5. Valvular Heart Disease IM 8-12 New

8/17/2019 5. Valvular Heart Disease IM 8-12 New

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Aortic Stenosis Mitral Stenosis Aortic Regurgitation

Acute and Chronic Mitral Regurgitation

Acute and Chronic









Normal Aortic Valve Area: 3- cm !

Symptoms: "ccur #hen $al$e area is %& th o' normal area(

Types:

Supra$al$ularSu)$al$ularValvular



Congenital Rheumatic Degenerative/Calcific

Patients under !: *+, ha$e a congenitalcause

Patients over !: +, due to degenerati$e











A pressure gradient de$elops )et#een thele't $entricle and the aorta( .increaseda'terload/

01 'unction initially maintained )ycompensatory pressure hypertrophy 2hen compensatory mechanisms exhausted

01 'unction declines(



- Syncope: .exertional/- Angina: .increased myocardial oxygen

demand4 demand&supply mismatch/

- Dyspnea: on exertion due to heart 'ailure.systolic and diastolic/

- Sudden death



Slo# rising carotid pulse . pulsus tardus / 5decreased pulse amplitude . pulsus parvus /

Heart sounds- so't and split second heart sound

S gallop due to 01H(

Systolic e6ection murmur- cresendo-decrescendocharacter( This pea7s later as the se$erity o' the

stenosis increases("oudness does N#T tell you anything a$outseverity



Mild AS to Se$ere AS89 in %, years!! in !! years

39 in !+ years

The onset of symptoms is a poor prognosticindicator%





Echocardiography is the most $alua)le test 'ordiagnosis :uanti'ication and 'ollo#-up o'patients #ith AS(

T#o measurements o)tained are8

a/ 0e't $entricular si;e and 'unction801H <ilation and E=

)/ <oppler deri$ed gradient and $al$earea .A1A/



Cardiac catheterization: Should only be done for a directmeasurement if symptom severity and echo severity don’tmatch OR prior to replacement when replacement is planned.



&eneral - >E prophylaxis in dental procedures #ith aprosthetic A1 or history o' endocarditis(

'edical - limited role since AS is a mechanicalpro)lem( 1asodilators are relativelycontraindicated in se$ere AS

Aortic (alloon Valvotomy) sho#s little )ene'it( Surgical Replacement: <e'initi$e treatment



'ild: E$ery + years 'oderate: E$ery ! years Severe: E$ery ? months to % year





Any S@MPT"MAT>C patient #ith se$ere AS.includes symptoms #ith exercise/

Any patient #ith decreasing E=

Any patient undergoing CA B #ith moderateor se$ere AS



<isease o' aging 0oo7 'or the signs on physical exam Echocardiogram to assess se$erity Asymptomatic8 Medical management and

sur$eillance Symptomatic8 Ao1 replacement .e$en in elderly

and CH=/





Definition: ")struction o' 01 in'lo# thatpre$ents proper 'illing during diastole

Normal 'V Area: -? cm !

Transmitral gradients and symptoms )egin atareas less than ! cm !

Rheumatic carditis is the predominant cause Prevalence and incidence: decreasing due to a

reduction o' rheumatic heart disease(



Rheumatic heart disease8 -DD o' all cases >n'ecti$e endocarditis8 3(3 Mitral annular calci'ication8 !(











Progressive Dyspnea * !+,: 0A dilation pulmonary congestion .reduced emptying/

#orse #ith exercise 'e$er tachycardia and

pregnancy -ncreased Transmitral Pressures: 0eads tole't atrial enlargement and atrial'i)rillation(

Right heart failure symptoms: due toPulmonary $enous HTN .emoptysis: due to rupture o' )ronchial

$essels due to ele$ated pulmonary pressure



Disease of plateaus:Mild MS8 %, years a'ter initial RH< insult'oderate: %, years laterSevere: %, years later

'ortality: <ue to progressi$e pulmonary

congestion in'ection and throm)oem)olism(



prominent a 0ave in 1ugular venouspulsations 8 <ue to pulmonary hypertension andright $entricular hypertrophy

Signs of right)sided heart failure: in ad$anceddisease

'itral facies: 2hen MS is se$ere and thecardiac output is diminished there is$asoconstriction resulting in pin7ish-purplepatches on the chee7s



Diastolic murmur: 0o#-pitched diastolic rum)le most prominent at theapex(

Heard )est #ith the patient lying on the le't side inheld expiration>ntensity o' the diastolic murmur does not correlate#ith the se$erity o' the stenosis



"oud #pening S 2 snap: heard at the apex #henlea'lets are still mo)ile

<ue to the a)rupt halt in lea'let motion in early

diastole a'ter rapid initial rapid opening due to 'usionat the lea'let tips(A shorter S3 to opening snap interval indicates moresevere disease%



4C&8 may sho# atrial 'i)rillation and 0Aenlargement

C5R 8 0A enlargement and pulmonarycongestion( "ccasionally calci'ied M1

4C.# 8 The GOLD STANDARD 'or diagnosis(Asses mitral $al$e mo)ility gradient andmitral $al$e area





Serial echocardiography: Mild8 3-+ yearsModerate8%-! yearsSe$ere8 yearly

'edications: MS li7e AS is a mechanicalpro)lem and medical therapy does notpre$ent progression

