Transcript Slide 1

Valvular Diseases
• Causes of valve regurgitation
– congenital, senile degeneration, acute and chronic
rheumatic carditis, infective endocarditis, syphilitic aortitis
– traumatic valve rupture, damage to chordae and papillary
muscles (e.g. in MI), dilated valve ring (e.g. dilated CMP)
• Causes of valve stenosis
– congenital, senile degeneration
– rheumatic carditis
• Common clinical scenarios
– Young people: functional murmurs, MVP, AS
– Old people: aortic sclerosis, aortic stenosis
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Mitral Stenosis
• Symptoms
– pulmonary congestion: dyspnea, cough, hemoptysis (also due to
PE)
– chest pain (PH), edema and ascites (RVF)
– fatigue (low COP), palpitation (AF), thromboembolic
complications
• Signs
– inspection: mitral facies
– palpation: tapping apex (palpable first heart sound), RV heave
(PH)
– auscultation: loud first heart sound, loud P2 (PH), opening snap,
rumbling mid-diastolic murmur, presystolic accentuation
– atrial fibrillation, raised pulmonary capillary pressure:
crepitations, pulmonary edema, effusion
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Mitral Stenosis
• ECG
– LA hypertrophy, RVH, AF
• CXR
– enlarged LA, pulmonary venous congestion
• Echo
– thick immobile cusps, reduced valve area, reduced rate of
LV diastolic filling
• Doppler
– pressure gradient across MV, pulmonary artery pressure
• Cardiac catheterization
– pulomnary wedge pressure, pressure gradient between LA
and LV
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Mitral Stenosis
• Medical management
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digoxin for AF + BB or CA
diuretics for pulmonary congestion
anticoagulant to reduce the risk of systemic emboli
antibiotic prophylaxis against infective endocarditis
• Mitral balloon valvoplasty
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significant symptoms
isolated MS
no to trivial MR
mobile non-calcific valve / subvalvular apparatus on echo
LA free of thrombus
• Mitral valve surgery
– closed mitral valvotomy
– open mitral valvotomy
– mitral valve replacement: mechanical, bioprosthesis [St. Jude (bi-leaflet),
Carpentier-Edwards (porcine), Medtronics (single leaflet, open)]
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Mitral Regurgitation
• Causes
– mitral valve prolapse (myxomatous changes) is the most common cause in
developed world
– damage to cusps: rheumatic valve disease, IE, congenital cleft mitral valve
– damage to chordae: rheumatic valve disease, IE, trauma, degenerative
– damage to papillary: ischemia, infarction, infiltrative, HCM
– damage of annulus: calcification, IE (abscess)
– dilation of MV ring: IHD, CMP, acute rheumatic valve
• Symptoms
– dyspnea, edema, ascites, fatigue, palpitations (AF, increased stroke volume),
thromboembolic complications
• Signs
– jerky pulse (AF), displaced apex (hyperdynamic circulation)
– 3rd heart sound, apical pansystolic murmur with or without thrill
– signs of pulmonary congestion and pulmonary hypertension
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Mitral Regurgitation
• ECG
– LAH, LVH, AF
• CXR
– enlarged LA, enlarged LV, pulmonary venous congestion
• Echo
– dilated LA and LV, dynamic LV, structural abnormalities
(e.g. MVP)
• Doppler
– detects and quantifies MR
• Cardiac catheterization
– dilated LA and LV, MR, assess PH, detect co-existing CAD
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Mitral Regurgitation
• Medical (mild and moderate cases)
– diuretics, vasodilators (e.g. ACEI)
– digoxin and anticoagulant (for AF)
– antibiotic prophylaxis (for IE)
• Surgical
– MV valvoplasty (repair)
– MV replacement
• Indications for surgery
– worsening symptoms
– progressive cardiomegaly
– deterioration of LV function: EF < 60%, LVEDD > 55
• Complications of artificial valves
– IE, thromboembolic complications, hemolysis, valve dysfunction
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Mitral Regurgitation
• Emergency minor criteria for surgery in isolated severe
chronic MR
– any symptoms of heart failure or suboptimal exercise tolerance
test
– flail mitral leaflet
– left atrial diameter > 45 mm
– paroxysmal atrial fibrillation
– abnormal exercise end-systolic volume index or ejection fraction
• MVP
– asymptomatic, acute MR (ruptured chordae), chronic MR, CHF
– mid-systolic click, late systolic murmur or pan-systolic murmur
– increased risk for IE, arrhythmias, embolic stroke and TIA
(small), sudden death (rare)
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Aortic Stenosis
• Causes
– young patient: thick congenital bicuspid valve,
unicuspid valve, supravalvular stenosis,
subvalvular stenosis (discrete, diffuse)
– middle age: thick bicuspid valve, rheumatic
disease
– old age: thick degenerative valve, calcification of
bicuspid valve, rheumatic AS
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Aortic Stenosis
• Symptoms
– angina, exertional pre-syncope and dizziness, dyspnea, impaired
exercise tolerance, episodes of acute pulmonary edema, sudden
death
– other signs of LVF (systolic and diastolic dysfunction)
• Signs
– slow-rising carotid pulse, narrow pulse pressure, thrusting apex
beat (LV pressure overload)
– ejection systolic murmur, basal crepitations
• Severity
– indicated by: diamond-shaped murmur, anacrotic pulse,
paradoxical S2, S4 (LVH), S3 (LVF)
– not indicated by: intensity, presence of thrill
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Aortic Stenosis
• ECG
– LVH, LBBB, normal
• CXR
– enlarged LV, dilated ascending aorta, calcified AV, normal
• Echo
– calcified AV with restricted opening, thickened LV walls
• Doppler
– detects AR, estimates gradient
