M. a. Sungkar - Diagnosis and Management of Valvular Heart Disesase

7/26/2019 M. a. Sungkar - Diagnosis and Management of Valvular Heart Disesase

1/43

Diagnosis and Managementof Valvular Heart Disesase

Division Cardiovascular, Department Internal MedicineMedical Faculty, Diponegoro University/

Kariadi Hospital Semarang

M A Sungkar, MD


2/43

Evaluation of Valve Disease

History

Inspection

Palpation

Percution

Auscultation


3/43


4/43

Strategy for evaluating heart murmurs

Present of Cardiac murmur

Systolic murmur Diastolic or continuous murmur

Grade 1 plus 2and midsystolic

Asymptomatic

And no associatedfindings

No furtherworkup

Grade 3 or higherholosystolic orlate systolic

Other sign or

symptoms ofcardiac disease

Echocardiography

Catheterization and angiographyif appropiate


5/43

Common Valvular Heart Diseases(by murmur timing/quality)

Systolic Murmurs:

Aortic stenosis

Mitral insufficiency

Mitral valve prolapse

Tricuspid insufficiency

Diastolic Murmurs:

Aortic insufficiency

Mitral stenosis

S1 S2 S1


6/43

Murmurs and theCardiac Cycle

Aortic stenosis

Mitral Regurgitation

1 2

1 2

Mitral valve prolapse withlate regurgitation

1 2


7/43


8/43

Aortic Stenosis - Clinical features

Symptoms

None, SOB, dizziness, HF, syncope, angina

Examination

Pulse - amplitude, delay, Sustained apexS2- soft and single paradoxical splitting

ESM - loud late peak soft

Echocardiography

Mean

gradient

(mmHg)

Peak Ao

velocity

AVA

(cm2)

Normal 1.0 -2.0 >2.5

Mild 1.7

Moderate 20 -40 3.0 -4.0 1.0 - 1.7

Severe >40 >4.0


9/43

Aortic Stenosis: Physical Findings

Intensity DOES NOT predict severity

Diamond shaped, systolic crescendo-decrescendo

Decreased, delay & prolongation of pulseamplitude

S4 (with left ventricular hypertrophy)

S3 (with left ventricular failure)

S1 S2 S1 S2

Mild-Moderate Severe


10/43

100

80

80

60

40

20

00 70605040

Latent period(increasing obstruction,

myocardial overload)

%S

urvival

Average agedeath (male)

Average survival (yr)

AnginaSyncope

Failure

0 2 4 6

Onset severe symptoms

Ross J Jr, Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61, 1968

Natural History of AS


11/43


12/43


13/43

Mitral Regurgitation - Clinical findings

Acute

dyspnoea, orthopnoea, no cardiomegaly,

short murmur, S3

Chronic

variable symptoms, cardiomegaly, murmur,

P2loud, S3

Quantification

Serial studies, LV function

Echocardiography,

CXR - Cardiomegaly
http://d/Holistic/Echo-MR.ppthttp://d/Holistic/CXR%20MR.ppthttp://d/Holistic/CXR%20MR.ppthttp://d/Holistic/Echo-MR.ppt


14/43

Physical Examination

Mitral Insufficiency

Apical holosystolic murmur

Radiation to the axilla Palpable thrill at cardiac

apex

S1 S2 S1


15/43

SymptomsMajority are asymptomatic for entire life

Palpitations

Chest pain (atypical):

Often substernal, prolonged, poorly related

to exertion, and rarely resembles typical

angina

Syncope

Mitral Valve Prolapse


16/43

Complications

Arrhythmias (PVC, PSVT>>VT)Transient cerebral ischemia (embolicrare)

Infective endocarditis (if assoc w/ MR)

Sudden death (rare)



17/43

Physical Examamination

Most important finding: mid late systolic click

Acute tensing of the mitral valve chordae

Variable murmurs: high pitched late systolic crescendo-decrescendo

murmur,

Occasionally whooping or honking at the apex

S1 C S2



18/43

TreatmentReassurance

Asymptomatic pts w/o sev MR or arrhythmia.

Follow-up q 2-4 years, with ECHO

-blocker treatment for atypical chest pain

Infective endocarditis prophylaxis with

Systolic murmur &/or

Typical echocardiagraphic findings

Men definitely! Women? No consensus.

Severe sx (e.g. MR) Rxd as mitral

insufficiency.



19/43


20/43


21/43

Mitral Regurgitation - Treatment

Diuretics

- LV filling P, p. oedema

Vasodilators

- forward SVIABP

Acute

Chronic

No known effective therapy

Vasodilators - theoretical risks

Treat complications


22/43

When to Intervene in Mitral Regurgitation

Time

Survival

LeftVentricularFunction


23/43


24/43

Fatigue

SOB

EdemaSensation of pulsations in the neck.

Right upper quadrant abdominal

fullness or discomfort due to livercongestion.

Tricuspid Regurgitation

History


25/43

Tricuspid Regurgitation

Clinical Features

Systolic waves on JVP (time withcarotid pulse) therefore not v waves.

