Valvular Heart Disease

Valvular Heart Disease
dr. Agnes Lucia Panda, SpPD, SpJP(K)

Cardiology and Vascular Department
Faculty Of Medicine
Sam Ratulangi University
Aortic stenosis
• Aortic stenosis is a narrowing
of the aortic valve opening.
Aortic stenosis restricts the
blood flow from the left
Definition
ventricle to the aorta and
may also affect the pressure
in the left atrium.
http://www.heart.org/HEARTORG/Conditions/More/HeartValveProblemsandDisease/
Problem-Aortic-Valve-Stenosis_UCM_450437_Article.jsp#.WeqdDNuB0Wo
Three principal causes:
01 02 03
A congenital Calcification of a Rheumatic
bicuspid valve normal trileaflet disease
with valve 
superimposed “degenerative
calcification, AS”
Valvular heart disease : a companion to Braunwald’s heart disease / [edited

by] Catherine M. Otto, Robert O. Bonow. – 3rd ed.
Netter’s cardiology / edited by Marschall S. Runge, George A. Stouffer, Cam Patterson ; illustrations by Frank H. Netter ;
contributing illustrator, Carlos A. G. Machado.—2nd ed.
Age-related calcific (senile or degenerative) 
most common cause of AS in adults
Calcific Calcific valve disease, even in the absence of

valve obstruction  50 percent increased risk
of cardiovascular death and myocardial
Aortic infarction.
Stenosis
Disease process represents proliferative and
inflammatory changes, with lipid accumulation,
upregulation of angiotensin-converting
enzyme (ACE) activity, and infiltration of
macrophages and T lymphocytes

Results from adhesions and
fusions of the commissures and
cusps and vascularization of the
leaflets of the valve ring 
retraction and stiffening of the
Rheumatic free borders of the cusps
Aortic
Stenosis
The rheumatic valve is often
regurgitant, as well as stenotic

Pathophysiology
Braunwald’s heart disease : a textbook of cardiovascular medicine /

edited by Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O.
Bonow, Eugene Braunwald.—10th edition.
Exertional dyspnea
Angina pectoris
Symptoms
Syncope
Heart failure
Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative

project o medical students and aculty / editor, Leonard S. Lilly. — Sixth edition.
Angina
Occurs : two thirds of patients

with severe AS (about half of Precipitated by exertion and
whom have associated significant relieved by rest
coronary artery obstruction)
In patients without CAD: angina

In patients with CAD: angina is
results from the combination of
caused by a combination of the
the increased oxygen needs of the
epicardial coronary artery
hypertrophied myocardium and
obstruction in combination with
the reduction of oxygen delivery
the oxygen imbalance
secondary to the excessive
characteristic of AS.
compression of coronary vessels

Most commonly due to the reduced cerebral
perfusion that occurs during exertion when arterial
pressure declines consequent to systemic
vasodilation in the presence of a fixed cardiac output
Attributed to malfunction of the baroreceptor

mechanism in severe AS, as well as to a
vasodepressor response to a greatly elevated LV
systolic pressure during exercise
Syncope Exertional hypotension may also be manifested as

“graying out” spells or dizziness on effort.
Syncope at rest may be due to transient ventricular

fibrillation, from which the patient recovers
spontaneously

Atrial Fibrillation, pulmonary hypertension, and
systemic venous hypertension.
Gastrointestinal bleeding  severe AS,  angiodysplasia (most

commonly of the right colon) or other vascular malformations 
arises from shear stress–induced platelet aggregation with reduction
in high-molecular-weight multimers of von Willebrand factor and
Other increases in proteolytic subunit fragments
Infective endocarditis
late
findings Cerebral emboli resulting in stroke or transient ischemic
attacks may be due to microthrombi on thickened
bicuspid valves
Calcific AS may cause embolization of calcium to

various organs including the heart, kidneys, and brain.
Abrupt loss of vision has been reported when calcific
emboli occlude the central retinal artery

01 02 03 04
Palpation of Evaluation of Assessment of Examination
the carotid the systolic splitting of the for signs of
upstroke murmur second heart heart failure
sound
Physical Examination

A systolic thrill is usually best
appreciated when the patient leans
forward during full expiration. It is
The cardiac impulse is sustained
palpated in the 2nd right
and becomes displaced inferiorly
intercostal space or in the
and laterally with LV failure
suprasternal notch and is
frequently transmitted along the
carotid arteries
Cardiac examination

