Valvular Heart DiseaseValvular Heart Disease

J.B. Handler, M.D.J.B. Handler, M.D.

Physician Assistant Program Physician Assistant Program

University of New EnglandUniversity of New England

AbbreviationsAbbreviations VHD- valvular heart diseaseVHD- valvular heart disease RF- rheumatic feverRF- rheumatic fever MR- mitral regurgitationMR- mitral regurgitation AR- aortic regurgitationAR- aortic regurgitation HF- congestive heart failureHF- congestive heart failure MS- mitral stenosisMS- mitral stenosis LAP- left atrial pressureLAP- left atrial pressure PuVR- pulmonary vascular resistancePuVR- pulmonary vascular resistance RV- right ventricleRV- right ventricle CO- cardiac outputCO- cardiac output TR- tricuspid regurgitationTR- tricuspid regurgitation PI- pulmonic insufficiencyPI- pulmonic insufficiency NSST-T- non specific ST-TNSST-T- non specific ST-T PAH- pulmonary artery hypertensionPAH- pulmonary artery hypertension SV- stroke volumeSV- stroke volume

RVH- right ventricular hypertrophyRVH- right ventricular hypertrophy AoV- aortic valveAoV- aortic valve MVA- mitral valve areaMVA- mitral valve area PSVT- paroxysmal supraventricular PSVT- paroxysmal supraventricular

tachycardiatachycardia MVR- mitral valve replacementMVR- mitral valve replacement MVP- mitral valve prolapseMVP- mitral valve prolapse AS- aortic stenosisAS- aortic stenosis SEM- systolic ejection murmurSEM- systolic ejection murmur LVEDP- left ventricular end diastolic LVEDP- left ventricular end diastolic

pressurepressure PND- paroxysmal nocturnal dyspneaPND- paroxysmal nocturnal dyspnea LSB- left sternal borderLSB- left sternal border ACE- angiotensin converting enzymeACE- angiotensin converting enzyme BE- bacterial endocarditisBE- bacterial endocarditis RF- rheumatic feverRF- rheumatic fever

Etiologies of VHDEtiologies of VHD

Rheumatic valve diseaseRheumatic valve disease Congenital, including bicuspid aortic valve.Congenital, including bicuspid aortic valve. Coronary heart disease: MI, papillary musclesCoronary heart disease: MI, papillary muscles Dilation of the aorta: Aortic root diseaseDilation of the aorta: Aortic root disease Chronic “wear and tear”: aortic sclerosis/stenosisChronic “wear and tear”: aortic sclerosis/stenosis Dilation of the LV- from any cause: MRDilation of the LV- from any cause: MR Endocarditis Endocarditis MV prolapseMV prolapse Others Others

Acute Rheumatic Fever: IOAcute Rheumatic Fever: IO

2/3 all cases - developing countries2/3 all cases - developing countries Episodes of RF are quite uncommon in U.S., except in Episodes of RF are quite uncommon in U.S., except in

immigrants.immigrants. Epidemiology - Identical to that of Group A Epidemiology - Identical to that of Group A

Streptococcus; children 5-15Streptococcus; children 5-15 Pathogenesis- Pathogenesis- oropharyngeal infectionoropharyngeal infection; RF follows ; RF follows

the sore throat; usually within 2-3 wks.the sore throat; usually within 2-3 wks. Mechanism - systemic immune process involving Mechanism - systemic immune process involving

Group A strep. antigens; abnormal immune response. Group A strep. antigens; abnormal immune response. Preventable with adequate Rx of streptococcal Preventable with adequate Rx of streptococcal pharyngitis.pharyngitis.