RV+

S3+ pansystolic murmur in 4th

intercostal space

Pulsatile liver

Ascites

Peripheral oedema

Echocardiography
http://d/Holistic/TR%20Echo.ppthttp://d/Holistic/TR%20Echo.ppt


26/43

Aortic regurgitation

1 2

Mitral Stenosis

1 2

OS

Murmurs and theCardiac Cycle


27/43


28/43

Physical Findings in Aortic Regurgitation

Wide pulse pressure: Bounding pulses

Soft aortic second sound (A2)

Early diastolic murmur (blowing) immediately

after A2- Upper RSB with root dilation

- Mid to lower LSB with leaflet dysfunction

Systolic murmur at base (similar to aorticstenosis)

Austin Flint murmur: mid to late diastolicrumble at apex
http://d/Holistic/Austin.ppthttp://d/Holistic/Austin.ppthttp://d/Holistic/Austin.ppthttp://d/Holistic/Austin.ppthttp://d/Holistic/Austin.ppt


29/43

Austin Flint - Murmur

LV

AV

MV

AR

DiastolicFilling

1 2

Anterior leaflet of mitral valve vibrates between AR and filling jets

1


30/43

Clinical Signs in Aortic Regurgitation

Wide pulse pressure / low diastolic bloodpressure

de Mussets signhead bobbing

Corrigans pulsecollapsing / waterhammer Traubes sign - pistol shot femorals

Mullers signsystolic pulsation of the uvula

Duroziez signsystolic murmur over thefemoral artery

Quinckes - capillary pulsation


31/43

Investigations

Clinical Signs in Aortic Regurgitation

ECGLVH

CXR - Cardiomegaly

Echocardiogram

- Assess severity

Coronary angiography- Exclude coronary disease
http://d/Holistic/CXR-AR.ppthttp://d/Holistic/CXR-AR.ppthttp://d/Holistic/Echo%20AR.ppthttp://d/Holistic/Echo%20AR.ppthttp://d/Holistic/Echo%20AR.ppthttp://d/Holistic/Echo%20AR.ppthttp://d/Holistic/CXR-AR.ppt


32/43

Natural history of aortic regurgitation

%S

urviving

? ??

Onset ? Decades AnotherDecade

(1) ProgressiveCardiomegaly

(2) LV dilatation(3) Maintenance of

myocardial and

pump failureEstablishedmyocardial

disease

Symptoms ofincreasing fillingpressureappear

( LVEDP + MR)

Symptoms of low COInsidously begin

(1) Pump function maintained(2) Myocardial function deteriorates

100

80

60

40

20

0


33/43


34/43


35/43

Stages of Mitral Stenosis

Class MVA (cm2) Symptoms

Minimal > 2.5 None

Mild 1.42.5 Dyspnea with exertion

Moderate 1.01.4 Dyspnea, OT,PND, pulmonaryedema

Severe < 1.0 Resting dyspnea, disable(NYHA IV), bed chair

Reactive PH < 1.0 As in severe, plus fatique &RVH


36/43

Mitral Stenosis

Clinical manifestation

Dyspnea ,cough, palpitation, fainting, orthopnea

Hemoptysis, Hoaseness (ortners syndrome)

Cerebral embolism

Physical examination

Mitral facies (malar facial flush),

Pulse : irregular, low amplitude

JVP : distention, prominent A wave

Palpation

Apex : Tapping ,Diastolic thrill

RV heave

Palpable P2(if PHT)


37/43

Mitral Stenosis (Cont)

Physical examination

Loud S1 ; Loud P2(PHT)Mitral opening snap; Diastolic rumbling murmur

Presystolic accentuation

Auscultation

Investigation

- Echocardiography

- CXR

- EKG
http://d/Holistic/MS%20CXR.ppthttp://d/Holistic/MS%20EKG.ppthttp://d/Holistic/MS%20EKG.ppthttp://d/Holistic/MS%20CXR.ppt


38/43

Physical Examination

First heart sound (S1) is accentuated andsnapping

Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex

Pre-systolic accentuation (esp. if in sinusrhythm)

S1 S2 OS S1

Mitral Stenosis


39/43

Natural History Progressive, lifelong disease

Slow & stable in the early years

Progressive acceleration in the later years 20-40 year latency from rheumatic fever to

symptom onset

Additional 10 years before disablingsymptoms

Mitral Stenosis


40/43

Complications Atrial dysrrhythmias

Systemic embolization (10-25%)

Congestive heart failure Pulmonary infarcts (result of severe CHF)

Hemoptysis

Endocarditis Pulmonary infections

Mitral Stenosis


41/43

Treatment

Endocarditis prophylaxis

Anticoagulation if concurrent A-Fib or

previous embolic event

Valve repair/replacement

Mitral Stenosis


42/43


43/43

M. a. Sungkar - Diagnosis and Management of Valvular Heart Disesase

Documents

Transcript of M. a. Sungkar - Diagnosis and Management of Valvular Heart Disesase