Cardiac valves disease

Introduction

Cardiac valve disease is a common heart condition affecting millions

of people worldwide. To understand this condition, we need to
understand the basic anatomy of the heart and the role that valves
play in keeping the blood flowing.
Heart Anatomy
The heart is a complex organ made up of four chambers, four valves, and a network of blood
vessels. Valves control the flow of blood in and out of each chamber.

Atrioventricular Valves
The tricuspid valve and the mitral valve are the
two atrioventricular valves. They control the
blood flow between the atria and ventricles of
the heart.
Semilunar valves
The aortic valve and the pulmonary valve are
the two semilunar valves. They control the
blood flow out of the heart into the aorta and
pulmonary artery.
What is Cardiac Valve Disease?
Cardiac valve disease is a condition where one or more heart valves are not functioning properly.
This can lead to an abnormal flow of blood in the heart, causing symptoms like fatigue, shortness of
breath and chest pain. The condition may be caused by a variety of factors including age, congenital
heart defects, infections, and certain medications.

Regurgitation Stenosis

This is when the valve does not close tightly This is when the valve opening is too narrow,
which allows blood to flow backwards. making the heart work harder to pump blood
Common causes of regurgitation include through it. Calcification and buildup of plaque
birth defects and endocarditis. are the most common causes of stenosis.
Types of Valve Disease
There are four main types of valve disease, each with a unique cause and set of symptoms.
Knowing the type of valve disease you have is crucial in determining the most effective treatment
plan.
1 2 3 4

Mitral Valve Aortic Stenosis Mitral Stenosis Aortic

Prolapse Regurgitation

A condition where A condition where A condition where

A condition where
the aortic valve the mitral valve is the aortic valve does
the mitral valve does
narrows, making it narrowed, causing not close properly,
not close properly,
harder for blood to blood to flow allowing blood to
causing blood to
flow out of the backwards into the flow backward into
flow backward.
heart. Symptoms lungs. Symptoms the heart.
Symptoms include
include chest pain, include shortness Symptoms include
chest pain, fatigue,
shortness of breath of breath, fatigue shortness of breath,
and palpitations.
and fainting. and coughing. fatigue and heart
palpitations.
 Aortic Stenosis
Aortic stenosis occurs when the aortic valve narrows and
blood cannot flow normally. The condition may range from
mild to severe. Over time, aortic valve stenosis causes your
heart's left ventricle to pump harder to push blood through
the narrowed aortic valve.
Aortic Stenosis – pathophysiology
Causes and Mechanisms of Aortic
Stenosis

Congenital Other Underlying

Malformation
Calcification of Valve
A congenital malformation of
The most common cause of
the valve can also cause aortic
aortic which occurs due to aging
stenosis to develop in infants
or high cholesterol levels.
and young children.
Conditions
Other underlying conditions,
such as rheumatic fever or
radiation, can also lead to the
development of aortic stenosis
in some cases.
Symptoms and Signs

Systolic Ejection Murmur

Chest Pain Shortness of Breath
Murmur may be more
Chest pain or discomfort may occur in some Difficulty breathing, especially during prominent at the apex.
patients, particularly during exercise or exertion, is a common symptom of aortic The murmur intensity is
reduced during Valsalva
physical activity. stenosis.
strain.)

S4 gallop (from LVH)

Fatigue Dizziness and Syncope Pulsus Parvus et Tardus

(Carotid Impulse)
Patients with aortic stenosis may become Dizziness, fainting, or syncope can occur in
easily tired or fatigued, even after light severe cases, indicating a need for immediate
physical activity or while resting. medical treatment.
Stages of Aortic Stenosis
1 normal

Normal aortic valve area 2.5-3.5 cm2

2 mild
aortic valve area 1.5-2.5 cm2
Ongoing medical observation, mean gradiant > 25
mm Hg

moderate
3 4 Severe
AVA 1.5-2.5 cm2
Medication, Surgical repair or replacement of AVA 1.0-1.5 cm2
aortic valve, Surgical repair or replacement of aortic valve,
mean gradiant 25-40 mm Hg mean gradiant > 40 mm Hg
 Aortic Valve
Regurgitation
is a condition that occurs when your heart's aortic valve doesn't close tightly.
As a result, some of the blood pumped out of your heart's main pumping
chamber (left ventricle) leaks backward.

As the left ventricle works harder to keep pushing blood through the aortic
valve, it may eventually become enlarged and weakened. A weakened left
ventricle may lead to heart failure.
Acute aortic regurgitation Chronic aortic regurgitation.
Causes and Mechanisms
Underlying Causes and Mechanisms of Aortic Valve Regurgitation

Valve Leaflet Damage Congenital Abnormalities

The most common cause of aortic valve regurgitation In some cases, aortic valve regurgitation may be
is damage to the valve leaflets, which can lead to present at birth due to a congenital abnormality.
improper closure and blood flow.