The ejection systolic murmur of AS typically is late
peaking and heard best at the base of the heart with
radiation to the carotids
In patients with calcified aortic valves, the systolic

murmur is loudest at the base of the heart, but high-
frequency components may radiate to the apex 
Gallavardin phenomenon
Cardiac In general, a louder and later peaking murmur,
indicates more severe stenosis.
examination
Splitting of the second heart sound is helpful in
excluding the diagnosis of severe AS because normal
splitting implies the aortic valve leaflets are flexible
enough to create an audible closing sound (A2).
When the left ventricle fails and the stroke volume
falls, the systolic murmur of AS becomes softer
Constant, Jules, 1922, Essentials of bedside cardiology : with a complete

course in heart sounds and murmurs on CD / by Jules Constant.--2nd ed.

Principle in management  Patients with severe AS should be
education regarding the disease cautioned to avoid vigorous
course and typical symptoms. athletic and physical activity
Treatment
Although medical therapy has not
been shown to affect disease
Evolving recommendations for progression, adults with AS (as
infective endocarditis prophylaxis any other adult) should be
should be explained evaluated and treated for
conventional coronary disease
risk factors
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by

Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene
Braunwald.—10th edition.
European Heart Journal (2017) 00, 1–53 doi:10.1093/eurheartj/ehx391
01 02 03 04
Considered to be Diuretics  abnormal ACE inhibitors  Beta-adrenergic blockers
inoperable (usually accumulation of fluid  symptomatic LV systolic can depress myocardial
because of comorbid caution because dysfunction who are not function and induce LV
conditions that preclude hypovolemia may reduce candidates for surgery. failure and should be
surgery). the elevated LV end- They should be initiated at avoided in patients with
diastolic pressure, lower low doses and increased AS
cardiac output, and slowly to target doses,
produce orthostatic avoiding hypotension.
hypotension.
Medical Treatment

http://www.cardiosurgeon.co.uk/treatment-guide/aortic-valve/
Aortic Regurgitation
• Aortic regurgitation (AR) is the diastolic flow
of blood from the aorta into the left ventricle
(LV). Regurgitation is due to incompetence
Definition of the aortic valve or any disturbance of the
valvular apparatus (eg, leaflets, annulus of
the aorta) resulting in the diastolic flow of
blood into the left ventricular chamber.
Aortic Regurgitation
https://emedicine.medscape.com/article/150490-overview
Aortic Primary valvular causes of AR include calcific AS in
the elderly
Regurgitation Infective endocarditis
Congenital  isolated regurgitation or a

combination of stenosis and regurgitation
Rheumatic fever
Causes of Aortic Regurgitation Progressive AR may occur in patients with a large

ventricular septal defect, as well as in patients with
membranous subaortic stenosis and as a complication of
percutaneous aortic balloon valvotomy.
Progressive regurgitation may also occur in patients

with myxomatous proliferation of the aortic valve.
An increasingly common cause of valvular AR is

structural deterioration of a bioprosthetic valve.
MARFAN SYNDROME
MARFAN SYNDROME
Pathophysiology
Braunwald’s heart disease : a textbook of cardiovascular medicine /

edited by Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O.
Bonow, Eugene Braunwald.—10th edition.
Symptoms
1 2 3 4 5
Asymptomatic Exertional dyspnea, Angina pectoris Uncomfortable Tachycardia,

orthopnea, and awareness of the occurring with
paroxysmal nocturnal heartbeat emotional stress or
dyspnea  gradually exertion, may cause
troubling palpitations
and head pounding
project o medical students and aculty / editor, Leonard S. Lilly. — Fifth edition.
Acute Vs Chronic
Acute Vs
Chronic
Valvular heart disease : a companion to Braunwald’s heart

disease / [edited by] Catherine M. Otto, Robert O. Bonow. – 3rd
• The apical impulse is diffuse and hyperdynamic and is displaced

laterally and inferiorly; there may be systolic retraction over the
parasternal region.
• A rapid ventricular filling wave is often palpable at the apex.
• The augmented stroke volume may create a systolic thrill at the
base of the heart or suprasternal notch, and over the carotid
arteries


• Soft S1 • The severity of AR correlates

• A2 may be normal or accentuated better with the duration than with
the intensity of the murmur.
• P2 may be obscured by the early
diastolic murmur. • In mild AR, the murmur may be
limited to early diastole and is
• S2 may be absent or single or exhibit
typically high pitched and
narrow or paradoxical splitting
blowing.
• An S3 gallop correlates with an
increased LV end-diastolic volume • In severe AR, the murmur is
holodiastolic and may have a
• The murmur is heard best with the rough quality.
diaphragm of the stethoscope while
the patient is sitting up and leaning
forward, with the breath held in deep
• the diastolic murmur is heard best
along the left sternal border in the
exhalation. 3rd and 4th intercostal spaces.

