Valvular Heart Disease Vincent E. Friedewald, M.D

Valvular Heart

DiseaseVincent E.

Friedewald, M.D.

Classification of Heart Disease

CongenitalCoronaryElectrical

EndomyocardialPericardial

Valvular

The Cardiac Valves

Cardiac Valve Anatomy

Valvular Heart Disease

Acute and Chronicare

Different Diseases

Aortic Stenosis

Aortic StenosisTypes

ValvularSubvalvular

Supravalvular

Aortic Valve

Stenosis

Aortic Valve StenosisBicuspid

RheumaticDegenerative

Aortic Valve StenosisAge Relationship

Bicuspid Aortic Stenosis

Rheumatic Aortic Stenosis

Degenerative Aortic Stenosis

Degenerative Aortic Stenosis

Risk FactorsElevated LDL-

cholesterolDiabetes mellitusSystemic arterial

hypertensionCigarette smoking

Aortic Valve Stenosis

Symptoms

Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope

Aortic Valve StenosisSigns

ARTERIAL PULSE, GEN – RISE, SLOW ARTERIAL PULSE, GEN – AMP, ABSENT OR

REDUCED ARTERIAL PULSE, GEN – DOWNSLOPE

GRADUAL ARTERIAL PULSE, GEN – PULSE

PRESSURE, NARROW ARTERIAL PULSE, GEN – SHUDDER ARTERY, CAROTID – THRILL HEART, LV APEX – IMPULSE,

PRESYSTOLIC HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – MURMUR, SYSTOLIC

Aortic Valve Stenosis

Signs (cont)HEART, LV APEX – CLICK, SYSTOLIC HEART, LV APEX – IMPULSE, SUSTAINED HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – CLICK, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SINGLE HEART, SOUND S2 – SPLIT REVERSED

(PARADOXICAL) NECK, SUPRATERNAL NOTCH – THRILL,

SYSTOLIC

Aortic Valve Stenosis

SymptomsFATIGUE BREATHING – DIFFICULT WITH EFFORT

(DYSPNEA) CHEST, ANT – PAIN, NONPLEURITIC (ANGINA

PECTORIS)CHEST, ANT – PALPITATIONS CONSCIOUSNESS – LOSS, SUDDEN

(SYNCOPE) CONSCIOUSNESS – LOSS, SUDDEN EFFORT

(EFFORT SYNCOPE) DIZZINESS – EFFORT

Aortic Valve Stenosis

Untreated Prognosis

Aortic Valve Stenosis

Chest X-Ray

Aortic Valve Stenosis

ECG

Aortic Valve Stenosis

Echo

Aortic Valve Stenosis

AV Pressure Gradient

Aortic Valve Stenosis

Medical RXNo drugs alter course – only

valve repair/replacementAntibiotic Prophylaxis? StatinsFor symptoms (if not candidate

for valve replacement) – after-load reduction, i.e., nitroglycerine, used with caution to avoid BP fall

Aortic Valve Stenosis

Surgical RxValvotomyReplacement

ArtificialBioprosthesisMinimally-

invasive transfemoral

Aortic Valve ReplacementTransfemoral

Aortic Valve Stenosis

ComplicationsAtrial fibrillationAortic Dissection

Heart failureInfective endocarditisMyocardial infarction

Sudden death

Aortic Regurgitation (Insufficiency

)

Aortic Regurgitation

EtiologiesPrimary aortic valve diseaseAortic root abnormalities

(Dissection, Syphilis)Connective tissue disorders

(Marfan’s)Infective endocarditisInflammatory disorders (SLE)Tumors

Aortic RegurgitationSymptoms

BREATHING – DIFFICULT , NOCTURNAL BREATHING – DIFFICULT WITH EFFORT CHEST, ANT – PAIN, NONPLEURITIC

(ANGINA)CHEST, ANT – PALPITATIONS HEAD, GEN – PAIN SWEATING – NOCTURNAL

Aortic RegurgitationSigns

ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED ARTERIAL PULSE, GEN – DOUBLE ARTERIAL PULSE, GEN – FALL, RAPID ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE ARTERIAL PULSE, GEN – RISE, RAPID ARTERY, CAROTID – THRILL ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING

HEAD – BOBBING HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – THRILL, DIASTOLIC HEART, LV APEX – IMPULSE, INF

DISPLACEMENTHEART, LV APEX – IMPULSE, LAT

DISPLACEMENT HEART, LV APEX – IMPULSE, DIFFUSE HEART, LV APEX – MURMUR, DIASTOLIC HEART, RSB UPPER – MURMUR , SYSTOLIC HEART, RSB UPPER – MURMUR, DIASTOLIC

Aortic RegurgitationSigns (cont)

Aortic Regurgitation

Signs (cont)HEART, RSB UPPER – THRILL, SYSTOLIC HEART, SOUND A2 – ABSENT OR

REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SPLIT REVERSED HEART, SOUND S3 LV MOUTH, UVULA – PULSATIONS NAILS – PULSATIONS NECK, SUPRATERNAL NOTCH – THRILL,

