible. The
rhythm is irregularly irregular (random).
There is the suggestion of right ventricular hypertrophy.
Right axis deviation and deep S waves in the lateral leads.
Another important feature of right ventricular hypertrophy
not shown here is a dominant R wave in lead V1.
The combination of Atrial Fibrillation and Right Axis Deviation on
the ECG suggests the possibility of mitral stenosis.
Radiograph of the heart: The abnormalities characteristic of mitral
stenosis are more expressed in this case. The heart is enlarged, the
dilatation of the left ventricle (arrow) is associated with the
dilatation of the right ventricle
Mitral Stenosis:Therapy

Medical
Diuretics for LHF/RHF
Digitalis/Beta blockers/CCB: Rate control in
A Fib
Anticoagulation: In A Fib
Endocarditis prophylaxis
Balloon valvuloplasty
Effective long term improvement
Mitral Stenosis:Therapy

Surgical
Mitral commissurotomy
Mitral Valve Replacement
Mechanical
Bioprosthetic
Recommendations for Mitral Valve
Repair for Mitral Stenosis

ACC/AHA Class I
Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),*and valve
morphology favorable for repair if percutaneous mitral balloon
valvotomy is not available
Patients with NYHA functional Class III-IV symptoms,
moderate or severe MS (mitral valve area <1.5 cm 2 ),*and
valve morphology favorable for repair if a left atrial thrombus is
present despite anticoagulation
Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable
or calcified valve with the decision to proceed with either repair
or replacement made at the time of the operation.
Recommendations for Mitral Valve
Repair for Mitral Stenosis

ACC/AHA Class IIB

Patients in NYHA functional Class I,

moderate or severe MS (mitral valve

area <1.5 cm 2 ),* and valve
morphology favorable for repair who
have had recurrent episodes of embolic
events on adequate anticoagulation.
ACC/AHA Class III
Patients with NYHA functional Class I-IV

symptoms and mild MS.

*
Mitral Regurgitation
Etiologies
Alterations of the Leaflets, Commissures, Annulus
Rheumatic
MVP
Endocarditis

Alterations of LV or LA size and Function

Papillary Muscle (Ischemic, MI, Myocarditis, DCM)
HOCM
LV Enlargement Cardiomyopathies -
LA Enlargement from MR
MR begets MR
Gambar 2. mitral valve prolapsed
Mitral Regurgitation

Symptoms
Fatigue and weakness
Dyspnea and orthopnea
Right sided HF
MVP Syndrome (if present)
Mitral Regurgitation

Physical Exam
Holosystolic Apical Blowing Murmur
Laterally displaced apical impulse
Split S2 (but is obscured by the murmur)
S3 Gallop (increased volume during diastole)
Radiation depends on the etiology
Mitral Regurgitation
Diagnosis

Ecg LAE, LVH

Echo 2D/color doppler test of choice
Cardiac Cath helpful, confirmatory, needed if
the pt is older look at the coronaries
Mitral Regurgitation

- SBE Prophylaxis
Valvular Heart Disease

Aortic Valve

Aortic Stenosis
Aortic Regurgitation
Aortic Stenosis

Etiologies

Congenital 0-30 yrs

Bicuspid 30-50 yrs
Rheumatic 30-60 yrs
Degenerative >60 yrs
Aortic Stenosis
Etiology

Congenital aortic stenosis occurs due to improper

development of the aortic valve in the first 8 weeks of fetal
growth. It can be caused by a number of factors, though,
most of the time, this heart defect occurs sporadically (by
chance), with no apparent reason for its development.

Some congenital heart defects may have a genetic link,

either occurring due to a defect in a gene, a chromosome
abnormality, or environmental exposure, causing heart
problems to occur more often in certain families.

Acquired aortic stenosis may occur after a strep infection

that progresses to rheumatic fever.
Aortic Stenosis pathophysiology
Aortic Stenosis

Physical Exam
Harsh Systolic Ejection Murmur late
peaking
S4 gallop (from LVH)
Sustained Bifid LV impulse (from LVH)
Symptomp

fatigue
dizziness with exertion
shortness of breath
irregular heartbeats or palpitations
chest pain
Aortic Stenosis

Symptoms

Angina
Syncope
Congestive Heart Failure (CHF)
Aortic Stenosis
Aortic Stenosis
Aortic Stenosis