• Austin Flint murmur : A mid-diastolic and late diastolic

apical rumble is common in severe AR and may occur in
the presence of a normal mitral valve. This murmur
appears to be created by rapid antegrade flow across a
mitral orifice that is narrowed by the rapidly rising LV
diastolic pressure caused by severe aortic reflux
impinging on the anterior leaflet of the mitral valve.


Treatment
• Recommendations for antibiotic prophylaxis for

infective endocarditis
• Systemic arterial diastolic hypertension, if present,
should be treated because it increases the regurgitant
flow; vasodilating agents such as nifedipine or ACE
inhibitors are preferred, and beta-blocking agents
should be used with great caution.
• AF and bradyarrhythmias are poorly tolerated and
should be prevented if possible. If these arrhythmias
occur, they must be treated promptly and vigorously.
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes,
Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th edition.
Treatment

Mitral Stenosis
• Mitral valve stenosis — or mitral stenosis —
is a narrowing of the heart's mitral valve.
Definition This abnormal valve doesn't open properly,
blocking blood flow into the main pumping
chamber of your heart (left ventricle).
Mitral valve stenosis

https://www.mayoclinic.org/diseases-conditions/mitral-valve-stenosis/symptoms-causes/syc-
20353159
Predominant cause of mitral stenosis (MS) is
rheumatic fever
25% of all patients with rheumatic heart disease

have isolated MS, and about 40% have combined
MS and mitral regurgitation (MR).
Mitral Multivalve involvement is seen in 38% of MS

patients, with the aortic valve affected in about
35% and the tricuspid valve in about 6%. The
Stenosis pulmonic valve is rarely affected
Two thirds of all patients with rheumatic MS are
female
The interval between the initial episode of

rheumatic fever and clinical evidence of mitral
valve obstruction is variable, ranging from a few
years to more than 20 years
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann,

Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th edition.
Lutembacher • The association of atrial septal defect
syndrome with rheumatic MS
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P.
Zipes, Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th edition.
Clinical Presentation
1 2 3 4 5
Dyspnea Hemoptysis Chest pain Palpitation and Other symptom
Embolic events  (Ortner
syndrome)
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes, Peter
Libby, Robert O. Bonow, Eugene Braunwald.—10th edition.
The most common findings  an irregular pulse
caused by Atrial Fibrillation
Signs of left and right heart failure.
Physical The classical diastolic murmur and loud first heart

sound are often difficult to appreciate.
Examination
Mitral facies, characterized by pinkish-purple
patches on the cheeks.
Palpation of the cardiac apex usually reveals an

inconspicuous left ventricle; the presence of
either a palpable presystolic expansion wave or an
early diastolic rapid filling wave speaks strongly
against serious MS.

A readily palpable, tapping Left lateral recumbent

S1 suggests that the position, a diastolic thrill of
anterior mitral valve leaflet MS may be palpable at the
is pliable. apex.
A loud pulmonic closure

Often a RV lift is felt in the sound (P2) may be palpable
left parasternal region in in the 2nd left intercostal
patients with pulmonary space in patients with MS
hypertension. and pulmonary
hypertension


Left atrial
Atrial RV
enlargemen
Fibrillation hypertrophy
t
Electrocardiogram

Infective
Atrial Systemic
endocarditi
Fibrillation embolism
s
Complications

Medical Treatment
• prevention of recurrent rheumatic fever

• prevention and treatment of complications of MS
• monitoring disease progression to allow intervention
at the optimal time point
Surgical treatment
Management

Anticoagulation also may be
considered in patients with severe MS
Indicated for prevention of systemic
and sinus rhythm when there is severe
embolism in MS patients with AF
left atrial enlargement (diameter >55
(persistent or paroxysmal), any prior
mm) or spontaneous contrast on
embolic events (even if in sinus rhythm)
echocardiography. Treatment with
and in those with documented left
warfarin is used to maintain the
atrial thrombus
international normalized ratio (INR)
between 2 and 3
Anticoagulant therapy

Similar to management in patients with AF of
any cause
Administration of intravenous heparin

followed by oral warfarin.
Atrial
Fibrillation Beta-blocker or nondihydropyridine calcium
channel antagonist, followed by long-term
rate control with oral doses of these agents.
Digoxin or amiodarone may be considered.