Infections Other Factors

Endocarditis, an infection of the inner lining of the Less common causes of aortic valve regurgitation
heart, can damage the aortic valve and lead to include connective tissue disorders, aortic aneurysm,
regurgitation. and rheumatic fever.
Clinical Presentation and Symptoms

Heart Palpitations Fatigue

Feeling tired or worn out even after adequate
A sensation of rapid or irregular heartbeat, often with rest or exertion.
a pounding or fluttering feeling in the chest.

Aortic Diastolic Murmur

Bounding Pulses
Shortness of Breath Austin Flint Murmur
Difficulty breathing, especially during
physical activity or when lying down.
 Diagnosis and Evaluation
Magnetic Resonance Imaging (MRI)
A test that uses a magnetic field and radio
waves to create detailed images of the
heart and blood vessels.
Electrocardiogram
An electrocardiogram (ECG) may be used
to evaluate the heart's electrical activity
and identify any abnormalities.
1 Echocardiography
A non-invasive test that uses sound waves
to generate images of the heart and check
2 for valve abnormalities.
3 Cardiac Catheterization
A procedure in which a thin tube is
inserted into a blood vessel and guided to
the heart to measure pressures and assess
4 blood flow.
5 Chest X-ray
A chest X-ray shows the condition of the
heart and lungs. It can help determine
whether the heart is enlarged. It can also
show swelling of the aorta and calcium
buildup on the aortic valve.
 Treatment Options and Management
1 Medication 2 Lifestyle Adjustments 3 Surgical Interventions

Angiotensin-Converting Enzyme (ACE) Inhibitors, Angiotensin Quitting smoking, maintaining a For severe cases of aortic
Receptor Blockers (ARBs), Calcium channel blockers, Diuretics, healthy weight, and getting regular valve regurgitation, surgery
Adrenergic Agonists used In mild cases of aortic valve regurgitation, exercise can help reduce the risk of may be needed to repair or
medication can help manage symptoms and slow the progression complications. replace the valve.
of the disease.
ACE inhibitors, Medicines for heart rhythm problems ,Beta-blockers,
Diuretics may be used to manage symptoms and slow disease
progression, but it cannot cure aortic stenosis.

4 Transcatheter Aortic Valve Implantation (TAVI) 5 Balloon valvuloplasty

This procedure can treat aortic valve stenosis in infants
A newer minimally invasive procedure that and children. In adults, the aortic valve tends to narrow
involves replacing the aortic valve through a again after the procedure.

small incision in the leg or chest.

Complications and Prognosis

• Heart failure
• Arrhythmias (abnormal heart rhythms)
• Infection of the heart valve (endocarditis)
• Untreated severe aortic valve regurgitation can lead to a shortened life
span.
• With timely diagnosis and appropriate treatment, most people with aortic
valve regurgitation can lead normal, healthy lives.
Prevention and Self-care
1 Lowering Cholesterol
high-fat foods and saturated fats increases the risk of aortic valve stenosis

2 Quit Smoking

Smoking increases the risk of aortic valve regurgitation and can worsen the condition.

3 Maintain a Healthy Weight

Being overweight or obese can put extra strain on the heart and increase the risk of valve
disease.

4 Exercise Regularly
Aim for at least 30 minutes of moderate-intensity exercise most days of the week to improve
heart health.

5 Follow Your Treatment Plan

If you have aortic valve regurgitation, work with your healthcare provider to develop a
personalized treatment plan and follow it closely.
 Mitral stenosis- Etiology and pathology
• Rheumatic fever is the leading cause of mitral stenosis .

• Other less common etiology include:-

o Congenital mitral valve stenosis
o Cor triatriatum
o Mitral annular calcification with extension onto the leaflets
o SLE
o Rheumatoid arthritis
o Left atrial myxoma
o Infective endocarditis with large vegetation
• pure or predominant MS occur in ~40% of all patient with rheumatic heart disease and history of rheumatic fever.
• In other patient with rheumatic heart disease lesser degree of MS may accompany mitral regurgitation and aortic valve
disease
 Mitral stenosis- pathology
• In rheumatic MS, chronic inflammation leads to diffuse thickening of the valve leaflets with formation of fibrous
tissue often with calcific deposits.

• The mitral commissures fuse

• the chordae tendineae fuse and shorten
• the valvular cusps become rigid
 leads to narrowing of the mitral valve .

• Calcification of the stenotic mitral valve immobilizes the

leaflets and narrows the orifice further.
 Mitral stenosis- pathophysiology
• Normally in adults, the mitral valve orifice is 4–6 cm2.

• In significant obstruction - orifice area <~2 cm2 blood can flow from the LA to LV only with
abnormally elevated left atrioventricular pressure gradient.

• Severe MS - orifice area <1.5 cm2 an LA pressure of ~25 mmHg is required to maintain a
normal CO.

• Patient usually remain asymptomatic until the stenosis become ~ 2 cm2 or less.

• The elevated pulmonary venous and pulmonary arterial wedge pressures reduce
pulmonary compliance, contributing to exertional dyspnea.
 Mitral stenosis- pathophysiology
• In patient with severe MS (1-1.5 cm2) - the CO is normal or almost normal at rest but raise subnormally with
exertion.