IO – Interest Only

Diagnosis - Jones CriterionDiagnosis - Jones Criterion

Carditis - Pancarditis involving Carditis - Pancarditis involving valvesvalves, , endocardium, myocardium and pericardiumendocardium, myocardium and pericardium– Healing of Rheumatic valvulitisHealing of Rheumatic valvulitis - fibrous thickening - fibrous thickening

resulting in valvular stenosis or insufficiencyresulting in valvular stenosis or insufficiency

Migratory polyarthritisMigratory polyarthritis Sydenham’s ChoreaSydenham’s Chorea Subcutaneous nodulesSubcutaneous nodules Erythema marginatumErythema marginatum

TreatmentTreatment

Antistreptoccal Rx until regimen finished; Antistreptoccal Rx until regimen finished; Penicillin IM or oral (10 day course)Penicillin IM or oral (10 day course)Erythromycin and others are alternativesErythromycin and others are alternatives

Arthritis/fever - SalicylatesArthritis/fever - Salicylates Severe carditis- GlucocorticoidsSevere carditis- Glucocorticoids HF, MR, AI - specific Rx.HF, MR, AI - specific Rx. Secondary prophylaxis to prevent Secondary prophylaxis to prevent

recurrences- PCN or alternative until adult.recurrences- PCN or alternative until adult.

Cardiac PressuresCardiac Pressures

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Mitral Regurgitation-EtiologyMitral Regurgitation-Etiology

Chronic Rheumatic heart disease- Chronic Rheumatic heart disease- ing ing frequency frequency

LV dilatation from any causeLV dilatation from any cause Coronary Heart Disease: Papillary muscle Coronary Heart Disease: Papillary muscle

dysfunction with ischemia/infarctiondysfunction with ischemia/infarction Mitral Valve ProlapseMitral Valve Prolapse Infective endocarditisInfective endocarditis

Mitral RegurgitationMitral Regurgitation

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Pathophysiology of MRPathophysiology of MR Blood regurgitates from LV into LABlood regurgitates from LV into LA. . LV LV volumevolume increases progressively as severity of MR increases progressively as severity of MR

increases.increases.– Increased blood return to LA: pulmonary veins + regurgitant Increased blood return to LA: pulmonary veins + regurgitant

volume from previous beat.volume from previous beat. LV function- well preserved initially; often deteriorates in LV function- well preserved initially; often deteriorates in

later stages as does cardiac output (CO). LV compensates later stages as does cardiac output (CO). LV compensates for volume overload via the for volume overload via the Starling mechanismStarling mechanism. .

Left atrium (and LV) dilates over time - Left atrium (and LV) dilates over time - LAPLAP and LVEDP and LVEDP gradually risegradually risepulmonary congestionpulmonary congestion– Afib. commonAfib. common..

SymptomsSymptoms

Often asymptomatic for yearsOften asymptomatic for years Fatigue, DOE, orthopnea- symptoms of Fatigue, DOE, orthopnea- symptoms of left sided left sided

heart failureheart failure (detailed discussion later in CV (detailed discussion later in CV system).system).

With chronic severe MR –Elevation of pulmonary With chronic severe MR –Elevation of pulmonary venous pressure leads to venous pressure leads to PuVR PuVR PAH and PAH and subsequent Rt Heart failure: hepatic congestion, subsequent Rt Heart failure: hepatic congestion, peripheral edema, etc.peripheral edema, etc.

Physical ExamPhysical Exam

Palpation: Systolic thrill may be present at Palpation: Systolic thrill may be present at apex depending on turbulence. apex depending on turbulence.

Auscultation: SAuscultation: S11 soft or absent; soft or absent; SS33 gallop gallop if if

significant MR; significant MR; Systolic MurmurSystolic Murmur is is hallmark - Gr. II-IV/VI hallmark - Gr. II-IV/VI holosystolicholosystolic in most in most cases -radiates to axilla (exception is MVP); cases -radiates to axilla (exception is MVP); murmur is murmur is high pitchedhigh pitched and and blowingblowing..

Additional FindingsAdditional Findings

ECG: LAE; Atrial arrhythmias (Afib).ECG: LAE; Atrial arrhythmias (Afib). Echo/DopplerEcho/Doppler: LA & LV size; LV : LA & LV size; LV

function. Can estimate severity of MR; function. Can estimate severity of MR; LV often dilates with progressive MR.LV often dilates with progressive MR.

CxR: Late findings - Progressive LVE; HF; CxR: Late findings - Progressive LVE; HF; pulmonary edema.pulmonary edema.

LVE- left ventricular enlargement CxR- chest x-ray

Treatment of MRTreatment of MR

Medical - Treatment Medical - Treatment depends on severitydepends on severity..Once symptomatic: Decreased physical activity Once symptomatic: Decreased physical activity and Na restriction. Drug therapy often and Na restriction. Drug therapy often significantly improves symptoms and patients may significantly improves symptoms and patients may do well for many years. do well for many years. – ACE inhibitorsACE inhibitors or other vasodilators: or other vasodilators: decrease decrease

afterloadafterload and preload. and preload.