Mitral Regurgitation
• Mitral regurgitation (MR) is defined as an
abnormal reversal of blood flow from the left
Definition ventricle (LV) to the left atrium (LA). It is
caused by disruption in any part of the mitral
valve (MV) apparatus.
Mitral Regurgitation
https://emedicine.medscape.com/article/155618-overview
Mitral valve prolapse (MVP)
Rheumatic heart disease
Infective endocarditis
Causes
Annular calcification
Cardiomyopathy
Ischemic heart disease

• Depends on:
• Severity of MR
• The rate of its progression
• The level of left atrial, pulmonary
venous, and pulmonary arterial
Symptoms pressure
• The presence of episodic or chronic
atrial tachyarrhythmias
• The presence of associated
valvular, myocardial, or coronary
artery disease

LV decompensation
Symptoms Chronic weakness and fatigue
Right-sided heart failure,

characterized by congestive
hepatomegaly, edema, and ascites

Wide splitting of S2  shortening of LV ejection
and an earlier A2 as a consequence of reduced
resistance to LV ejection
P2 is louder than A2
S3
Physical The systolic murmur  holosystolic murmur of chronic MR is

usually constant in intensity, blowing, high-pitched, and loudest
Examination at the apex with frequent radiation to the left axilla and left
infrascapular area
MVP the posterior leaflet  murmur  toward
the sternum or the aortic area
Silent MR  patients with severe MR caused by

LV dilation, acute myocardial infarction, or
paraprosthetic valvular regurgitation, marked
emphysema, obesity, chest deformity, or a
prosthetic heart valve
a ventricular septal defect
(VSD)  loudest at the
The holosystolic murmur of TR  heard best along the left
sternal border rather than the
MR resembles that produced sternal border, is augmented
apex and is often
by: during inspiration
accompanied by a parasternal,
rather than an apical, thrill.
Differential Diagnosis

Echocardiography plays a central role in the
diagnosis of MR, in determining its etiology and
potential for repair, and in quantifying its
severity
ECG findings : left atrial enlargement and AF, LV
enlargement (⅓ severe MR). RV hypertrophy
(15%)
Supporting
Examination X ray: Cardiomegaly with LV enlargement, and
particularly with left atrial enlargement 
chronic, severe MR
Interstitial edema with Kerley B lines is

frequently seen in patients with acute MR or
with progressive LV failure

uncertainty and some
debate  nitroprusside,
nifedipine, and ACE
inhibitors, beta-blocking
drugs
Medical All patients with AF,

paroxysmal or chronic,
Treatment should receive chronic
anticoagulation
Antibiotic prophylaxis to
prevent infective
endocarditis is no longer
recommended routinely

Surgical Treatment
• Mitral Valve Repair • Mitral Valve Replacement

• children and • papillary muscle
adolescents with dysfunction secondary
pliable valves to ischemia or rupture
• adults with • chordal rupture
degenerative MR
secondary to MVP
• perforation of a mitral
leaflet due to infective
• annular dilation endocarditis

Tricuspid Stenosis
Tricuspid Stenosis
rheumatic tricuspid
Etiology almost
valve disease  TR
always rheumatic
or a combination
in origin
of TS and TR

The low cardiac output
characteristic of TS 
fatigue, discomfort due to
hepatomegaly, ascites,
and anasarca
Symptoms
Fluttering discomfort in
the neck, caused by giant a
waves in the jugular
venous pulse

Management
Intensive
Surgical Diuretic
sodium
treatment therapy
restriction

Tricuspid
Regurgitation
Tricuspid Regurgitation
Etiology  The most common

cause is not intrinsic involvement of
the valve itself (i.e., primary TR) but
RV systolic pressure greater than 55
rather dilation of the right ventricle
mm Hg will cause functional TR
and of the tricuspid annulus causing
secondary (functional) TR  RV
failure of any cause

In the absence of pulmonary
hypertension, TR is generally well
tolerated.
pulmonary hypertension and TR

coexist  cardiac output declines,
Symptoms and the manifestations of right-
sided heart failure
symptoms of TR result from a

reduced cardiac output and from
ascites, painful congestive
hepatomegaly, and massive edema

Evidence of weight loss and cachexia, cyanosis,
and jaundice  severe TR.
AF is common.
Jugular venous distention
Physical A venous systolic thrill and murmur in the neck

Examination may be present in patients with severe TR.
The RV impulse is hyperdynamic and thrusting
in quality
Systolic pulsations of an enlarged, tender liver
are commonly present initially.
Ascites and edema are frequent


