Valvular heart

disease
Classification of valvular
heart disease.

1.Congenital valvular
heart disease
2.Acquired valvular heart
disease
 By the origin:
•due to rheumatic fever
•due to atherosclerosis
•due to infective endocarditis
•due to systemic disorders of
the connective tissue (SLE,
SSDI)
Valvular heart disease is
divided according the
localisation:
•Mitral valve disease
•Aortic valve disease
•Pulmonary valve disease
•Tricuspid valve disease
According the type
of affection:
•Stenosis
•Regurgitation
•Combination
 Mitral stenosis
Almost all mitral stenosis is due to
rheumatic heart disease.

Table 1. Rheumatic valvular lesions

Valves involved Percentage of cases
Mitral valve alone 50
Mitral and aortic valves 40
Mitral,aortic and tricuspid 5
Aortic valve alone 2
All other combinations 3
Rheumatic mitral stenosis is much more
common in women.
Other causes include:
• Lutembacher's syndrome, which is the
combination of acquired mitral stenosis and an
atrial septal defect
• a rare form of congenital mitral stenosis
• in the elderly, a syndrome similar to mitral
stenosis, which develops because of calcification
and fibrosis of the valve, valve ring and
subvalvular apparatus (chordae tendineae)
• carcinoid tumours metastasizing to the lung or
primary bronchial carcinoid.
 Pathophysiology
•When the normal valve
orifice area of 5 cm2 is
reduced to approximately
1 cm2, severe mitral
stenosis is present.
 Left atrial pressure increases and left
atrial hypertrophy and dilatation occur
 (Consequently)
Pulmonary venous, pulmonary arterial
and right heart pressures also increase

Development of pulmonary oedema


Alveolar and capillary thickening and
pulmonary arterial vasoconstriction
(reactive pulmonary hypertension)

Right ventricular hypertrophy,
dilatation and failure

Signs of mitral stenosis
Face
So-called mitral facies or
malar flush -
a bilateral, cyanotic or dusky
pink discoloration over the
upper cheeks (due to
arteriovenous anastomoses
and vascular stasis).
 Pulse
•small-volume pulse
(regular early on in
the disease process)
•atrial fibrillation
(irregularly irregular
pulse)
 Jugular veins
•If right heart failure
develops, there is
obvious distension of the
jugular veins.
 Palpation
• There is a tapping impulse felt
parasternally on the left side
which is not localized.
• This is the result of a palpable first
heart sound combined with left
ventricular backward displacement
produced by an enlarging right
ventricle.
• A sustained parasternal impulse
due to right ventricular hypertrophy
may also be felt.
 Auscultation
• loud first heart sound
• an 'opening snap'
• a low-pitched 'rumbling' mid-
diastolic murmur (best heard
with the bell of the stethoscope
held lightly at the apex with the
patient lying on the left side)
The severity of mitral stenosis
is judged clinically on the
basis of several criteria:
• The presence of pulmonary hypertension
implies that mitral stenosis is severe.
• The closeness of the opening snap to the
second heart sound is proportional to
the severity of mitral stenosis.
• The length of the mid-diastolic murmur
is proportional to the severity.
 Investigations
Chest X-ray
• a generally small heart with an
enlarged left atrium.
• pulmonary venous hypertension.
• a calcified mitral valve (on a
penetrated or lateral view).
• the signs of pulmonary oedema or
pulmonary hypertension (when the
disease is severe).
Electrocardiogram
•a bifid P wave owing to
delayed left atrial activation
• atrial fibrillation is frequently
present
• right ventricular hypertrophy
(right axis deviation and
perhaps tall R waves in lead
V1)
 Echocardiogram
• Two-dimensional echocardiography is
invaluable in assessing the mitral
valve apparatus and calculating
mitral valve area.
• The information provides a useful
guide in determining whether balloon
valvotomy or valve replacement is
the treatment of choice in patients
symptomatic on medical therapy.
• Two-dimensional echocardiography
also determines left atrial size and
right ventricular size and function.
 Cardiac catheterization
• This is required only if an adequate
echocardiogram (transthoracic or
transoesophageal) is impossible to
obtain or if coexisting cardiac problems
(e.g. mitral regurgitation or coronary
artery disease) are suspected.
• The typical findings in mitral stenosis
are a diastolic pressure that is
higher in the left atrium than in the
left ventricle.
• This gradient of pressure is usually
proportional to the degree of the
stenosis.
Mitral stenosis diagnosis is
based on the:
• Signs of pulmonary hypertension
(dyspnoea, haemoptysis, asthma,
pulmonary oedema)
• Signs of the right ventricular failure
(lower limb swelling, hepatomegaly,
ascitis)
• Auscultative features
• Left atrium enlargment
• Echocardiografic features
• The history of rheumatic fever
 Diagnostical steps:
• Revealing of MS
• Determining of the stenosis degree
• Presence of complications
• Presence of heart failure
• Rheumatic fever activity
• Presence of infective endocarditis
 Stages of MS :
1.Compensation of MS – no
subjective signs, but there
are auscultative signs and
left atrium hypertrophy
2.Pulmonary hypertension
3.Right ventricular failure
Stadies of MS according
Bakulev-Damir:
• Complete compensation of MS
• Signs of pulmonary hypertension only in
physical exertion
• Signs of severe pulmonary hypertension
and initial signs of the congestive right
ventricular failure
• Severe congestive right ventricular
failure or signs of the 3-d stady plus
atrial fibrillation
• Dystrophy
 DIFFERENTIAL
DIAGNOSIS:
•Primary pulmonary
hypertension
•Atrial septal defect
•Left atrial myxoma
 Complications
of mitral stenosis.
• Atrial fibrillation
• Systemic embolization
• Pulmonary hypertension
• Pulmonary infarction
• Chest infections
• Infective endocarditis (rare)
• Tricuspid regurgitation
• Right ventricular failure
 Treatment
• Early symptoms of mitral stenosis such
as mild dyspnoea can usually be treated
with low doses of diuretics.
• The onset of atrial fibrillation requires
treatment with digoxin and
anticoagulation to prevent atrial
thrombus and systemic embolization.
• If pulmonary hypertension develops or
the symptoms of pulmonary congestion
persist despite therapy, surgical
relief of the mitral stenosis is advised.
 There are four operative
measures:
1. Trans-septal balloon valvotomy
• A catheter is introduced into the right atrium via the femoral vein.
2. Closed valvotomy
3. Open valvotomy
• This operation is often preferred to closed valvotomy.
4. Mitral valve replacement
• Replacement of the mitral valve is necessary if:
-mitral regurgitation is also present
-there is a badly diseased or badly calcified stenotic valve that
cannot be reopened without producing significant regurgitation
-there is moderate or severe mitral stenosis and thrombus in the
left atrium despite anticoagulation.
• Artificial valves may work successfully for more than 20 years.
• Anticoagulants are generally necessary to prevent the formation
of thrombus, which might obstruct the valve or embolize.
 Mitral
regurgitation
• Of the many causes of mitral
valve regurgitation, rheumatic
heart disease (50%) and a
prolapsing mitral valve are the
most common.
 Other causes include:
• aortic valve disease
• acute rheumatic fever
• myocarditis
• dilated cardiomyopathy
• hypertensive heart disease
• ischaemic heart disease
• infective endocarditis - mitral regurgitation may result from destruction of the
mitral valve leaflets
• hypertrophic cardiomyopathy - left ventricular contraction is disorganized and
mitral regurgitation often results
• connective tissue disorders - systemic lupus erythematosus (SLE) may cause
mitral regurgitation
• collagen abnormalities - Marfan's syndrome and Ehlers-Danlos syndrome cause
mitral regurgitation
• degeneration of the valve cusps or mitral annular calcification - results in mitral
regurgitation
• rupture of the chordae tendineae (due to myocardial infarction, infective
endocarditis or trauma) - results in acute and very severe mitral regurgitation
• drugs, e.g. fenfluramine is associated with mitral regurgitation.
 Physical signs:
• laterally displaced, thrusting (hyperdynamic),
diffuse apex beat and a systolic thrill
• soft first heart sound, owing to the incomplete
apposition of the valve cusps and their partial
closure by the time ventricular systole begins
• pansystolic murmur, owing to the occurrence
of regurgitation throughout the whole of
systole, being loudest at the apex but
radiating widely over the precordium and into
the axilla
• prominent third heart sound, owing to the
sudden rush of blood back into the dilated left
ventricle in early diastole (sometimes a short
mid-diastolic flow murmur may follow the
third heart sound).
 Investigations

