VALVULAR HEART DISEASE

Faris Basalamah, MD FIHA

 Mitral Stenosis
Etiology :
predominant cause : rheumatic fever
rare cause
Pathology :
thickening, shortening, adhering, calcium depositing, and
scarring
four forms of fusion :
(1) commissural,
(2) cuspal,
(3) chordal,
(4) combined two types of shape :
fish-mouth shaped, funnel-shaped
 Mitral Stenosis
Pathophysiology :
normal cross-sectional area : 4-6 cm2
mild MS : 1.5-2 cm2, LAPLAH
compensated period
moderate MS : 1-1.5 cm2, PVP, PCWP
interstitial edema
severe MS : <1.0 cm2, PAP RV overload
RV failure TR PR
 Mitral Stenosis
Clinical Manifestations (MVA<1.5cm2)
1. Symptom: dyspnea, hemoptysis, cough,
hoarseness (ortners syndrome)
2. Signs:
-Mitral faces
-Diastolic thrill at apex
-S1(flexible), OS, Diastolic rumbling murmur
at apex,
-P2, splitting, Graham-Steel murmur(PR),TR
 Mitral Stenosis
Laboratory Examination
- ECG:
1) left atrial enlargement: P wave (II,V1)
2) Atrial Fibrilasi
3) Right ventricular hypertrophy
- X-film: change in cardiac silhouette,
Kerley B lines
- Echocardiography: M-mode, Two-
dimensional, Doppler
Normal Mitral 2D Echo
2D Echocardiogram
Rheumatic mitral stenosis
2D echocardiogram short axis
Rheumatic mitral stenosis
M-mode Echocardiogram
Rheumatic mitral stenosis
Apical view echocardiogram
Rheumatic mitral stenosis
 Dopler flow
Rheumatic mitral stenosis
 Mitral Stenosis
Diagnosis & Differential diagnosis :
- Diastolic rumbling murmur at apex
+ X-film + ECG + Echo
- relative MS; Austin-Flint murmur;
left atrial myxoma ; Graham steell murmur
Complication :
Atrial fibrillation; acute pulmonary edema;
congestive heart failure; thromboembolism;
infective endocarditis; pulmonary infective
 Mitral Stenosis
Management :
- Medical treatment :
Antibiotics, Diuretics and Digitalis,
Antiarrhythmic drugs, Anticoagulant
- Percutaneous balloon mitral valvuloplasty ( PBMV)
- Surgical treatment :
Closed mitral valvotomy
Open valvotomy
Mitral valve replacement
 Mitral Regurgitation
Etiology and Pathology
- Abnormalities of valve leaflets :
Rheumatic, infective
- Abnormalities of the mitral annulus:
Dilatation, calcification
- Abnormalities of the chordae tendineae:
Congenitally, infective, trauma, Rheumatic
- Involvement of papillary muscle: CAD
 Mitral Regurgitation
Pathophysiology
In systolic period, blood flow from LV
LA, LA filling pressure;
in diastolic period, LV accepts more blood
LV dilation, hypertrophy LVEDP
LAPPCWPPAPRHF; CO
Chronic
Acute
 Mitral Regurgitation
Clinical Manifestations
(1) Symptoms: asymptomatic( gradually,>20 years),
palpitation, fatigue, dyspnea, pulmonary edema
(2) Signs:
- apical pulseleft,lower
- apical beat heavy
- cardiac dullness enlargedleft
- pansystolic murmur at apex, radiate to left
axilla, subscapular
- S1,P2
 Mitral Regurgitation
Examination:
- ECG : LA enlargement, Af, LV hypertrophy
- X- Film : chronic cardiomegaly (LV, LA)
acute interstitial edema (Kerley B)
- Echocardiography : two-dimensional,
Doppler , color flow mapping
- Angiocardiography & Magnetic resonance
imaging
 2D Echocardiogram
Mitral Regurgitation/MVP
Dopler flow MR
 Mitral Regurgitation
Diagnosis :
systolic murmur at apex + LA, LV+ Echo
Differential Diagnosis :
relative MR, ventricular septal defect,
tricuspid regurgitation, aortic stenosis
Management :
- Medical treatment
- Surgical treatment
 Aortic Stenosis
Etiology & Pathology :
- Rheumatic AS, Congenital AS,
Degenerative calcific AS

