Valvular Heart Disease (Clinical & Echocardiographic Features)

Presented By:Ahmed Mohamed AdelCardiovascular medicine specialist

Valvular Heart Disease(Clinical & Echocardiographic Features)

Heart ValvesMAINTAIN ONE-WAY BLOOD FLOW THROUGH YOUR HEART

The four heart valves make sure that blood always flows freely in a forward direction and that there is no backward leakage.

Any disease of these valves is called valvular heart disease!

Topics to be covered:Mitral Valve Diseases:Mitral regurgitationMitral StenosisMitral valve prolapseAortic Valve Diseases:Aortic stenosisAortic regurgitationTricuspid Valve Diseases:Tricuspid stenosisTricuspid regurgitation

Pulmonary Valve diseases:

Prosthetic Valves.

Rheumatic Heart Disease.

Infective Endocarditis.

Valvular Heart Disease in Pregnant.

Mitral Regurgitation - EtiologyRheumatic disease is the principal cause (in countries where disease is common)

Mitral valve prolapse

Dilatation of the LV and mitral valve ring (Functional) (e.g. coronary artery disease, cardiomyopathy)

Damage to valve cusps and chordae (e.g. rheumatic heart disease, endocarditis)

Ischaemia or infarction of papillary muscle (MI)Congenital, Iatrogenic.

Mitral Regurgitation pathophysiology

With every Systole blood regurgitates from LV to LA. LA dilates.During Diastole The large amount of blood in the LA flows to LV. So the mean LA EDP and Pulmonary venous pressure don't rise a lot initially.LV dilates dt volume overload. This dilates the MV ring (vicious circle).If MR is severe and prolonged. LV failure occurs. Pulmonary congestion. Pulmonary HTN. RV failure. (less with MR than MS).

PathophysiologyIncomplete closure of mitral valve vol. of blood ejected by left ventricle Left atrial pressureRight-sided heart failureLeft atrial Dilates CO Pulmonary pressureBackflow of blood to the left atrium Right ventricular pressure

Mitral Regurgitation ClinicalSymptoms: appear lateExertional dyspnea & cough pulmonary congestionFatigue & weakness due to CO predominant complaintPalpitations due to increased stroke volume &/or atrial fibrillation.Edema, ascites Right-sided heart failure

SignsAtrial fibrillation CardiomegallySoft S1, apical S3Apical pansystolic murmur thrillSigns of pulmonary venous congestion (crepitations, pulmonary edema, effusions)Signs of pulmonary hypertension & right heart failure

Mitral Regurgitation - InvestigationsECG: p mitrale Chest X-ray (CXR): large heart, calcified mv annulus, pulmonary odemaEchocardiogram: Dimensions (large LA, LV), valve morphology, MR severity grading.Cardiac catheterization: - dilated LA,LV, mitral regurgitation severity, pulmonary hypertension, coexisting coronary artery disease.

Mitral Regurgitation CXR

Mitral Regurgitation Echo

Echocardiographic criteria for the definition of Severe MR: (ESC guidelines 2012):

Mitral Regurgitation Treatment:Medical For patients in whom surgery is contra-indicated or those waiting for surgery.Vasodilators (e.g. ACE inhibitors)Diuretics

If atrial fibrillation presents,Anticoagulant according to CHA2DS2 VASC score.Rate/Rhythm control IE & RF prophylaxis. Surgical Mitral valve repair OR Mitral valve replacement

Date of download: 12/1/2016Copyright The American College of Cardiology. All rights reserved.From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice GuidelinesJ Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536Figure Legend:

Indications for Surgery for MR*Mitral valve repair is preferred over MVR when possible.AF indicates atrial fibrillation; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; ERO, effective regurgitant orifice; HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation, MV, mitral valve; MVR, mitral valve replacement; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; and Rx, therapy.

Mitral Stenosis - EtiologyAlmost always rheumatic in origin

Older people: can be caused by heavy calcification of mitral valve congestion

Congenital (rare, Parachute MV)

Tumers (Myxoma, Carcinoid)

Relative MS

PathophysiologyAtrial fibrillation due to progressive dilatation of the LA is very common.Its onset often precipitates pulmonary oedemaIn contrast, a more gradual rise in left atrial pressure tends to cause an increase in pulmonary vascular resistance pulmo. HTN RVH, TR RHF

PathophysiologyNarrowing of mitral valve COO2/CO2 exchange(fatigue, dyspnea, orthopnea)Left ventricular atrophypulmonary congestion pulmonary pressure left atrial pressureHypertrophy left atrium blood flow to left ventricleRight-sided failure

Fatigue

Mitral Stenosis - SymptomsBreathlessness, cough (pulmonary congestion)Hemoptysis (pulmonary congestion or pulmonary embolism)Fatigue (low cardiac output)Edema, ascites (right heart failure)Palpitation (atrial fibrillation)Thromboembolic complications.