S3 originating from the right ventricle, which is accentuated by
inspiration.
P2 is accentuated
TR occurs in the presence of pulmonary hypertension  the systolic

murmur is high-pitched, pansystolic, and loudest in the 4th ICS in the
parasternal region but occasionally is loudest in the subxiphoid area.
Physical TR occurs in the absence of pulmonary hypertension  murmur low
intensity and limited to the first half of systole.
Examination
When the right ventricle is greatly dilated and occupies the anterior
surface of the heart, the murmur at the apex and difficult to distinguish
with MR.
The murmur is characteristically augmented during inspiration (Carvallo

sign).
The murmur also increases during the Mueller maneuver (forced

inspiration against a closed glottis), exercise, leg-raising, and hepatic
compression


Supporting Examination
ECG is usually nonspecific

Echocardiography  The
and characteristic of the
goal of echocardiography is
lesion causing TR 
to detect TR, estimate its
Incomplete right bundle
severity, and assess
branch block, Q waves in lead
pulmonary arterial pressure
V1, and AF are commonly
and RV function
found

Management
TR in the absence of
Surgical treatment 
pulmonary
excision, annuloplasty
hypertension usually is
techniques, with or
well tolerated and may
without an annuloplasty
not require surgical
ring, valve replacement
treatment

Pulmonic Stenosis
& Pulmonic
Regurgitation
congenital form is the most common
cause of pulmonic stenosis
Pulmonic
Stenosis &
Pulmonic
Regurgitation most common cause of pulmonic
regurgitation (PR) is dilation of the valve
ring secondary to pulmonary hypertension
(of any etiology) or to dilation of the
pulmonary artery, either idiopathic or
consequent to a connective tissue disorder
such as the Marfan syndrome

is a high-pitched, blowing,
Systolic pulmonary arterial
decrescendo murmur beginning
pressure exceeds approximately
immediately after P2 and is
55 mm Hg, dilatation of the
most prominent in the left
pulmonic annulus results in a
parasternal region in the 2nd to
high-velocity regurgitant jet
4th intercostal spaces
increases in intensity with

inspiration
Graham Steell murmur

Thank You

Valvular Heart Disease - DR Agnes

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dr. Agnes Lucia Panda, SpPD, SpJP(K)

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Calcific Calcific valve disease, even in the absence of

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Braunwald’s heart disease : a textbook of cardiovascular medicine /

Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative

Occurs : two thirds of patients

In patients without CAD: angina

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Attributed to malfunction of the baroreceptor

Syncope Exertional hypotension may also be manifested as

Syncope at rest may be due to transient ventricular

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Gastrointestinal bleeding  severe AS,  angiodysplasia (most

Other increases in proteolytic subunit fragments

Calcific AS may cause embolization of calcium to

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

In patients with calcified aortic valves, the systolic

Constant, Jules, 1922, Essentials of bedside cardiology : with a complete

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Regurgitation Infective endocarditis

Congenital  isolated regurgitation or a

Causes of Aortic Regurgitation Progressive AR may occur in patients with a large

Progressive regurgitation may also occur in patients

An increasingly common cause of valvular AR is

Braunwald’s heart disease : a textbook of cardiovascular medicine /

Asymptomatic Exertional dyspnea, Angina pectoris Uncomfortable Tachycardia,

Valvular heart disease : a companion to Braunwald’s heart

• The apical impulse is diffuse and hyperdynamic and is displaced

Constant, Jules, 1922, Essentials of bedside cardiology : with a complete

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

• Soft S1 • The severity of AR correlates

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

• Austin Flint murmur : A mid-diastolic and late diastolic

Constant, Jules, 1922, Essentials of bedside cardiology : with a complete

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

• Recommendations for antibiotic prophylaxis for

European Heart Journal (2017) 00, 1–53 doi:10.1093/eurheartj/ehx391

Mitral valve stenosis

25% of all patients with rheumatic heart disease

Mitral Multivalve involvement is seen in 38% of MS

The interval between the initial episode of

Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann,

Signs of left and right heart failure.

Physical The classical diastolic murmur and loud first heart

Palpation of the cardiac apex usually reveals an

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

A readily palpable, tapping Left lateral recumbent

A loud pulmonic closure

Constant, Jules, 1922, Essentials of bedside cardiology : with a complete

Valvular heart disease : a companion to Braunwald’s heart disease / [edited

Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative

Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative

• prevention of recurrent rheumatic fever

Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative

Pathophysiology o heart disease (Lilly) Pathophysiology o heart disease : a collaborative