– Diuretics: decrease preload, Na and volume overloadDiuretics: decrease preload, Na and volume overload

– Inotropic agents: digoxin- limited roleInotropic agents: digoxin- limited role

Treatment of MRTreatment of MR Surgical- Indications: Surgical- Indications:

– Severe MR with SxSevere MR with Sx

– Dilating LV with progressive dysfunction Dilating LV with progressive dysfunction EF (even EF (even with mild symptoms). with mild symptoms).

– Timing of surgery is important; needs to be done before Timing of surgery is important; needs to be done before significant deterioration of LV function/EF.significant deterioration of LV function/EF.

Surgical result dependent on pre-existing LV Surgical result dependent on pre-existing LV function. Mitral valve repair is preferred to MV function. Mitral valve repair is preferred to MV replacement. replacement.

Mitral Valve ProlapseMitral Valve Prolapse

Very common (3-5% adults) - Excessive redundant Very common (3-5% adults) - Excessive redundant MV tissue from abnormal connective tissue:MV tissue from abnormal connective tissue:– MVP MVP - most common form involves MV without major - most common form involves MV without major

connective tissue disease elsewhere in body. Familial form connective tissue disease elsewhere in body. Familial form also exists- autosomal dominant.also exists- autosomal dominant.

– MVP as part of major CT disease (Marfan’s, Ehler’s-MVP as part of major CT disease (Marfan’s, Ehler’s-Danlos) or variations; these disorders are uncommon.Danlos) or variations; these disorders are uncommon.

Pathology- myxomatous degeneration of MV leaflet Pathology- myxomatous degeneration of MV leaflet tissue. tissue.

Associated deformities: high arched palate; pectus Associated deformities: high arched palate; pectus excavatum.excavatum.

Mitral Valve ProlapseMitral Valve Prolapse

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MVP: PathologyMVP: Pathology

Mitral regurgitation can develop due to redundant Mitral regurgitation can develop due to redundant floppy valve leaflets and/or involvement of the floppy valve leaflets and/or involvement of the MV supporting structures – chordae tendineae.MV supporting structures – chordae tendineae.

Stress on Papillary muscles or chordae is Stress on Papillary muscles or chordae is presumed reason for localized and atypical presumed reason for localized and atypical chest chest painpain..

Abnormal valve structure and MR can predispose Abnormal valve structure and MR can predispose to infective endocarditisto infective endocarditis but incidence is very but incidence is very lowlow antibiotic prophylaxis no longer indicated. antibiotic prophylaxis no longer indicated.

Clinical FeaturesClinical Features

Female > male; Sx, when present, commonly Female > male; Sx, when present, commonly occur at ages 15-30.occur at ages 15-30.

Most are asymptomaticMost are asymptomatic; often detected on PE- ; often detected on PE- characteristic murmur.characteristic murmur.

Most common symptoms when present: Most common symptoms when present: chest chest pain pain (*atypical)(*atypical) and palpitations. and palpitations.

Arrhythmias common: PAC’s, PVC’s, PSVT, Arrhythmias common: PAC’s, PVC’s, PSVT, non-sustained VTach.non-sustained VTach.

Sudden death – exceedingly rareSudden death – exceedingly rare arrhythmias arrhythmias

*Atypical – CP unlike the pain/discomfort that is present with coronary heart disease

Physical FindingsPhysical Findings

Auscultation: Auscultation: Mid to late systolic clickMid to late systolic click (tensing (tensing of chordal structures).of chordal structures).

High pitched late systolic murmurHigh pitched late systolic murmur best heard at best heard at apex.- click and murmur occur earlier and get apex.- click and murmur occur earlier and get louder with maneuvers thatlouder with maneuvers that decrease LV decrease LV volumevolume: standing after squatting, valsalva. : standing after squatting, valsalva. Maneuvers that increase LV volume delay the Maneuvers that increase LV volume delay the click and soften the murmur: isometric hand grip, click and soften the murmur: isometric hand grip, squatting. squatting.