Chest X-ray
• left atrial enlargement
• left ventricular enlargement
• an increase in the CTR
• valve calcification
 Electrocardiogram
• left atrial delay (bifid P waves)
• left ventricular hypertrophy (tall
R waves in the left lateral leads
and deep S waves in the right-
sided precordial leads)
• atrial fibrillation may be present.
 Echocardiogram
•a dilated left atrium and left
ventricle
•specific features of chordal or
papillary muscle rupture
•CW Doppler can determine the
velocity of the regurgitant jet.
Cardiac catheterization
• This demonstrates a
prominent left atrial systolic
pressure wave, and when
contrast is injected into the
left ventricle it is seen
regurgitating into an enlarged
left atrium during systole.
 Treatment
• Mild mitral regurgitation in the absence of
symptoms can be managed conservatively by
following the patient with serial echocardiograms.
• Prophylaxis against endocarditis is required
• Any evidence of progressive cardiac enlargement
generally warrants early surgical intervention by
either mitral valve repair or replacement.
• ACE inhibitors
• diuretics
• anticoagulants
MITRAL VALVE PROLAPSE

MVP, also variously termed the

systolic click-murmur syndrome,
Barlow's syndrome, floppy-valve
syndrome, and billowing mitral
leaflet syndrome, is a relatively
common, but highly variable, clinical
syndrome resulting from diverse
pathogenic mechanisms of the
mitral valve apparatus.
• myxomatous degeneration and
greatly increased
concentration of acid
mucopolysaccharide
• heritable disorders of
connective tissue, including
the Marfan syndrome,
osteogenesis imperfecta, and
the Ehler-Danlos syndrome.
 In most patients with
MVP, the cause is
unknown, but in some
it appears to be a
genetically determined
collagen tissue
disorder.
 CLINICAL FEATURES
• MVP is more common in females.
• It affects individuals in a wide age
range but most commonly between the
ages of 14 and 30 years.
• The clinical course is often benign.
• Most patients are asymptomatic and
remain so for their entire lives.
• However, MVP is now the most common
cause of isolated severe MR requiring
surgical treatment.
• Arrhythmias, most commonly
ventricular premature
contractions and paroxysmal
supraventricular and ventricular
tachycardia, have been reported
and may cause palpitations,
light-headedness, and syncope.
• Sudden death has been noted
but is a very rare complication.
• Many patients have chest pain
that is difficult to evaluate.
 Auscultation
• The most important finding is the
mid- or late (nonejection) systolic
click.
• Systolic clicks may be multiple and
may be followed by a high-pitched,
late systolic murmur, which
occasionally is "whooping" or
"honking," and is heard best at the
apex.
 Two-dimensional
echocardiography is
particularly effective in
identifying the abnormal
position and prolapse of
the mitral valve leaflets.