Pathophysiology :
- Obstruction to LVOT LVH LAH PVP
Pulmonary edema;
- LVEFischemia of peripheralbrainheart
 Aortic Stenosis
Clinical Manifestations :
- Symptoms:
heart failure (fatigue, dyspnea), angina pectoris, syncope, sudden
death
- Signs :
Apical impulse , to left
Systolic thrill in AV area, pulse
Cardiac dullness left
Ejection sound & Systolic Murmur in AV area, radiate to neck
A2 splitting paradoxically
 Aortic Stenosis

Examination:
ECG; X- film; Echocardiography;
Angiography
Diagnosis & Differential Diagnosis:
Murmur + Echo
- MI, TI, VSD
- other murmurs of LVOT obstruction
2D Echocardiogram
Rheumatic aortic stenosis and
regurgitation
M-mode Echocardiogram
Rheumatic aortic stenosis and regurgitation
Apical view Echocardiogram
Rheumatic aortic stenosis and regurgitation
 Dopler flow
Rheumatic aortic stenosis and regurgitation
 Aortic Stenosis

Complications :
Sudden death, heart failure, arrhythmia,
infective endocarditis, systemic embolism
Management :
- Medical treatment
- Surgical treatment
 Aortic Regurgitation
Etiology & Pathology
- Valvular Disease:
rheumatic, congenital, infective
prolapse, ankylosing spondylitis, degenerative
- Aortic Root Disease:
syphilitic aoritis, Marfan syndrome,
ankylosing spondylitis, degenerative
- Acute AR :
infective, trauma, aortic dissection
 Aortic Regurgitation

Pathophysiology:
- LV receives both blood from LA & AO
volume overload LV dilation
pulmonary edema relative MI,MS;
- Diastolic pressure, pulse pressure
 Aortic Regurgitation
Clinical Manifestations :
- Symptom: palpitation, angina
- Sign: apical impulse left, inferior
cardiac dullness left, inferior
Boot-shaped shadowcardiac waist
DM in AV2 area apex
S1,A2
relative MISM at apex
relative MSAustin Flint
 Aortic Regurgitation

Sign :
Peripheral vascular sign:
- pulse pressure, carotid pulsation
- Musset sign, water hammer pulse, Traube sign,
- Duroziez murmur, Muller sign, Quincke sign,
Examination :
ECG, X-Film, Echo, etc
 Aortic Regurgitation

Diagnosis & Differential Diagnosis :

AI + peripheral vascular signs + Echo

Complication :
infective endocarditis
ventricular arrthymia

heart failure
 Aortic Regurgitation

Management :
Medical treatment
Surgical treatment
 Rheumatic Fever

Definition :
autoimmune disease caused by streptococcal
infection, cross-react between streptococcal
antigens and structural glycoprotein of heart, joints,
central nerves system and connective tissue.
Pathology :
exuduation, proliferation (Aschoff nodes), scarring
 Rheumatic Fever
Clinical Manifestations :
fever, rheumatic carditis, arthritis, chorea,
deformity of skin
Laboratory finding :
ASO>500U, ASK>80U, ESR,
Alb,+a2

CRP (+),

CPK-MB, GOT,TnT TnI,

C3, IgA
 Rheumatic Fever
Diagnosis :
Jones criteria, WHO Guidelines
Treatment :
1) rest
2) antibiotics : Penicillin
3) anti- inflammation : Aspirin
Corticosteroids
4) others
Prevention
Management
Reference
Reference
Reference