Additional Findings/TreatmentAdditional Findings/Treatment ECG: NST-TW changes. Usually in leads II, III, ECG: NST-TW changes. Usually in leads II, III,

aVF.aVF. Echo/Doppler: DiagnosticEcho/Doppler: Diagnostic; shows MVP and ; shows MVP and

identifies MR when present.identifies MR when present. Treatment: Treatment: ReassuranceReassurance; ; ß-ß-Blockers for chest Blockers for chest

pain or arrhythmias; additional anti-arrhythmics pain or arrhythmias; additional anti-arrhythmics usually not necessary.usually not necessary.

Infrequently, severe MR develops requiring MV Infrequently, severe MR develops requiring MV repair (more common in men than women).repair (more common in men than women).

Mitral StenosisMitral Stenosis

2/3 females, 1/3 males- only cause is RF.2/3 females, 1/3 males- only cause is RF. About 40% of all cases of RF develop MS.About 40% of all cases of RF develop MS. Valve leaflets thicken and calcify, Valve leaflets thicken and calcify,

commisures fuse; valve orifice narrows; commisures fuse; valve orifice narrows; subvalvular supporting apparatus involved.subvalvular supporting apparatus involved.

Least common rheumatic valvular lesion.Least common rheumatic valvular lesion.

Mitral StenosisMitral Stenosis

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PathophysiologyPathophysiology Normal MVA - 4-6 cmNormal MVA - 4-6 cm22. Valve leaflets fuse, . Valve leaflets fuse,

decreasing valve area. Severe MS < 1 cmdecreasing valve area. Severe MS < 1 cm22.. LA pressure rises in order to propel blood across LA pressure rises in order to propel blood across

the stenotic valve- pressure gradient compared to the stenotic valve- pressure gradient compared to LVEDP. LVEDP.

LAP reflected backwards into the pulmonary LAP reflected backwards into the pulmonary circulation results in pulmonary venous circulation results in pulmonary venous congestioncongestionpulm capillary congestion pulm capillary congestion interstitial fluid interstitial fluid dyspnea. Pulmonary dyspnea. Pulmonary arterioles subsequently constrict. arterioles subsequently constrict.

LV function usually normal. LVEDP normal.LV function usually normal. LVEDP normal. Chronic severe MS - Elevation of pulmonary vascular resistance (PVR) Chronic severe MS - Elevation of pulmonary vascular resistance (PVR)

and subsequent development of and subsequent development of Pulmonary Artery Hypertension (PAH)Pulmonary Artery Hypertension (PAH).. Chronic PAH Chronic PAH RVHRVH RV dysfunction and failure. RV dysfunction and failure. CO at rest- usually normal but does not rise adequately with exercise. With CO at rest- usually normal but does not rise adequately with exercise. With

severe MS and PAH, CO eventually falls.severe MS and PAH, CO eventually falls.

Symptoms/ComplicationsSymptoms/Complications

DOE, orthopnea, PNDDOE, orthopnea, PND pulmonary edema pulmonary edema Findings of Rt Ht failure - lateFindings of Rt Ht failure - late Atrial arrhythmias: PAC’s, Atrial arrhythmias: PAC’s, Atrial Atrial

FibrillationFibrillation and Flutter and Flutter Hemoptysis Hemoptysis ruptured pulmonary ruptured pulmonary

capillariescapillaries Atrial Thrombi and embolization - (AFib)Atrial Thrombi and embolization - (AFib)

Physical ExamPhysical Exam

Palpation: prominent RV impulse Palpation: prominent RV impulse Auscultation: SAuscultation: S11 loud/accentuated; S loud/accentuated; S22 loud if loud if

PAH present PAH present Opening SnapOpening Snap of MV-apex, follows S of MV-apex, follows S22..

Diastolic RumbleDiastolic Rumble- Follows OS; - Follows OS; low low pitchedpitched/apex; length correlates with /apex; length correlates with severity; MR murmur often audible.severity; MR murmur often audible.

Additional FindingsAdditional Findings

ECG: LAE/LAA; RAD, RVH (over time)ECG: LAE/LAA; RAD, RVH (over time) Echo/DopplerEcho/Doppler: diagnostic-shows abnormal : diagnostic-shows abnormal

valve motion, estimates the gradient and valve motion, estimates the gradient and MVA, defines LA size and LV function.MVA, defines LA size and LV function.