SYSTOLIC

Aortic Regurgitation – ChronicChest X-Ray

Aortic RegurgitationEcho

Aortic Regurgitation

Medical Rx Vasodilators to

reduce systolic BPAntibiotic prophylaxis

Aortic Regurgitation

Surgical Rx

Aortic valve replacement

Mitral Regurgitation (Insufficiency)

Mitral RegurgitationEtiologies

Congenital deformities Degenerative, i.e., myxomatous

Endomyocardial fibroelastosisMitral annular calcificationPapillary muscle dysfunction

– ischemic heart diseaseRheumatic

Mitral RegurgitationEtiologies (cont)Ergotamine toxicityCarcinoid syndromeRadiation RxSLEDiet-drug therapy

Mitral RegurgitationPapillary Muscles

Mitral RegurgitationLeaflet Prolapse (MVP Syndrome)

Mitral Regurgitation

Calcified Annulus

Mitral Regurgitation

SymptomsBREATHING – DIFF, EFFORTFATIGUE SKIN, GEN – TEMPERATURE, COOL

SWEATING – EXCESSIVE

Mitral RegurgitationSigns

ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN - FALL, RAPID ARTERIAL PULSE, GEN - RISE, RAPID CHEST, ANT LEFT - BULGE HEART, LV APEX - IMPULSE, FORCEFUL HEART, LV APEX - IMPULSE, DIFFUSE

Mitral RegurgitationSigns (cont)

HEART, LV APEX - IMPULSE, SUSTAINED

HEART, LV APEX - MURMUR, DIASTOLIC

HEART, LV APEX - MURMUR, SYSTOLIC

HEART, SOUND P2 - LOUD HEART, SOUND S3 LV SKIN, GEN - TEMPERATURE, COOL

Mitral Regurgitation2-D Echo

Mitral RegurgitationDoppler Echo

Mitral RegurgitationComplications

Atrial fibrillationPulmonary

hypertensionLV dysfunctionInfective

endocarditis

Mitral RegurgitationMedical Rx

Antibiotic prophylaxis

ACEIs (functional form of MR)

Beta-blockers (functional form of MR)

Mitral RegurgitationSurgical Rx

Mitral repairMitral valve

replacement

Mitral Stenosis

Mitral StenosisIncreased LA

Pressure

Mitral StenosisEtiologiesRheumaticRare:

CongenitalChest radiationLeft atrial myxomaMucopolysaccharidosisSevere mitral annular

calcification

Mitral StenosisSymptoms

ABDOMEN, GEN – PAIN BREATHING – DIFF, NOCTURNALBREATHING – DIFF, EFFORTBREATHING – DIFF, RECLINING FLATBREATHING – DIFF, RESTINGBREATHING – RAPIDCHEST, ANT – PAIN, NONPLEURITIC CHEST, ANT – PALPITATIONS COUGH – CHRONIC, NONSPECIFIC FATIGUE SPUTUM – BLOODY

Mitral StenosisSigns

ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW ARTERIAL PULSE, GEN – AMP, ABSENT OR

REDUCED BREATH SOUNDS, GEN – WHEEZES EXTREMITIES, LOWER BILATERAL - EDEMA HEART RATE – RAPID HEART, LSB LOWER – IMPULSE, SYSTOLIC

Mitral StenosisSigns (cont)

HEART, LSB LOWER – MURMUR, DIASTOLIC HEART, LSB MID – PERCUSSION, DULLNESS HEART, LV APEX – MURMUR, DIASTOLIC HEART, LV APEX – OPENING SNAP, MITRAL HEART, LV APEX – THRILL, DIASTOLIC HEART, RSB – SOUND, SYSTOLIC EJECTION HEART, RSB UPPER – MURMUR, DIASTOLIC HEART, SOUND P2 – LOUD

Mitral StenosisSigns (cont)

HEART, SOUND P2 – PALPABLE HEART, SOUND S1 – SOFT HEART, SOUND S1 – LOUD LIVER – ENLARGEDSKIN, CHEEKS – COLOR, PINK PURPLESKIN, GEN – COLOR, BLUEVENOUS PULSE, JUGULAR - A WAVE,

LARGEVENOUS PULSE, JUGULAR – ELEVATED

Mitral StenosisChest X-ray

Mitral StenosisEcho

Mitral StenosisLA Thrombus

Mitral StenosisECG

Mitral Stenosis Complications

Atrial fibrillationInfective EndocarditisPeripheral embolismPulmonary

hypertension

Mitral StenosisMedical RX

Antibiotic prophylaxisAnticoagulation for

Atrial fibrillationPrior embolic eventDocumented LA

thrombusArrhythmia control

Mitral StenosisSurgical RX

Invasive valvuloplastyPercutaneous valvotomy

Valve replacement

Mitral StenosisInvasive

Valvuloplasty

Mitral StenosisSurgical RX –

Valvuloplasty with Balloon Catheter

Valvular Heart Disease

Follow upAntibiotic prophylaxis

New symptomsChange in symptomsChange in physical

findingsEchocardiography/other

imaging

Thank you!