Valvular  disease

Mitral Stenosis
Pathophysio:

Complication

Pressure from large LA on local struc :

Recurrent laryngeal N
Esophageal
Bronchus

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hoarsesness
dysphagia
Bronchial obstruc
Causes

1. Rheumatic (aftr acute rheumatic fever)

2. Congenital parachute valve (all
chordate tendinae insert into 1
papillary muscle)
3. Mucopolysaccharidoses
4. Endocardial fibroelastosis
5. Malignant carcinoid (mets to lung or 10
bronchial carcinoid)
6. Prosthetic valve
7. Lutembacher’s synd (acquired mitral
stenosis + arterial septal defect)

1. Dyspnoea
2. Orthopnea
Symptoms

3. Paroxysmal nocturnal dyspnea

(↑ Lf atrial P)
4. Haemoptysis (ruptured bronchial
veins)
5. Ascites
6. Edema
7. Fatigue (pulmonary HPT)
8. Chest pain

Sign of Severe Mitral Stenosis

(valve area < 1cm2)

1. Small pulse pressure

2. Soft 1st  sound (immobile valve
cusps)
3. Early opening snap (d/t ↑ Lf atrial P)
4. Long diastolic murmur
5. Diastolic thrill at d apex
6. Sx o pulm HPT
p
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 Sign

General sx Severe MS :
 Tachypnoea
 “mitral facies”
(biL, cyanotic discoloration o
upper cheek)
 Peripheral cyanosis
Pulse & BP  Norm/↓ volume
 Lf atrial enlarge → AF
JVP  Norm
 Pulm HPT → prominent a
wave
 AF → loss o a wave
Palpation  Palpable 1st  sound → Investigation
tapping apex beat
 Pulm HPT → RV heave & ECG  Sinus rhythm w bifid P
palpable P2 wave (P-mitrale)
 Diastolic thrill *rare*  Delayed Lf atrial
Auscultation  Loud S1 activation
- Valve cusps widely  AF
apart at onset o systole  RV hypertrophy features :
- Indicate that valve - Rt axis deviation
cusps remain mobile - Tall T wave in lead V1
 Loud P2 CXR  Lf atrial enlarge
- Pulm HPT  Pulmonary edema
 Opening snap  Mitral valve calcify
- ↑ Lf atrial P force valve Echo Diagnostic
cusps apart but valve Cardiac  Indications ;
cone halted abruptly catheterizatn - Prev valvotomy
 ↓ pitched rumbling diastolic
- Sx o other valve dz
murmur
- Angina
 Late diastolic accentuation
- Severe pulm HPT
o diastolic murmur
- Calcified mitral valve
- Occur if px in sinus
rythym  Findings:
- Absent if hv AF Lf atrium diastolic P ↑ > Lf
ventricle

Treatment

Avoid IE Prophylaxis AB
Early symp o MS : Low dose diuretics
SOB
AF Digoxin & anticoagulant
prevent atrial thrombus &
emboli
If Pulm HPT or symp pulm congestion persist
despite therapy surgical relief :
1. Trans septal ballon valvotomy
2. Closed valvotomy
3. Open valvotomy

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 4. Mitral valve replacemnt
Mitral Regurgitation
Pathophysio

 Long standing MR → LA enlarge →

little ↑ in LA P
But
 Acute MR → no LA enlarge bcoz norm
compliance o LA → ↑ LA P→ LA ‘y’ wave
↑ & pulm v. P ↑ → pulmonary edema
 Since propotion o SV is regurt → to
maintain CO → SV ↑ → LV enlarge

Acute MR Chronic MR
Pulmonary edema
Cardiovascular prolapsed
Systolic apical thrill
Loud apical systolic murmur
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e

Chronic MR
Causes  MI (dysfx/rupture o papillary  Mitral valve prolapsed
muscle)  Degenerative (a/w ageing)
 IE  Rheumatic
 Trauma or surgery  Papillary muscle dysfx d/t LV fail/ischaemia
 Spontaneous rupture o  Cardiomyopathy
myxomatous chord  CT dz (Marfan, RA,AS)
 Congenital (atrioventricular canal defect)

