VALVULAR HEART DISEASE

Mefri Yanni, MD, FIHA

Department of Cardiology and Vascular Medicine
Faculty of Medicine, Universitas Andalas
ANATOMY
 POLL NO. 1

What makes the valve open and close well ?

a. Response to volume
b. Response to pressure differences
c. Timing of heart rate
 Normal Valve Function
• Maintain forward flow and prevent reversal of flow
• Valves open and close in response to pressure differences (gradients) between cardiac
chambers

Wiggers Diagram
Cardiac Cycle
 Abnormal Valve Function
• Valve Stenosis
 Obstruction to valve flow during that phase of the cardiac cycle
when the valve is normally open
 Hemodynamic Hallmark : “Pressure Gradients”

• Valve Regurgitation / Insufficiency / Incompetence

Inadequate valve closure  back leakage

A Single Valve can be both stenosis and regurgitant ;

but both lesions cannot be severe !
MITRAL VALVE DISEASE
 POLL NO. 2
How many leaflets does the mitral valve have ?
a. Two
b. Three
c. Four
 MITRAL VALVE APPARATUS

• Annulus
• Leaflet
• Musculus pappilaris
• Chordaes
• Primary
• Secondary
• Tertiary
• LV function and geometry
 POLL NO.3
What is the most common etiology in Mitral Stenosis ?
a. Infective Endocarditis
b. Congenital heart disease
c. Degenerative Calcification
d. Rheumatic Heart Disease
 ETIOLOGY
Mitral Regurgitation
Mitral Stenosis
Acute Chronic
Rheumatic – 99.9% Infective Endocarditis Infective Endocarditis
Congenital Papillary Muscle Rupture in
Ischemic Heart Disease
ACS
Prosthetic Valve Stenosis
Chordal Rupture in MVP Mitral Valve Prolapse
Mitral Annular Calcification
Chest Trauma Rheumatic Heart Disease
Left Atrial Myxoma
Prosthetic Valve Dysfunction
Mitral Annular Calcification
Cardiomiopathy
 MR : PATOPHYSIOLOGY
VOLUME OVERLOAD
• Leakage of blood into LA during systole

• Early phase : Loss of forward SV into LA

• Compensatory mechanisms :
- Increase in SV and EF
- Forward SV + Regurgitant Volume
- LV Volume Overload
- LV dilatation
- Increased LA pressure -- LA dilatation
 MR : PATOPHYSIOLOGY

ACUTE
• Normal (non compliant) LA
• Increase LA pressure
• Acute Pulmonary Edema

CHRONIC
• Dilated, compliant LA
• LA pressure normal or slightly increased
• Atrial arrhythmias

Most patients fall between these two extremes !

 MR : CLINICAL MANIFESTATIONS

SYMPTOMS SIGNS
Fatigue, weakness S1 : Soft or Normal

Exertional dyspnea ( pulm congestion ) S2 : P2 increased if Pulm HT

Cough ( pulmonary congestion ) Pansystolic murmur blowing at apex (MR) +/- thrill

Palpitation ( due to A Fib ) Midsystolic click ( in MVP )

Edema, Ascites ( Right HF ) Decrescendo systolic murmur ( in acute MR )

S3 Gallop and diastolic flow rumble ( in HF )

Signs of Pulmonary Congestion

( rales, pulmonary edema, effusions )
Signs of Right HF
( Increased JVP, Ascites, Hepatomegaly,
Ankle edema )
Cardiomegaly
MR : SUPPORTING EXAMS
Left atrial enlargement
ECG Left Ventricular Hypertrophy
Atrial Fibrillation
Cardiomegaly
Cardiac Waist (-)
Downward Apex (LVH)
Chest X-Ray
Pulmonary venous congestion
Pulmonary edema
Prominent pulmonary segment ( if PH )
Dilated LA
Echocardiography Dilated LV
Structural abnormalities of mitral valve
Dilated LA, LV
Mitral regurgitation
Cardiac catheterization
Pulmonary Hypertension, if PH
Coexisting Coronary Artery Disease
 MR : MANAGEMENT

MEDICALLY INTERVENTION
• Diuretics
• Non Surgical Intervention : Mitraclip, etc
• Vasodilators ( ACE inhibitors / ARB )
• Surgical :
• Mitral Valve Repair, OR
• If AF presents :
• Mitral Valve Replacement
•Anticoagulation
•Digoxin / anti arrhythmia
 MITRAL STENOSIS :
PATOPHYSIOLOGY

