Valvular Heart Disease

Valves of the Heart

 Learning Objectives
• Identify the characteristics and
positions of murmurs.
• Describe the pathophysiology,
etiology, signs and symptoms,
natural history, and treatment
 Aortic Valve

• Aortic Stenosis

• Aortic Regurgitation
Aortic Stenosis
Aortic Valve
 Valvular Aortic Stenosis

• Pathophysiology: Related to pressure

changes, valve obstructed, LV
>pressure, LV hypertrophy, LA
enlarges, decreased cardiac output
Left Ventricular Hypertrophy

LVH Aortic Stenosis

 Valvular Aortic Stenosis
• Etiology
• Rheumatic Heart Disease
• Congenital AV Disease
• Stenotic from birth
• Bicuspid Aortic Valve
• Idiopathic Calcific Aortic
Stenosis
 Valvular Aortic Stenosis
• Symptoms
• Fatigue
• Dyspnea on exertion (DOE)
• Angina
• Exertional Syncope
• Heart Failure (HF)
• Sudden Cardiac Death (SCD)
Mechanisms of Dyspnea in
Aortic Stenosis
♥ LVH → diastolic dysfunction

♥ Progressive LV dilation and

contractile failure → systolic
dysfunction
Mechanisms of Anginal Chest Pain in
Aortic Stenosis
♥ Increased wall stress → increased
myocardial O2 demand, exceeds
ability to coronary flow to meet
demand
♥ Associated coronary artery
disease
 Mechanisms of Syncope in
Aortic Stenosis
♥ Fixed cardiac output: Vasodilation
(exercise, vagal stimulation, drug induced),
inability to augment CO, drop in cerebral
perfusion pressure.

♥ Heart block: Ca++ deposits in aortic ring

encroach upon conduction tissue

♥ Ventricular arrhythmias (LVH, ischemia)

 Aortic Stenosis
• Vital Signs
• Narrow pulse pressure
• PMI [point of maximum impact]
• Displaced
• Ascultation
• S2
• Murmur
crescendo-decrescendo harsh murmur which is best heard in the right upper sternal border (RUSB) and
radiates to the neck
 Aortic Stenosis
• EcG
• Hypertrophy
• Estes criteria
• CXR The chest xray (CXR)
• Cardiomegaly 50% of the time
• ECHO
• Confirm, Severity
• Gradient across aortic valve and aortic valve area can be
estimated from increased flow velocity across aortic valve

• LHC Left heart catheterization

• Severity, Coronary Artery Disease
Left Ventricular Hypertrophy
 Severity of AS

Severity Mean gradient AV area

(mm Hg) (cm2)
Mild <25 >1.5

Moderate 25-50 1-1.5

Severe >50 <1.0

Critical >80 <0.7

 Natural History

• Asymptomatic
• For many years
• Duration of symptoms until death
• Angina - 3 years
• Syncope - 2 years
• CHF - 18 months
 Natural History

• Treated Aortic Stenosis

• 40% survived for 5 years
• 20% survived for 10 years
• Sudden Cardiac Death
• Decreased cerebral blood flow
• Arrhythmias
 AS Treatment
• Strenuous Activity
• Limit for symptomatic
• Medical treatment of HF: ACC/AHA
guidelines for preload/afterload reduction
and fluid management
 Treatment of Aortic Stenosis
♥ Mild to moderate asymptomatic aortic stenosis:
Close follow up: History and physical exam, serial
echocardiograms
Endocarditis prophylaxis

♥ Severe, symptomatic aortic stenosis (1 year

survival 57%)
valvuloplasty or Aortic valve replacement with
either mechanical or bioprosthetic valve
- Ten year survival ~75%
- Complications of prosthetic heart valves:
infection, thromboembolism, mechanical
failure
♥ Severe, symptomatic aortic stenosis NOT surgically
treatable:
Palliative option: aortic balloon valvuloplasty
 AS Treatment
• Surgical treatment
• Indications, techniques, outcome
depend on age/cause
• Children/ adolescents
• the most common cause of aortic
stenosis (AS) is a bicuspid valve. These
patients respond well to
commissuratomy or valvuplasty
• Adults: valve replacement
Replacement
Valves
Etiology of Aortic Insufficiency

• Valvular Disease
• Rheumatic Heart Disease
• Infective Endocarditis
• Trauma
• Tear of the ascending aorta
• Bicuspid valve
Aortic Insufficiency
 Pathophysiology of Chronic
Aortic Regurgitation
♥ Slowly progressive diastolic volume overload
♥ Augmented stroke volume with rapid runoff
Increased systolic pressure with low
diastolic pressure: wide pulse pressure
♥ Progressive left ventricular dilation, some
hypertrophy