Symptoms  ↑ Lf ventricle P →
dyspnoea
 ↓ CO → fatigue Auscultatio  Soft/absent S1
General sx Tachpnoea n By end o diastole, atrial &
Pulse  Norm ventricular P hv equalized &
 Rapid LV decompression→ valve cusps drifted back
sharp upstroke 2gether
 AF  LV S3
Palpation  Displaced apex beat d/t rapid LV filling in early
 Diffuse & hyperdynamic diastole
 Pansystolic thrill at apex  Pansystolic murmur
 Parasternal impulse Sx o severe chronic MR
1. Small volume pulse
2. Enlarged LV
3. Loud S3
4. ‘soft S1
5. A2 early

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 6. Early diastolic rumble
7. Sx o pulmonary HPT
8. Sx o LV failure
Investigation

CXR  LA & LV enlarge

 ↑ CTR
 Valve calcification
ECG  LA delay (bifid P
waves)
 LV hypertrophy
 AF
Echo  LA & LV dilated
 features of chordal or
papillary muscle rupture
 helps to identify
structural valve
abnormalities
Transoesophagea  identify structural
l valve abnormalities
echocardiography b4 surgery
(TOE)
Cardiac  prominent LA sys p
catheterization wave
 when contrast is
injected into the LV
→regurgitating into an
enlarged LA during
systole.

Treatment

Mild MR & 
Mx conservatively
no symp 
f/up w serial echo

prophylaxis AB vs
IE
If mild MR progress Surgery
Px x suitable for Medical tx :
surgery  ACEi
Px hv LATE surgery  Diuretics
 anticoagulant
Chordal/papillary Emergency mitral v
muscle rupture replacemnt
IE

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 Aortic Stenosis
Pathophysio

 Normal px : exercise → ↑ CO

But

 LV systolic fx is typically preserved in px

with aortic stenosis (cf. aortic regurgitatn).

Causes

Congenital aortic v  develops

stenosis progressively
 BF through a
congenitally abnorm
aortic valve
Rheumatic fever progressive fusion,
thickening & calcify of a
prev norm 3-cusped
aortic valve
Calcific valvular dz In elderly
Valvular aortic
stenosis
Other causes o obstruct o LV emptying:
 supravalvular obstruct –
congenital fibrous diaphragm above the aortic
valve often a/w mental retardation & hyperC
(William's syndrome)
 hypertrophic cardiomyopathy –
septal muscle hypertrophy obstructing LV
outflow
 subvalvular aortic stenosis –
congenital condition in which a fibrous ridge
or diaphragm situated immediately ↓ d aortic
valve.
.
Symptoms  Exertional chest pain

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  Exertional dyspnoea
 Exertional syncope CXR  relatively small 
Pulse  Plateau or anacrotic pulse  prominent, dilated
 Peaking (tardus) pulse ascending aorta 'post-stenotic
 Small volume (parvus) dilatatn'
Palpation Apex beat :  aortic valve calcified.
- Hyperdynamic ECG  LV hypertrophy
- Displaced  LA delay
- Systolic thrill at base o   LV 'strain' pattern d/t
(aortic area) 'pressure overload' (depressed
Auscultatn  Split or reversed S2 ST segments & T wave
delayed LV ejection inversion in leads orientated
 Harsh midsystolic ejection towards LV i.e. leads I, AVL,
murmur V5 and V6
- Max at aortic area  sinus rhythm present, but
- Radiate to carotid ventricular arrhythmias may be
- Loudest → px sit up & in recorded.
full expiration Echo  thickened, calcified &
 Ejection click immobile aortic valve cusps.
- In congenital aortic  LV hypertrophy
stenosis Cardiac  document the systolic o
- Absent if valve is calcified catheterizatn difference (gradient) btwn
or stenosis is not at the aorta & LV
valve level but above or  assess LV fx
below it. Coronary  b4 surgery
angiography
Sign of severe severe aortic stenosis
(valve area <1 cm2, or valve gradient > 50 Treatment
mmHg)
Asympt px  regular assessment of
1. plateau pulse, symptoms & echo
2. carotid pulse ↓ in force; Sympt px  Aortic v replacement
3. thrill in the aortic area;  AB prophylaxis
4. length of the murmur & lateness of the  Valvotomy
peak of the systolic murmur,
5. soft or absent A2
6. left ventricular failure (very late sign)
7. pressure loaded apex beat.

nvestigation

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 Aortic Regurgitation
Pathophysio

Causes

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