CxR: Pulmonary congestion; RVE.CxR: Pulmonary congestion; RVE. Cardiac Cath: Documents gradient, MVA, Cardiac Cath: Documents gradient, MVA,

presence or absence of MR and more.presence or absence of MR and more.

MS - TreatmentMS - Treatment

Sodium restriction, diuretics.Sodium restriction, diuretics. Rate control of Afib or cardioversion.Rate control of Afib or cardioversion. Surgery -Mitral valvulotomy - marked Surgery -Mitral valvulotomy - marked

symptomatic improvement. MVR only when symptomatic improvement. MVR only when repair cannot be done (mortality 3-5 %).repair cannot be done (mortality 3-5 %).

Percutaneous balloon valvuloplasty- alternative to Percutaneous balloon valvuloplasty- alternative to surgery; if successful, avoids or delays need for surgery; if successful, avoids or delays need for surgery.surgery.

Aortic Stenosis-EtiologiesAortic Stenosis-Etiologies

Common: 20% all valvular disease; 80% malesCommon: 20% all valvular disease; 80% males Bicuspid valve Bicuspid valve leaflets thicken, fuseleaflets thicken, fuse

Rheumatic valvulitisRheumatic valvulitis leaflets thicken, fuse leaflets thicken, fuseIdiopathicIdiopathic – Sclerocalcific: chronic wear and tear- – Sclerocalcific: chronic wear and tear- develops in the elderly develops in the elderly leaflets thicken, fuseleaflets thicken, fuse

NoteNote: Thickening/calcification (without fusing) of the : Thickening/calcification (without fusing) of the AoV often occurs with aging (AoV often occurs with aging (Aortic SclerosisAortic Sclerosis) ) without progressing to significant aortic stenosiswithout progressing to significant aortic stenosis Gr II/IIIGr II/III murmur.murmur. Important to differentiate using Important to differentiate using history (asymptomatic), history (asymptomatic), PEPE and and echocardiogramechocardiogram if if needed.needed.

Aortic StenosisAortic Stenosis

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PathophysiologyPathophysiology

Obstruction to LV outflow- Obstruction to LV outflow- pressure overloadpressure overload.. Systolic gradient between LV and Ao.Systolic gradient between LV and Ao. Obstruction gradual - initially well tolerated; Obstruction gradual - initially well tolerated; LV LV

hypertrophyhypertrophy is compensatory. is compensatory. Cardiac Output often normal at rest - does not Cardiac Output often normal at rest - does not

adequately rise with activity.adequately rise with activity. Late in course- LV failure, LVEDP rises, CO falls.Late in course- LV failure, LVEDP rises, CO falls.

Myocardial oxygen consumption (MVOMyocardial oxygen consumption (MVO22) increases ) increases from LVH and high LV pressures.from LVH and high LV pressures.

Coronary blood flow is impaired from high LV Coronary blood flow is impaired from high LV pressures.pressures.

Myocardial ischemia can occur in the absence of Myocardial ischemia can occur in the absence of *CHD*CHD severe LVH/ high pressures severe LVH/ high pressures outstrips outstrips coronary blood flowcoronary blood flow– Associated CHD may be present.Associated CHD may be present.

Normal AoV area: 2.5-3.0 cmNormal AoV area: 2.5-3.0 cm22

Critical AS: valve area <0.75 cmCritical AS: valve area <0.75 cm22

*CHD- coronary heart disease

AS HemodynamicsAS Hemodynamics

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Symptoms of ASSymptoms of AS

Exertional dyspnea - elevation of LVEDP Exertional dyspnea - elevation of LVEDP transmitted backward into pulmonary circuit.transmitted backward into pulmonary circuit.

Angina Pectoris-Increased MVOAngina Pectoris-Increased MVO22 (pressure (pressure overload and hypertrophy) and decreased coronary overload and hypertrophy) and decreased coronary reserve. *CHD may co-exist but does not have to reserve. *CHD may co-exist but does not have to be present for angina to develop. be present for angina to develop.

