CV 3: Valvular Heart Disease LabSeptember 19, 2011

Case 1

Case 1

• A 75 year-old man presents with exertional angina, syncope, and dyspnea.

• The patient also admits to having occasional spells of lightheadedness and fainting on exercise

• On physical examination: – Systolic ejection murmur to right of

sternum radiating to the neck– Weak and delayed carotid pulses

• A chest x-ray shows calcifications of aortic valve leaflets and an enlarged cardiac shadow

• The patient does not have any evidence of significant coronary artery disease on angiogram.

What do you think is the most likely diagnosis?

In a 75 year-old man, what is the most likely etiology of the valvular disease

The patient underwent surgery for aortic valve replacement

The excised valve is shown in image 1B

Image 1A shows a normal aortic valve.

1A

1B

Image 1A, 1B

In a 50 year-old man with similar symptoms and with no evidence of significant coronary artery disease, what would the most likely diagnosis

be?

Image 1C

Image 1D

In a 25 year old-man with similar symptoms, what would be the most likely cause of the

disease?

Image 1E

Image 1F

Case 2• A 25 year old white-male presents to his cardiologist with

complaints of pounding of the heart and angina.• There is no family history of coronary artery disease• The patient denies smoking or drinking and claims to have

had no major illnesses in the past• On physical examination the patient has a bounding pulse,

large in volume and a wide pulse pressure and a diastolic murmur.

• His systolic blood pressure is high and diastolic blood pressure low

• Chest X-ray shows an enlarged left ventricle and dilated ascending aorta.

Why would this patient have a bounding pulse? What is the most likely diagnosis?

On additional questioning the patient mentioned that his older brother died of aortic dissection at the age of 30 years.

Why is this relevant?

A CT angiogram of this patient is shown in image 2A and 2B

2A2B

The next two slides(2C, 2D) demonstrate the pathology in this patient.

Image 2C

Image 2D

Case 3

• A 34-year-old white female is admitted to the hospital with progressively increasing dyspnea and orthopnea

• The patient denies any prior cardiovascular disease, but on additional questioning she reveals that she had rheumatic fever as a child

• On physical examination, the patient has elevated JVP, mid-diastolic murmur

• ECG: Left atrial hypertrophy and atrial fibrillation

• Chest X-ray (Image 3A) shows interstitial and alveolar densities

Image 3A

The patient underwent mitral valve replacement

Excised valve is shown in image 3B

Image 3B

• Image 3C is from another patient with similar history who underwent aortic valve replacement.

• Please describe the gross features.

Image 3C

Images 3D, 3E, 3F & 3G are autopsy images from another patient with

similar clinical history

Image 3D

Thrombus

Image 3E

Image 3F

Image 3G

Case 4

• A 50 year-old with a history of rheumatic fever in childhood presents to the emergency with fever for 10 days

• She has had dyspnea on exertion for the past two years, but says that the dyspnea has become worse since the onset of fever

• On physical examination splinter hemorrhages were seen in his finger nails as shown in image 4A

CASE 4

Image 4A

Blood cultures were positive for staphylococcus aureus

What is the most likely etiology of this patient’s fever and dyspnea?

A mitral valve replacement was performed. The next image is from the

mitral valve from an autopsy patient with similar findings

Image 4B

Image 4C

Image 4D

Case 5

• A 50 year-old-man died of bleeding complications following surgery for adenocarcinoma of the pancreas

• He was diagnosed with disseminated intravascular coagulation shortly before his death

• An autopsy was performed – The heart showed vegetations on his mitral valve and

aortic valve– Blood cultures were negative for microorganisms

Image 5A

Libman-Sacks Disease

-- Seen in patients with SLE

– No predilection for lines of closure

– Circulating antiphospholipid antibodies

Libman-Sacks Disease

Rheumatic valvulitis

Rheumatic valvulitis LSENBTEInfective endocarditis

Case 6

Case 6

• A 50 year-old man with known mitral regurgitation due to myxomatous degeneration presents in the ER with acute shortness of breath

• There is no fever. • A coronary angiogram performed 2 months prior did

not show any evidence of coronary artery disease. • Prior echo showed normal left ventricle and an

enlarged left atrium

What are the diagnostic possibilities in this patient?

The patient underwent emergent mitral valve replacement.

The gross and microscopic features of the excised mitral valve are shown in

kodachrome 6A and 6B.

What is your diagnosis?

Image 6A

Image 6B

In a patient with history of coronary artery disease the probable cause of acute mitral regurgitation is shown in the next kodachrome (6C)

What is your diagnosis?

Image 6C

Case 7

Case 7

• A 35 year-old-man presents with complaints of flushing, cramps, nausea, vomiting, diarrhea and wheezing.

• On physical examination: patient has increased jugular venous pressure, hepatomegaly, ascites and bilateral lower leg edema.

The patient underwent right tricuspid valve replacement.

Image 7B is from an autopsy heart of another patient with similar history.

Image 7B

Case 8

Case 8• A 40 year old man underwent mitral valve

replacement for mitral stenosis. • A year later the patient presented to the emergency

department with an acute surgical abdomen. • On examination the patient had generalized

peritonitis. • On urgent laparotomy a ruptured spleen was found.

The spleen was infarcted at the site of rupture. • An echo was performed.

The patient subsequently underwent a redo heart valve replacement

The pathologic abnormality of the valve is shown in image 8A which is from an autopsy

heart

Image 8A

• Another 40 year-old-man underwent mitral valve replacement for mitral stenosis.

• Four years later he developed mitral regurgitation.

The valve was excised and is shown in image 8B.

What is the possible etiology?

Image 8B