• Restriction of blood flow from LA to LV during diastole

• Normal MVA 4-6 cm2

• Mild MS 2 – 4 cm2
• Severe MS < 1.0 cm2

• MV pressure gradient

• As HR increases, diastole shortens disproportionally

and MV gradient increases
 POLL NO.4
Which cardiac chamber will be affected first with dilatation in Mitral
Stenosis ?
a. Left Atrium
b. Left Ventricle
c. Right Ventricle
d. Right Atrium
 MITRAL STENOSIS :
PATOPHYSIOLOGY

• MV Gradient  increased LA pressure

• Pulmonary HT

• RV pressure overload
•RVH / RV dilation
•RV failure
•Tricuspid regurgitation
•Systemic congestion

• LV unaffected ( protected )
 CLINICAL MANIFESTATIONS
SYM PT O M S
Symptoms related to MVA reduction
Symptoms related to pulmonary congestion
• Breathlessness
• Cough
• Hemoptysis
Symptoms related to severity of MS
• Palpitation, atrial fibrillation
• Systemic thromboembolism
Symptoms due to Pulm HT and RV Failure
• Fatigue
• Low output state
• Periperal edema, hepato-splenomegaly
• Hoarseness – recurrent laryngeal nerve palsy
SIGNS
Auscultatory findings :
• S1 – increased early, progressively decreased
• OS – opening snap, vaiable intensity
• A2 – OS interval – shortens as MVA disminishes
• Low pitched diastolic murmur at apex
• Duration of murmur correlates with MS
• Pres-systolic accentuation
• P2 increased (if PH )
Atrial fibrillation
Body habitus : thin, asthenic, female
Low Blood Pressure
LA Lift and RV heaving
SUPPORTING EXAMS
Left atrial enlargement
Right Axis Deviation
ECG
Right Ventricular Hypertrophy
Atrial Fibrillation
Cardiomegaly
Cardiac Waist (-) – LA enlargement
Chest X-Ray
Pulmonary venous congestion
Upward Apex (RVH)
Dilated LA
Thickened mitral valve
Echocardiography Reduced valve area
Pressure gradients across LA
RV/RA enlargement, dysfunction, TR
Pulmonary artery pressure
Cardiac catheterization Mitral stenosis
Signs of Mitral Regurgitation
 MANAGEMENT
INTERVENTIO
MEDICALLY
N
• Diuretics • Non Surgical Intervention :
to control congestion Balloon Mitral Valvulotomy

• beta blockers / Digoxin • Surgical :

to control ventricular rate • Mitral Valve Repair, OR

• Anti coagulant • Mitral Valve Replacement

to reduce the risk of thromboembolism
AORTIC VALVE DISEASE
 ANATOMY
 Three cusps, crescent shaped
3 commissures
3 sinuses
supported by fibrous annulus

 Valve Area : 3 – 4 cm2

 Node of Arantius

Aortic Stenosis
Degenerative Calcific Senile
Congenital – uni/bicuspid
Rheumatic
Prosthetic Valve Syfunction
ETIOLOGY
Aortic Regurgitation
Acute Chronic
Infective Endocarditis AORTIC LEAFLET DISEASE
Acute Aortic Dissection • Infective Endocarditis
• Rheumatic Heart Disease
• Marfan Syndrome
• Chest Trauma • Bicuspid Aortic Valve
• Prolapse Congenital AR
• Prosthetic Valve Dysfunction
• Cardiomiopathy
AORTIC ROOT DISEASE
• Aortic aneurysm / dissection
• Marfan syndrome
• Connective tissue disorder
• Syphilis
• Hypertension
• Annula-aortic ectasia
 AORTIC STENOSIS :
PATOPHYSIOLOGY

• Restriction of blood flow from LV to Aorta during

systole

• Normal AVA 3 – 4 cm2

• Severe AS < 1.0 cm2
• Critical AS < 0.5 cm2

• Hemodynamic Hallmark :
• Systolic Pressure Gradients
• AV gradient ~ AV flow / AVA
• AV flow = CO / Systolic Ejection Period
• As flow increases so does the gradients
 AORTIC STENOSIS :
PATOPHYSIOLOGY
LV PRESSURE
OVERLOAD
• Chronic Pressure overload  Concentric LVH

• Stiff / Non compliant LV :

•Increased LVEDP
•Increased LV mass
•If LV fails --> Heart Failure

• Atrial fibrillation may present

• Poorly tolerated
• Loss of atrial kick
• Rapid HR
• Acute Pulmonary Edema , OR
• Hypotension
 AORTIC STENOSIS :
NATURAL HISTORY

• Asymptomatic for many years

• Symptoms develop when valve is critically narrowed and LV

function deteriorates
•Bicuspid AV valve 5th-6th decade
•Senile AS 7th-8th decade