Syncope - Peripheral vasodilation with inadequate Syncope - Peripheral vasodilation with inadequate forward CO with activity or from arrhythmia.forward CO with activity or from arrhythmia.

HF occurs late - very poor prognosis. HF occurs late - very poor prognosis.

CHD – coronary heart disease

Physical ExamPhysical Exam Carotid pulse rises slowly; sustained peak.Carotid pulse rises slowly; sustained peak. Apex displaced laterally; +/- systolic thrill; systolic Apex displaced laterally; +/- systolic thrill; systolic

ejection sound (click ) variable.ejection sound (click ) variable. Aortic valve closure is delayed - fixed or Aortic valve closure is delayed - fixed or

paradoxical splitting of Sparadoxical splitting of S22.. SS4 4 gallopgallop common. common. Murmur - Murmur - SEM (crescendo-decrescendoSEM (crescendo-decrescendo)- peaks in )- peaks in

mid to late systole depending on severity; mid to late systole depending on severity; harsh, harsh, low pitchedlow pitched, best heard at base and radiates to , best heard at base and radiates to carotids – Grade II-IV/VI.carotids – Grade II-IV/VI.

Additional FindingsAdditional Findings

ECG: ECG: LVH commonLVH common; LAA.; LAA. Echo/DopplerEcho/Doppler: Diagnostic- identifies LVH, : Diagnostic- identifies LVH,

valve calcification and restriction; estimates valve calcification and restriction; estimates gradient and aortic valve area.gradient and aortic valve area.

CxR: LV prominence, displaced apex.CxR: LV prominence, displaced apex. Cardiac Cath: Usually necessary prior to Cardiac Cath: Usually necessary prior to

surgery; identifies gradient, valve area, LV surgery; identifies gradient, valve area, LV function and function and presence or absence of CADpresence or absence of CAD..

Natural History: UntreatedNatural History: Untreated

Angina Pectoris -death within 3 yearsAngina Pectoris -death within 3 years Syncope - death within 3 yearsSyncope - death within 3 years Dyspnea - death within 2 yearsDyspnea - death within 2 years CHF - death within 1.5 yearsCHF - death within 1.5 years

TreatmentTreatment Medical - Mild to moderate AS without Medical - Mild to moderate AS without

symptoms: Careful F/U; serial echo/doppler symptoms: Careful F/U; serial echo/doppler studies. studies. Limited role for medsLimited role for meds once symptoms once symptoms begin.begin.

Surgical-Surgical- severe or symptomatic AS. Valve severe or symptomatic AS. Valve replacement with tissue or mechanical valve - Op replacement with tissue or mechanical valve - Op risk 4%; 60-70% 10 yr. survival; marked risk 4%; 60-70% 10 yr. survival; marked symptomatic improvement.symptomatic improvement.– Ross procedure an option for young patients with AS.Ross procedure an option for young patients with AS.

Ballon valvuloplasty- palliativeBallon valvuloplasty- palliative

Aortic Regurgitation- EtiologyAortic Regurgitation- Etiology

75% male75% male Rheumatic Heart Disease Rheumatic Heart Disease Infective endocarditis on previously Infective endocarditis on previously

deformed valvedeformed valve Aortic Root disease and dilatationAortic Root disease and dilatation Bicuspic Aortic Valve (AS more common Bicuspic Aortic Valve (AS more common

than AR)than AR)

Aortic RegurgitationAortic Regurgitation

AR: PathophysiologyAR: Pathophysiology

Increase in LVEDV (preload): blood Increase in LVEDV (preload): blood returning from LA + regurgitant blood.returning from LA + regurgitant blood.

LV dilates- allows increased SV (stroke LV dilates- allows increased SV (stroke volume) and adequate effective forward SV volume) and adequate effective forward SV (Starling’s law).(Starling’s law).

Over time (years) LV function gradually Over time (years) LV function gradually declines and EF (ejection fraction) declines and EF (ejection fraction) deteriorates.deteriorates.

PathophysiologyPathophysiology

LV deterioration often precedes symptoms LV deterioration often precedes symptoms (reason for serial echo/doppler exams).(reason for serial echo/doppler exams).