♥ Late systolic failure with reduced ejection fraction and

CHF
 Natural History of Chronic
Aortic Regurgitation
♥ Long asymptomatic phase; may be decades long.
♥ Left ventricular systolic dysfunction ( decline in EF)
NOTE!!
LV dysfunction may occur in the absence of
symptoms
♥ Symptoms associated with LV dysfunction:
- Exercise intolerance
- Dyspnea on exertion
♥ Angina (rare)
♥ Sudden death (rare)
 Aortic Insufficiency
• Symptoms
• Angina, Palpitations, CHF
symptoms
• Vital Signs
• Wide pulse pressure
• = elevates the systolic blood pressure (SBP)--decreases the
diastolic blood pressure (DBP).
Physical Findings in Severe Chronic Aortic
Regurgitation
♥ deMusset’s sign: Head nod with each
systolic pulsation
♥ Corrigans’s pulses: “Pistol shot” pulses
over femoral artery
♥ Mueller’s sign: Pulsation of the uvula
♥ Duroziez’s sign: Systolic/diastolic bruit
over femoral artery
♥ Quincke’s pulses: Capillary pulsations
seen in the nailbeds
 Aortic Insufficiency
• Palpation
• PMI, Thrill
• Auscultation
• S2 variable, A2 absent
• Murmur
• Diastolic: patient sitting, leaning forward, on expiration,
• (3rd ICS LSB
• Austin Flint Murmur is a mid to late diastolic murmur
seen in severe AI. It is created by the rapid flow of blood across the mitral valve
into the LV that essentially has become non-distensible.
 Aortic Insufficiency

The murmur of aortic insufficiency is described as a

decrescendo diastolic murmur. This is because the
blood flows back into the left ventricle during diastole
creating a murmur. The pressure gradient is the highest
right after the aortic valve shuts and then the pressure
gradient decreases.
 AI-Findings and Treatment
• EcG
• LVH
• CXR
• Marked enlargement if AI is chronic
• ECHO
• Confirms/severity
• LHC
• Severity/CAD
 Management of Chronic
Aortic Regurgitation
♥ Close follow up of left ventricular size and function with
serial echocardiograms (Every few years with mild AR,
every 6-12 months with severe AR)
♥ Endocarditis prophylaxis
♥ Medical therapy:
Vasodilator therapy: reduces blood
pressurereduces regurgitant volume
Delays need for aortic valve replacement
Digoxin (enhance systolic function)
Diuretics (reduce LA pressure)
Do NOT slow heart rate!
♥ Aortic valve replacement with mechanical or
bioprosthetic valve
•Have a rest
 Rheumatic Heart Disease

Friable Vegetations at
Line of Closure

Mitral Stenosis with Diffuse

Thickening
 Rheumatic Heart Disease

Aschoff Body

Line of Closure Vegetations

 Mitral Valve Stenosis
• Etiology
• Rheumatic heart disease
• Female
• Congenital
• Rare
• Carcinoid
• SLE systemic lupus erythematosus
• Rheumatoid Arthritis
• Amyloid
 Mitral Valve Stenosis
• Pathophysiology
• Minimum of 2 yrs for severe MS to
develop after ARF(acute rheumatic
fever )
• Pressure elevates in
• Left atrium
• Pulmonary tree
• Right heart
• Atrial fibrillation , CO
Normal mitral valve area/opening 4-6cm2

>1.5cm2 mild
1-1.5cm2 moderate
<1cm2 severe
 Mitral Stenosis-Symptoms
• Dyspnea on exertion
• Hemoptysis
• Chest pain
• CHF symptoms
• Hoarseness
• Pulmonary Embolism
• Infective Endocarditis
MS-Physical Exam/Work up
• Inspection
• JVP(jugular venous pressure )rise
• Sternal lift
• Palpation
• Sternal heave
• Auscultation
• Accentuated S1, Opening snap,
Diastolic murmur at apex
MS-Physical Exam/Work up
• EcG
• LAE
• Pulmonary HTN (pulmonary
hypertension)
• CXR
• LAE
• ECHO
• Confirm/severity
• LHC
• Severity/CAD
 MS-Treatment
• Medical
• SBE prophylaxis
• Avoid strenuous exercise
• Diuretics
• Anticoagulants
• Rheumatic heart disease
• Atrial fibrillation
• Treatment AF/AF
• Digoxin [generic]
 MS-Treatment
• Surgical
• Asymptomatic
• Follow
• Symptomatic
• Balloon Valvuloplasty
• Open commissurotomy
• Valve replacement
• Mechanical
• Bio-prosthetic
Mitral Valve
 Etiology of Mitral /
Regurgitation Prolapse
• Valve leaflets: Do not close properly/Do
not stay closed
• Chronic RHD
• SLE
• Trauma
• Endocarditis
 Etiology of MR
• Papillary muscles
• Ischemia
• Dysfunction
• Scarring
• Infarction
• Necrosis
• Rupture
Mitral Valve
 Symtoms

• fatigue & weakness may represent early

symptoms of chronic severe MR
• Duration of apical impulse in chronic
severe MR is related to LV systolic
function
• Posterior leaflet prolapse: murmur to
aortic area
 Clinical Findings
• Auscultation
• S1
• Diminished
• S2
• Wide splitting
• Murmur
• Holosystolic
• Loudest at apex
 Mitral Regurgitation

Mitral regurgitation is described as a holosystolic murmur.

 Evaluation of MR

EKG
LAE
Atrial fibrillation
supraventricular tachycardia (SVT).
LVH
Nonspecific ST-T changes
CXR
LVE
LAE (straightening left border, atrial double density, elevation of
left main-stem bronchus)
Pulmonary venous congestion
• ECHO
• Confirm the diagnosis
• other abnormalities
 MR-Treatment
• Low sodium diet
• Preload reduction
• Diuretics
• Afterload reduction
• Vasodilators
• Nitroprusside [generic], ACE inhibitors, Hydralazine
[generic]
• Digoxin [generic]
• SBE prophylaxis
 MR-Treatment
• Surgical
• Symptomatic
• Class II, III, IV
• Asymptomatic
• Monitor Symptoms
• series Echo
• End
• Thank you !!!