• Risk Factors :
• Age > 70 years old
• CAD
• Dyslipidemia
• Chronic renal failure
 AORTIC STENOSIS :
CLINICAL MANIFESTATIONS
SYM PT O M S
Severity of AS Mild Moderate Severe
Classical Symptoms Triad :
• Angina Pectoris
• Heart Failure Carotid pulse normal Slow rising Parvus et Tardus
• Syncope
LV apical Heaving &
normal heaving
impulse sustained
Auscultation
SIGNS
S4 gallop - +/- ++
Ejection Systolic Murmur
Systolic ejection
+ +/- -
Slow rising carotid pulse Click

Thrusting apex beat ( LV pressure overload ) Early mid-to-late

SEM, peaking midsystole
systole systole
Narrow pulse pressure Normal or Single or
S2 normal
single paradoxical
 AORTIC STENOSIS :
SUPPORTING EXAMS
LVH with Strain
Left Axis Deviation
ECG
LBBB, may present
LA enlargement, may present
May be Normal
Enlarged LV
Chest X-Ray
Calcified Aortic Valve
Dilated Ascending Aorta, may present
Hypertrophied LV
Echocardiography
Calcified Valve with restricted opening
May be used to identify the gradient
Cardiac catheterization
To identify Coronary Artery Disease
 AORTIC STENOSIS :
MANAGEMENT
INTERVENTIO
MEDICALLY
N
• Diuretics • Non Surgical Intervention :
to control congestion
• TAVR
• Balloon Aortic Valvulolasty
• beta blockers / Digoxin
to control ventricular rate
• Surgical :
• Aortic Valve Replacement
• Anti coagulant
if Atrial Fibrillation present
 POLL NO.5
What is the hemodynamic problems in Aortic Regurgitation ?
a. Volume Overload
b. Pressure Overload
c. None
 AORTIC REGURGITATION
: PATOPHYSIOLOGY
LV VOLUME OVERLOAD

• Failure of the aortic valve to close tightly causes back

flow of blood into the LV

• 1st abnormality : LV Volume Overload

• Severity of LV Vol Overload depends on :

•Size of regurgitant orifice
•Diastolic pressure gradient between Ao and LV
•Heart Rate : duration of diastole

• Compensatory Mechanisms :
• LV dilatation and eccentric
• LV Hypertrophy
• Increased LV diastolic compliance
• Peripheral vasodilation
 LV VOLUME VS PRESSURE
OVERLOAD
LV Pressure Overload
Feature LV Volume Overload (MR,AR)
(AS)

LV Volume normal Dilated**

Wall thickness Conc. LVH Normal to slightly increased

LV compliance “stiff” noncompliant Increased compliance

LV Diastolic Pressure increased Normal to slightly increased

LV Systolic Pressure Increased** Normal to slightly increased

LVEF normal increased

 AORTIC REGURGITATION
: PATOPHYSIOLOGY
ACUTE
• Sudden Aortic Valve incompetence
• Non compliant LV
• Acute Pulmonary Edema

CHRONIC
• Long asymptomatic phase
• Progressive LV dilatation
• DOE, Ortopnea, PND
• Frequent PVCs
 AORTIC REGURGITATION
: CLINICAL FEATURES
• Pulses: • Other signs:
• Large volume or ‘collapsing’ pulse • Displaced, heaving apex beat
• Wide pulse pressure > 70 mmHg (volume overload)

• Low diastolic and increased pulse pressure < 60 mmHg • Pre-systolic impulse

• Bounding peripheral pulse: Corrigan/s pulse • 4th heart sound

• Capillary pulsation in nail beds: Quincke’s sign • Crepitations (pulmonary venous

congestion)
• Femoral bruit (‘pistol shot’): Duroziez’s sign
• Head nodding with pulse: de Musset’s sign

• Murmurs:
• Early diastolic murmur characteristic murmur is best heard
to the left sternum during held expiration
• Systolic murmur (increased stroke volume)
• Austin Flint murmur (soft mid-diastolic) – diastolic flow rumble at apex, due to interference with
transmitral filling by impingement from AR jet.
 AORTIC
REGURGITATION :
SUPPORTING EXAMS
LV Hypertrophy
ECG
T wave inversion
Cardiomegaly
Downward apex
Chest X-Ray
Pulmonary congestion
Dilated Ascending Aorta, may present
Dilated LV
Echocardiography Severity of AR
Hyperdynamic LV
Dilated LV
Cardiac catheterization Aortic regurgitation
Dilated Aortic root
 AORTIC
REGURGITATION :
MANAGEMENT
INTERVENTIO
MEDICALLY
N
• Diuretics
to control congestion • Surgical :
• Aortic Valve Replacement
• Vasodilator • May be combined with aortic root
to control systolic BP replacement and /or coronary bypass
surgery
Thank You !
AB
CD