As AR progresses, CO fails to rise As AR progresses, CO fails to rise adequately with exercise, LV dysfunction adequately with exercise, LV dysfunction worsens worsens Increased LVEDP Increased LVEDP pulmonary pulmonary congestioncongestion HF. HF.

AR: HistoryAR: History

Sometimes familial - Connective tissue Sometimes familial - Connective tissue disease.disease.

History of RF or infective endocarditis.History of RF or infective endocarditis. Patient often asymptomatic for 10-15 yrs. Patient often asymptomatic for 10-15 yrs.

with significant AI.with significant AI. Symptoms: Palpitations, exertional dyspnea, Symptoms: Palpitations, exertional dyspnea,

orthopnea; PND and HF occur later. orthopnea; PND and HF occur later. Atypical chest pain common.Atypical chest pain common.

AR: Physical Exam AR: Physical Exam Arterial Pulse - Rapid rising “water-hammer Arterial Pulse - Rapid rising “water-hammer

pulse” and collapsing pulse.pulse” and collapsing pulse.“Quinke’s pulse” - alternate flushing and palling “Quinke’s pulse” - alternate flushing and palling of the skin at the nail root.of the skin at the nail root.

““Pistol shot” sound over femoral artery in systole.Pistol shot” sound over femoral artery in systole. Derosiez’ sign - to and fro murmur over femoral Derosiez’ sign - to and fro murmur over femoral

artery.artery. Arterial pulse pressure widenedArterial pulse pressure widened- elevated - elevated

systolic pressure (often greater than 200mm) and systolic pressure (often greater than 200mm) and lowered diastolic pressure.lowered diastolic pressure.

Physical ExamPhysical Exam

Palpation - apex displaced laterally/inferiorly.Palpation - apex displaced laterally/inferiorly. Diastolic Thrill may be present along LSB.Diastolic Thrill may be present along LSB. Auscultation: S2 soft; Auscultation: S2 soft; S3 common;S3 common; high pitched high pitched

blowing diastolic decreshendo murmur (LSB).blowing diastolic decreshendo murmur (LSB). Best heard with diaphragm – patient sitting Best heard with diaphragm – patient sitting

upright/leaning forward.upright/leaning forward. Systolic ejection (increased flow across AoV) Systolic ejection (increased flow across AoV)

murmur.murmur.

Additional FindingsAdditional Findings

ECG - Increased voltage/LVH develops over time. ECG - Increased voltage/LVH develops over time.

Echo/DopplerEcho/Doppler: early on LV contractility normal : early on LV contractility normal or increased - later, LV dysfunction; AI jet or increased - later, LV dysfunction; AI jet detectable and semi quantitated by Doppler.detectable and semi quantitated by Doppler.

Cardiac Cath: Identifies severity of AI, degree of Cardiac Cath: Identifies severity of AI, degree of LV dysfunction and intra-cardiac pressures. LV dysfunction and intra-cardiac pressures. Needed to assess coronary arteries in older adults. Needed to assess coronary arteries in older adults. Cath may not be needed in younger patientsCath may not be needed in younger patients..

Treatment of ARTreatment of AR Medical - very close follow-up; serial Echo/Doppler Medical - very close follow-up; serial Echo/Doppler

studies. studies. Same Rx as for CHF: Same Rx as for CHF: Afterload reduction with Afterload reduction with vasodilators (ACEIvasodilators (ACEI, hydralazine). Preload , hydralazine). Preload reduction with diuretics; digoxin may be useful in reduction with diuretics; digoxin may be useful in selected individuals.selected individuals.

Surgical - Timing of surgery is difficult as pts. with Surgical - Timing of surgery is difficult as pts. with AI do not develop symptoms until after the AI do not develop symptoms until after the development of LV dysfunction.development of LV dysfunction.Surgery indicated for progressive LV dilatation and Surgery indicated for progressive LV dilatation and dysfunction +/- symptoms. dysfunction +/- symptoms.

SurgerySurgery

Aortic Valve Replacement with Aortic Valve Replacement with bioprosthesis (tissue valve) or mechanical bioprosthesis (tissue valve) or mechanical valve. Ross procedure an option if young.valve. Ross procedure an option if young.

Op mortality dependent on pre-op LV Op mortality dependent on pre-op LV function (5% or greater mortality).function (5% or greater mortality).