Diagnosis

Ecg LAE, LVH

Echo 2D/color doppler test of choice
Cardiac Cath helpful, confirmatory, needed
if the pt is older look at the coronaries
 Aortic Stenosis
Treatment of Symptomatic Aortic Stenosis or
Decreased LV Function
Medical Therapy treats the symptoms not the cause
Aortic Valve Replacement
Bioprosthetic vs Mechanical AVR
Treatment
balloon dilation -
valvotomy - surgical release of adhesions that are preventing the valve
leaflets from opening properly.
aortic valve replacement - the aortic valve is replaced with a new
mechanism. Replacement valve mechanisms fall into two categories:
tissue (biological) valves, which include animal valves, and mechanical
valves, which can be metal, plastic, or another artificial mechanism.
Children who have undergone a valve replacement will need to follow
antibiotic prophylaxis throughout their lifetime.
aortic homograft - a section of aorta from a tissue donor with its valve
intact is used to replace the aortic valve and a section of the ascending
aorta.
pulmonary homograft (Ross procedure) - a section of the child's own
pulmonary artery with the valve intact is used to replace the aortic valve
and a section of the aorta. A section of pulmonary artery from a tissue
donor with its valve intact is used to replace the transferred pulmonary
artery
Valvular Heart Disease

Aortic Valve

Aortic Stenosis
Aortic Regurgitation
Aortic Regurgitation

Etiologies
Abnormalities of the Leaflets
Rheumatic, Bicuspid, Degenerative
Endocarditis
Dilation of the Aortic Annulus
Aortic Aneurysm / Dissection
Inflammatory (Syphyllis, Giant Cell Arteritis.
Coll Vasc Dis-Ankylosis Spondylitis, Reiters)
Inheritable (Marfans, Osteogensis Imperfecta)
Aortic Regurg pathophysiology
Aortic Regurg pathophysiology
Aortic Regurgitation
Aortic Regurgitation

Physical Exam
Diastolic Murmur
Hyperdynamic LV apical impulse
Bounding Pulses
S4, S3 Gallop-advanced AI
Aortic Regurgitation

Diagnosis

Ecg LAE, LVH

Echo 2D/color doppler test of choice
Cardiac Cath helpful, confirmatory, needed
if the pt is older look at the coronaries
 Aortic Regurgitation
Treatment of Asymptomatic Aortic Regurg

Medical Therapy treats the symptoms not the cause

Serial Check ups with Echos (eval EF, Severity AR)
SBE Prophylaxis
Vasodialators (Nifedipine, ACE-I)
Diuretics

Treatment of Symptomatic Aortic Regurg

Aortic Valve Replacement
Bioprosthetic vs Mechanical AVR
Tricuspidalis

Regurgitasi trikuspidalis:
Keadaan kembalinya sebagian darah ke
atrium kanan pada saat sistolik
Primer: akibat kelainan organik dari katup
Sekunder: hipertensi pulmnal, perubahan
fungsi karena dilatasi ventrikel kanan,
maupun anulus trikuspid
Lebih sering bersamaan dengan katup lain
Manifestasi klinis

Tanpa hipertensi pulmonal biasanya

asimptomatik
Lebih sering bersamaan dengan stenosis
mitral (lebih dominan stenosis mitral)
Tanda tanda gagal jantung kanan
Tanda tanda gagal jantung kiri (bila
dengan stenosis mitralis)
Diagnostik

Klinis = gejala dan tanda

Pemeriksaan fisik
EKG
Ro thorax
Echo
Stenosis trikuspidalis

Jarang ditemui
Sering bersamaan dengan penyakit katup
lain
Disebabkan RHD
Tricuspid valve
Tricuspid valve disease
ausculatory findings

Stenosis : Low-to medium-pitch diastolic

rumble with inspiratory accentuation

Regurgitation : Soft, early, or holosystolic

murmur Augmented with inspiratory effort
(Caravallos sign)
Penyebab

Kongenital ( misal Tetralogi Fallot)

Didapat
Demam reumatik, Sarkoidosis
Jarang karena Rematik heart disease,
seringnya bersamaan dengan katup lain
yang terkena
PULMONAL VALVE

Stenosis pulmonalis
Regurgitasi pulmonalis
Pulmonary Stenosis
Majority of PS is congenital (accounts for
7.6% of CHD)
Rarely due to carcinoid disease,
compression of PA due to intracardiac or
extracardiac masses
Mild PS may be asymptomatic
Symptoms include shortness of breath,
chest pain, fainting, or exertional syncope,
sudden death
Pulmonary Regurgitation
Common complication after surgical or
percutaneous relief of pulmonary stenosis
May occur secondary to a dilated pulmonary
valve ring due to pulmonary hypertension
PR occurs rarely as a congenital anomaly
PR leads to progressive right ventricular
dilatation, right ventricular dysfunction,
exercise intolerance, ventricular tachycardia
and sudden cardiac death
DIAGNOSTIK

Manifestasi klinis
Ringan berat
Ro thorax
EKG
Echocardiografi
Cath jantung
Treatment

Tergantung derajat beratnya

Manifestasi klinis yang timbul
Perlu operatif apa tidak
Terapi erdikasi streptokokus dan
pencegahan sekunder bila ada PJR