Professional Documents
Culture Documents
Valvular Heart Disease
Valvular Heart Disease
Mitral regurgitation. Mitral stenosis. Aortic stenosis. Aortic regurgitation. Tricuspid regurgitation. Tricuspid stenosis. Pulmonary stenosis Pulmonary regurgitation.
M Chadi Alraies 2
Jones criteria
Major manifestations
M Chadi Alraies
Minor manifestations
Clinical findings
Arthralgia Fever Elevated acute phase reactants (erythrocyte sedimentation rate, C-reactive protein) CProlonged PR interval Positive throat culture for group A beta-hemolytic betastreptococci or positive rapid streptococcal antigen test. antistreptolysin O
M Chadi Alraies 5
Laboratory findings
MITRAL STENOSIS
Prevalence
43% of all VHD in 1960 9% of all VHD in 1985 Rheumatic heart disease still affecting 21 out of 1,000 school-age children in Asia. school2/3 of all patient with rheumatic MS are women.
M Chadi Alraies
Causes
Rheumatic fever. Congenital chordal fusion. Congenital papillary muscle malposition. Mitral annular calcification (e.g. ESRD, elderly) Mitral valve repair. Surgical valve replacement. Obstruction by large vegetation. Rheumatoid arthritis. Carcinoid syndrome.
M Chadi Alraies 8
Pathophysiology
Dyspnea Orthopnea PND LL edema Pulmonary edema Mitral facies. Hemoptysis Embolic events: MI, stroke, renal emboli.
M Chadi Alraies 10
Mild MS is asymptomatic at rest and mild exertion. Symptoms triggered by factors that increase blood flow across the mitral valve or shortening of the diastolic period
M Chadi Alraies
11
"Tapping" sensation over area of expected PMI. Accentuated S1 S1 Opening snap. MidMid-diastolic murmur (rumble) low in pitch. S2-OS interval of 70 msec is seen in severe MS. Best heard after exercise, left lateral recumbency. Bell chest piece lightly applied. Pulmonary HTN and RVF occur later in MS.
M Chadi Alraies 12
ECG
Lead II broad and bifid > 0.12 sec Lead V1 broad and deep negative component of biphasic P V1 wave, longer than 0.04 sec and 1 mm in depth.
If pulmonary hypertension is present, tall peaked P waves, right axis deviation, or right ventricular hypertrophy appears. Atrial fib. Atrial flutter.
M Chadi Alraies 13
CXR
M Chadi Alraies
15
CXR
M Chadi Alraies
16
CXR
Straight left heart border. Large left atrium. Sharply indenting esophagus. Elevation of left mainstem bronchus. Large right ventricle and pulmonary artery if pulmonary hypertension is present. Calcification occasionally seen in mitral valve.
M Chadi Alraies 17
2D echocardiogram
Estimates the severity of MS Measure the pressure gradient between LA to LV. Define the etiology.
M Chadi Alraies
18
Treatment
M Chadi Alraies
19
Surgery
M Chadi Alraies
20
Surgery
MVR:
M Chadi Alraies
21
Questions?
Mitral regurgitation
Etiology
Myxomatous degeneration: MVR, Marfans Mitral annular calcification. Rheumatic heart disease. Congenital malformation. Ruptured papillary muscles and cordae tindinea. Infective endocarditis. Tumors. Functional:
Prevalence
M Chadi Alraies
25
Symptoms typical for the underlying cause. Exercise intolerance. DOE Pulmonary edema and CHF. Triggers for symptoms
M Chadi Alraies
26
Physical exam
Forceful, brisk PMI; systolic thrill over PMI. Pansystolic: begins with M1 and ends at or after M1 A2 . Loudest over PMI; transmitted to left axilla, left infrascapular area. After exercise; diaphragm chest piece.
M Chadi Alraies
27
Tests
ECG
Left axis deviation. Left ventricular hypertrophy. P waves broad, tall, or notched in standard leads. Broad negative phase of diphasic P in V1. V1
M Chadi Alraies
29
CXR
M Chadi Alraies
30
M Chadi Alraies
31
2D echocardiogram
Thickened mitral valve in rheumatic disease. Enlarged left ventricle with above-normal, abovenormal, or decreased function. Regurgitant flow mapped into left atrium.
M Chadi Alraies
32
Management
Acute MR:
Emergency surgery. Stabilization with vasodilators (nitroprusside) Intra-aortic balloon counterpulsation. Intra
Chronic MR:
Afterload reduction: ACEI Anticoagulation in case of atrial fibrillation.
M Chadi Alraies 33
Acute symptomatic MR Severe MR, NYHA II-IV with EF >60%. II>60%. Severe MR, EF 50-60%, ESD 45-50 mm. 50-60%, 45Severe MR, EF 30-50%, ESD 50-55 mm. 30-50%, 50Severe MR, A. Fib with NL EF Severe MR, severe pulmonary HTN, NL EF.
M Chadi Alraies
34
Questions?
Aortic stenosis
Etiology
M Chadi Alraies
37
Prevalence
25% of patients over age 65 years and 25% 35% of those over age 70 years 35% The most common surgical valve lesion in developed countries, and many patients are elderly.