β-)loc7ers CC s <igoxin #hich control heart rateand hence prolong diastole 'or impro$ed diastolic'illing<uiretics 'or 'luid o$erload



>denti'y patient early #ho might )ene'it 'rompercutaneous mitral )alloon $al$otomy(

-4 prophyla6is: Patients #ith prosthetic$al$es or a Hx o' >E 'or dental procedures(











AN@ S@MPT"MAT>C Patient #ith N@HA Class >>> or>1 Symptoms

Asymptomatic moderate or Se$ere MS #ith aplia)le $al$e suita)le 'or PM 1







Definition: 0ea7age o' )lood into 01 duringdiastole due to ine''ecti$e coaptation o' theaortic cusps



Endocarditis Aortic <issection

Physical 7indings:2ide pulse pressure<iastolic murmur=lorid pulmonary edema



True Surgical Emergency8 Positi$e inotrope8 .eg dopamine

do)utamine/ 1asodilators8 .eg nitroprusside/ A$oid )eta-)loc7ers <o not e$en consider a )alloonpump





icuspid aortic $al$e

Rheumatic >n'ecti$e endocarditis



Com)ined pressure AN< $olume o$erload

Compensatory 'echanisms: 01 dilation

01H( Progressi$e dilation leads to heart'ailure



Asymptomatic until 8 th or 9 th decade Rate of Progression: 8) + per year Progressive Symptoms include:

- Dyspnea: exertional orthopnea and paroxsymalnocturnal dyspnea

- Nocturnal angina: due to slo#ing o' heart rate andreduction o' diastolic )lood pressure

-Palpitations: due to increased 'orce o' contraction



;ide pulse pressure: most sensiti$e Hyperdynamic and displaced apical impulse Auscultation -

Diastolic $lo0ing murmur at the le't sternal )order Austin flint murmur .apex/8 Regurgitant 6et impinges onanterior M10 causing it to $i)rateSystolic ejection murmur 8 due to increased 'lo# acrossthe aortic $al$e





MRI of the Heart Revealing a Central, High-Velocity Jet Projecting into the Left Ventricular Cavity.

The jet clearly strikes the anterior mitral-valve leaflet, causing distortion and premature closureduring diastole.



C5R: enlarged cardiac silhouette and aortic rootenlargement

4C.# 8 E$aluation o' the A1 and aortic root #ithmeasurements o' 01 dimensions and 'unction.cornerstone 'or decision ma7ing and 'ollo# upe$aluation/

Aortography: Fsed to con'irm the se$erity o'disease











AN@ Symptoms at rest or exercise Asymptomatic treatment i'8

E= drops )elo# +, or 01 )ecomes

dilated





Definition: ac7'lo# o' )lood 'rom the 01 to the0A during systole

Mild .physiological/ MR is seen in 9, o' normalindi$iduals(



Endocarditis Acute M>8 Mal'unction or disruption o' prosthetic $al$e



'yocardial infarction: Cardiac cath orthrom$olytics

'ost other cases of mitral regurgitation isafterload reduction:

Diuretics and nitratesnitroprusside< even in the setting ofa normal $lood pressure%



Do not attempt to alleviate tachycardia0ith $eta)$loc=ers% 'ild)to)moderatetachycardia is $eneficial in these patients$ecause it allo0s less time for the heart tohave $ac=fill< 0hich lo0ers regurgitantvolume%



alloon Pump Nitroprusside e$en i' hypotensi$e Emergent Surgery



Myxomatous degeneration .M1P/ >schemic MR

Rheumatic heart disease >n'ecti$e Endocarditis



Pure Volume #verload Compensatory 'echanisms: 0e't atrial

enlargement 01H and increased contractilityProgressi$e le't atrial dilation and right $entriculardys'unction due to pulmonary hypertension(Progressi$e le't $entricular volume overload leads todilation and progressi$e heart 'ailure(





Compensatory phase: %,-%+ years Patients #ith asymptomatic se$ere MR ha$e a

+ &year mortality rate "nce the patientGs E= )ecomes ?, and&or

)ecomes symptomatic mortality risessharply

'ortality: =rom progressi$e dyspnea andheart 'ailure



4C&: May sho# 0A enlargement atrial 'i)rillationand 01 hypertrophy #ith se$ere MR

C5R: 0A enlargement central pulmonary arteryenlargement(

4C.#: Estimation o' 0A 01 si;e and 'unction( 1al$estructure assessment

TEE i' transthoracic echo is inconclusi$e





'edicationsa/ 1asodilator such as hydrala;ine)/ Rate control 'or atrial 'i)rillation #ith β-)loc7ers

CC digoxinc/ Anticoagulation in atrial 'i)rillation and 'lutterd/ <iuretics 'or 'luid o$erload



Serial 4chocardiography:'ild: !-3 years'oderate: %-! years

Severe: ?-%! months

-4 prophyla6is: Patients #ith prosthetic $al$esor a Hx o' >E 'or dental procedures(







AN@ Symptoms at rest or exercise #ith.repair i' 'easi)le/

Asymptomatic8>' E= ?,>' ne# onset atrial 'i)rillation



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5. Valvular Heart Disease IM 8-12 New