• Cardiac catheterization
– systolic gradient between LV and aorta, post-stenotic
dilation of aorta, detects AR if present, detect presence of
CAD
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Aortic Stenosis
• Medical
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prophylaxis against IE
anticoagulants if in AF
diuretics for pulmonary congestion (cautiously)
vasodilators are contraindicated
• Surgical
– mechanical AV replacement: symptomatic with normal COP and valve gradient
> 50
– bioprosthesis: symptomatic elderly (disk valve, caged-ball valve, bio-prosthetic
valve)
– aortic balloon valvoplasty: congenital AS
• Mechanical versus bioprosthetic valve
– mechanical: durable, large orifice, best in left side, high thromboembolic
potential, chronic warfarin therapy
– bioprosthetic: not durable, small orifice/functional stenosis, best in tricuspid
orifice, low thromboembolic potential, consider in elderly
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Aortic Regurgitation
• Congenital:
– bicuspid AV, cystic medial necrosis (Marfan, EhlersDanlos, osteogenesis imperfecta, pseudoxanthoma
elasticum)
• Acquired
– rheumatic heart disease, dilated aorta
– degenerative, connective tissue disorders (ankylosing
spondylitis, rheumatoid arthritis, Reiter, giant-cell
arteritis), syphilis (chronic aortitis)
– acute AR: infective endocarditis, trauma, dissecting
aneurysm
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Aortic Regurgitation
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Symptoms
– mild to moderate: asymptomatic, palpitations
– severe: dyspnea, orthopnea, PND, chest pain (noctural and exertional angina) if aortic diastolic
pressure < 40
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Signs (peripheral)
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Quincke sign: capillary pulsation
Corrigan sign: water hammer pulse
Bisferens pulse (AS/AR > AR)
DeMusset sign: systolic head bobbing
Mueller sign: systolic pulsation of uvula
Durosier sign: femoral retrograde bruits
Traube sign: pistol shot femorals
Hill sign: lower extremity BP > upper extremity BP by > 20 mmHg (mild), > 40 mmHg
(moderate), > 60 mmHg (severe)
– widened pulse pressure
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Signs (central)
– apex: enlarged, displaced, hyperdynamic (forcible nonsustained), palpable S3, Austin-Flint
murmur
– diastolic murmur: length correlates with severity (chronic), in acute murmur shortens as
DP=LVEDP, mitral pre-closure
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Aortic Regurgitation
• ECG
– LVH, T inversion
• CXR
– cardiac dilation, aortic dilation, pulmonary congestion
• Echo
– dilated LV, hyperdynamic LV, fluttering AML
• Doppler
– detects reflux
• Cardiac catheterization
– dilated LV, AR, dilated aortic root
• Assessing severity
– more severity with more peripheral signs and larger LV
– S3, Austin-Flint murmur, LVH, radiological cardiomegaly
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Aortic Regurgitation
• Medical
– diuretics for pulmonary congestion, vasodilators (ACEI)
– prophylaxis against IE, treatment of underlying cause (e.g. IE,
syphilis)
• Surgical
– AV replacement: mechanical or bioprosthesis
– aortic root replacement: for dilated aortic root (Marfan, syphilis,
dissecting aneurysm) if LVEDD > 55, EF > 55%, FS > 27%
• Criteria for replacement
– symptoms: congestive heart failure, declining exercise tolerance
on exercise testing, angina
– anatomy: LV dysfunction (EF < 50%), progressive LV dilation or
decline in EF on serial studies, severe dilation (LVDD > 75 mm,
LVSD > 55 mm, aortic root dimension > 50)
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Tricuspid Stenosis
• Causes
– rheumatic: almost always have associated MS
(signs of PH), isolated TS is rare, uncorrected TS
worsens survival chance for patients undergoing
surgery for AV or MV
– carcinoid: mainly affects TV and PV
• Clinical
– similar to MS, JVD, edema, ascites, hepatomegaly
– rumbling diastolic murmur with opening snap
accentuated with respiration
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Tricuspid Regurgitation
• Causes
– functional overload: pulmonary hypertension, RV dilation from infarction or
myopathy
– structural leaflet abnormalities: infectious endocarditis, congenital (Ebstein
anomaly), acquired (carcinoid, plantain diet, ergot drugs)
• Clinical
– asymptomatic (tolerated for years), JVD
– high-pitch blowing holosystolic murmur varying with respiration (RiveroCarvallo sign) in xyphoid area
– complications: right heart failure, renal failure
• Treatment
– none to treat underlying condition
– diuretics, salt restriction
– valve replacement, rings
• Markers of severity
– large pulsations in neck, pulsatile enlarged liver, widespread edema (anasarca,
Michelin tire man), RV S3 (increases with respiration)
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Pulmonary Stenosis
• typically congenital
– valvular, supravalvular, subvalvular (infundibular)
• RVH
• harsh systolic ejection murmur at 2nd left
interspace (crescendo-decrescendo), thrill
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Pulmonary Regurgitation
• Causes
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PH (most common)
IE, rheumatic disease, carcinoid heart disease
congenital defects, trauma
physiological is normal variant
• Assessment
– color flow doppler: right atrial enlargement, right
ventricular volume overload
– typical murmur: low-pitched diastolic murmur heard at left
sternal border increasing with inspiration
– PH murmur: high-pitched blowing diastolic murmur at left
parasternal border (Graham-Steele murmur)
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