M Chadi Alraies
38
Risk factors
M Chadi Alraies
39
M Chadi Alraies
40
Cardiac output is maintained until the stenosis is severe (with a valve area < 0.8 cm2). cm2
LV failure, Angina pectoris. Syncope exertional and a late finding.
M Chadi Alraies
41
Physical exam
Powerful, heaving PMI to left and slightly below MCL. Small and slowly rising carotid pulse. A2 normal, soft, or absent. Paradoxic splitting of S2 if A2 is audible. S2 A2
M Chadi Alraies
42
Physical exam
Prominent S4. S4 Midsystolic: begins after M1, ends before A2, M1 A2 reaches maximum intensity in mid systole. Right second ICS parasternally or at apex, heard in carotids and occasionally in upper interscapular area. Patient resting, leaning forward, breath held in full expiration.
M Chadi Alraies 43
Tests
ECG
M Chadi Alraies
45
CXR
Concentric left ventricular hypertrophy. Prominent ascending aorta, small knob. Calcified valve.
M Chadi Alraies
46
2D echocardiogram
Poststenotic dilation of the aorta, Restricted opening of the aortic leaflets, Bicuspid aortic valve in about 30%. 30%. Increased transvalvular flow velocity
M Chadi Alraies
47
Management
Medical management
No vasodilators. Indicated in asymptomatic patients only with preserved LV function.
M Chadi Alraies
48
Surgery, when?
Symptomatic:
Improve survival in preserved and depressed LVF Depressed LV function.
Prophylactic AVR:
Patients going for CABG with severe AS Patients going for other valvular surgery with moderate AS.
M Chadi Alraies
49
Questions?
Aortic regurgitation
Etiology
1. 2. 3. 4. 5. 6. 7. 8.
Bicuspid aortic valve. HTN Rheumatic Congenital Aneurysm of the sinus of Valsalva. Infective endocarditis. Post aortic stenosis repair. Osteogenesis imperfecta.
M Chadi Alraies 52
Pathophysiology
Increased preload and afterload to the LV. The response to these effects is to hypertrophy by laying sarcomeres end to end. end. Increasing the LV chamber size greater than the wall thickness (eccentric hypertrophy). The amount of hypertrophy is substantial and greater than that seen in aortic stenosis or mitral regurgitation.
M Chadi Alraies 53
LV failure is a late event and may be sudden in onset. Exertional dyspnea and fatigue are the most frequent symptoms. Angina pectoris.
M Chadi Alraies
54
Physical exam
wide arterial pulse pressure. waterwater-hammer pulse or Corrigan's pulse. Quincke's pulses (subungual capillary pulsations) Duroziez's sign (to and fro murmur over a partially compressed peripheral artery, commonly the femoral) Musset's sign (head bob with each pulse).
M Chadi Alraies
55
M Chadi Alraies
56
The murmur
Aortic diastolic murmur is usually high-pitched highand decrescendo. A mid or late diastolic low-pitched mitral lowmurmur (Austin Flint murmur) may be heard. Patient leaning forward, breath held in expiration.
M Chadi Alraies
57
Tests
ECG
M Chadi Alraies
59
Management
Chronic regurgitation
vasodilators, such as hydralazine, nifedipine, and ACE inhibitors, can reduce the severity of regurgitation. prescribe ACE inhibitors whenever the LV diastolic size is increased > 5.0 cm.
M Chadi Alraies
60
Surgery, when?
LV dysfunction EF is < 55% or if the LV end55% endsystolic dimension is > 5.0 cm. aortic root diameters of > 5.0 cm in Marfan or > 5.5 cm in non-Marfan patients. nonsurgical risk is higher than in aortic stenosis patients with a similar EF.
M Chadi Alraies
61
Questions?
Tricuspid regurgitation
Etiology
1.
1. 2. 3. 4. 5. 6.
RV geometry abnormality:
Pulmonary hypertension Severe pulmonic regurgitation. LVF RV infarction. Cor pulmonale. Mitral stenosis.
2.
1. 2. 3. 4. 5.
RV failure
hepatomegaly, edema, and ascites
M Chadi Alraies
65
Physical exam
Cyanosis may be present. Occasionally systolic thrill at lower left sternal edge. Systolic pulsation of liver. Blowing, coarse, or musical murmur. Murmur usually becomes louder during inspiration.
M Chadi Alraies
66
Management
Elimination of the cause of the tricuspid regurgitation. Intravenous diuretics should initially be used. Torsemide is better absorbed.
M Chadi Alraies
67
Surgery, when?
Symptoms and annular dilatation. Endocarditis. Ebsteins anomaly. Bioprosthetic valve, and not a mechanical valve, is used.
M Chadi Alraies
68
DD of systolic murmur
Intervention
HOCM
Aortic Stenosis
Mitral Regurgitation
Mitral Prolapse
Valsalva
or
Standing Handgrip or squatting Supine position with legs elevated Exercise Amyl nitrite
IsoProterenol
References
1. 2.
CMDT 2007 ACC/AHA 2006 Guidelines for the management of patient with valvular heart disease.
THANK YOU
M Chadi Alraies 71