• In patient with very severe MS(< 1cm2) especially those with markedly elevated pulmonary vascular resistance
the CO is subnormal at rest and may fail to rise or may decline during activity .

• Pulmonary hypertension may lead to right ventricular hypertrophy and dilatation, tricuspid regurgitation and
right heart failure.
 Mitral stenosis- Symptoms
• Dyspnea
₋ Pulmonary venous congestion

• Fatigue
₋ Diminished cardiac output

• Palpitations

• Inability to tolerate increased volume

• Inability to tolerate increase HR
₋ Decreased filling
₋ Increased LA pressure / PV congestion

• Hemoptysis.

• Recurrent bronchitis.
 Mitral stenosis- Clinical examination
• Diastolic murmur:
• Low-pitched diastolic rumble most prominent at the apex.
• Heard best with the patient lying on the left side in held expiration
• Intensity of the diastolic murmur does not correlate with the severity of the stenosis.

• Loud Opening S1 snap:

• Heard at the apex when leaflets are still mobile .
• Due to the a sudden stop in leaflet motion in early diastole, after rapid initial rapid
opening, due to fusion at the leaflet tips.

• A shorter S2 to opening snap interval indicates more severe disease.

 Mitral stenosis- investigation
• ECG—”P” MITRALE (p wave shape like M - double P wave).

• Atrial fibrillation — absent p wave ,varying R-R interval.

• X-RAY chest —left atrial enlargement.

• Echo cardiogram — thickened , immobile cusps , reduce rate of diastolic

filling , reduce valve area .

• Cardiac catheterization — pressure gradient between LA and LV

 Mitral stenosis- Complication
• HEMOPTYSIS
• Due to pulmonary apoplexy.

• Acute Left ventricular failure

• Due to pulmonary edema.

• Pulmonary congestion.

• Recurrent bronchitis.

• Pulmonary infarction.
 Mitral stenosis- Treatment

• Drugs- B- blocker , Diuretics .

• Valve replacement .

• Balloon valvuloplasty ( special treatment)

₋ Used in rheumatic mitral stenosis when the problem is just fibrous tissue causing the valve
leaflet to become sticky .
 Mitral regurgitation Etiology
• The most common etiologies of MR :-

 Mitral valve prolapse

 Rheumatic heart disease

 Infective endocarditis

 Annular calcification

 Cardio myopathy

 IHD
 Mitral regurgitation pathology
• Mitral valve regurgitation is classified as primary and secondary.

• Primary mitral valve regurgitation is caused by an abnormality in the mitral valve.

• Secondary mitral valve regurgitation is caused by an abnormality in the left ventricle of the heart.
 Primary mitral regurgitation
• The most common cause is myxomatous degeneration of the valve .

• This cause a stretching out of the valve leaflets and the chordae tendineae.

• The elongation of the valve leaflets and chordae tendineae prevent the valve leaflets from fully coapting when
the valve is closed  causing the valve leaflets to prolapse into the left atrium  mitral regurgitation.
• Ischemic heart disease causes mitral regurgitation by the combination of ischemic dysfunction of the papillary
muscles, and the dilatation of the left ventricle that is present in ischemic heart disease, with the subsequent
displacement of the papillary muscles and the dilatation of the mitral valve annulus.
• Rheumatic disease, the chordae tendinae are thickened and foreshortened, producing restrictive leaflet
motion.
 Secondary mitral regurgitation
• This dilatation of the left ventricle can be due to any cause of dilated cardiomyopathy, including aortic
insufficiency.

• Dilatation of the left ventricle, causing stretching of the mitral valve annulus and displacement of the papillary
muscles.

• It is also called functional mitral regurgitation, because the papillary muscles, chordae, and valve leaflets are
usually normal.
 Functional Classification
• Carpentier's functional classification of mitral valve disease is used to describe the mechanism of valvular
dysfunction.

• This classification is based on the opening and closing motions of the mitral leaflets
 Mitral regurgitation clinical exam
Auscultation --→

• S1 is usually soft.

• laterally displaced apex beat, often with heave.

• high-pitched holosystolic murmur at the apex, radiating to the axilla heard best when lying on the left side.

• S3 is commonly heard.

• Commonly, atrial fibrillation.

 Mitral regurgitation investigation
Chest X-RAY:-
• Left ventricular enlargement
• Left atrial enlargement
• Pulmonary venous congestion

ECG:-
LA enlargement-> P- mitral
Atrial fibrillation

ECHO:-
Diagnostic and commonly used to confirm the diagnosis of mitral regurgitation .
 Mitral regurgitation Treatment
• Treatment Afterload-reducing agents and diuretics in MR with symptoms or LV dysfunction.

• Beta blockers for primary treatment of LV dysfunction in functional MR

• Intra aortic balloon pump in acute MR with hemodynamic compromise

• In the presence of AF, beta blockers, calcium channel blockers, digitalis, or a combination