Mitral Stenosis - SignsPulse: Atrial fibrillation, small volumeMitral facies (abnormal flushing of the cheeks that occurs from cutaneous vasodilation)Apex beat: -slapping in character, long diastolic thrill.Auscultation:- Loud first heart sound, opening snap (soften or lost when immobile) - Mid-diastolic murmur (Rumbling, apex)Crepitation, pulmonary edema, effusions (raised pulmonary capillary pressure)RV heave, loud P2 (pulmonary hypertension)

Mitral Stenosis - InvestigationsECG P mitrale, AF, right ventricular hypertrophyCXR:Pulmonary congestion, large LA:mitralization of left border, backward displacement of esophagus, double contourSigns of pulmonary HT and dilated PA.Large Right heart.Echo: thickened immobile cuspsreduced valve areaenlarged LAreduced rate of diastolic filling of LV Doppler: - pressure gradient across mitral valveCardiac Catheterization: rarely needed, if Male aged>40 to exclude CAD, to assess MR.

Mitral Stenosis CXR

Mitral StenosisEchocardiographyGold Standard.2D: mitral valve orifice (1cm1.5cm), thickness, mobility of the cusps, calcification, involvement of subvalvular structures, LAA.Doppler: Pressure gradient.Echocardiographic criteria for the definition of Severe MS: (ESC guidelines 2012):Valve Area < 0.1cm2.Mean Gradient > 10mmhg.

A parasternal long-axis view of a patient with rheumatic aortic and mitral valve stenoses. Note the thickening and reduced mobility of both aortic and mitral valve leaflets.

Mitral Stenosis TreatmentMedically

Anticoagulant (AF)To reduce the risk of systemic embolism

Beta blockers, rate limiting calcium antagonists or DigoxinTo control ventricular rate in atrial fibrillation

DiureticTo control pulmonary congestion

IE prophylaxisSurgically

Mitral balloon valvuloplasty***

Mitral valvotomy

Valve replacement

Date of download: 12/1/2016Copyright The American College of Cardiology. All rights reserved.From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice GuidelinesJ Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536Figure Legend:

Indications for Intervention for Rheumatic MSAF indicates atrial fibrillation; LA, left atrial; MR, mitral regurgitation; MS, mitral stenosis; MVA, mitral valve area; MVR, mitral valve surgery (repair or replacement); NYHA, NewYork Heart Association; PCWP, pulmonary capillary wedge pressure; PMBC, percutaneous mitral balloon commissurotomy; and T , pressure half-time.

Balloon Mitral Valvuloplasty

mitral valve prolapse floppy mitral valve

One of the most common cause of mild mitral regurgitation

Caused by congenital anomalies degenerative myxomatous changesfeature of connective tissue disorders like Marfans syndrome

mitral valve prolapseMildest form:Valve remains competent but bulges back into atrium during systole mid-systolic click but no murmur

In the presence of regurgitant valve:Click is followed by a late systolic murmur, which lengthens as the regurgitation becomes more severe

Severe form:Progressive elongation of chordae tendinae increasing regurgitation Chordal rupture severe regurgitation

Aortic Stenosis - EtiologyINFANTS, CHILDREN, ADOLESCENTSCongenital aortic stenosis, bicuspid aortic valveCongenital supravalvular aortic stenosisCongenital subvalvular aortic stenosis

YOUNG ADULTS TO MIDDLE-AGEDCalcification and fibrosis of congenitally bicuspid aortic valveRheumatic aortic stenosis

MIDDLE-AGED TO ELDERLYSenile degenerative aortic stenosis Calcification of bicuspid valve Rheumatic aortic stenosis

Aortic Stenosis PathophysiologyLVH Cardiac output on exerciseLV dilatation and failure

Aortic Stenosis PathophysiologyStiffening/Narrowing of Aortic ValveIncomplete emptying of left atriumLeft ventricular hypertrophyPulmonary congestionCompression of coronary arteriesRight-sided heart failure CO Myocardial O2 needsMyocardial ischemia(chest pain) O2 supply

Aortic Stenosis ClinicalAsymptomaticAnginaSyncopeHeart FailureSudden Death

Slow rising carotid pulseSigns of Pulmonary venous congestion.LV heave (sustained Apical impulse)Ejection systolic murmur radiating to carotids

Cardinal symptoms (ASH)SymptomsSigns

Aortic Stenosis - InvestigationsECG LVH

CXR: may be normal, enlarged LV & dilated ascending aorta (PA view), calcified valve on lateral view.

Echo: LVH, calcified restricted valve, AS severity by (velocity, peak gradient, mean gradient, estimated AVA).Echocardiographic criteria for the definition of Severe AS: (ESC guidelines 2012):Valve Area (cm2): < 0.1Indexed Valve Area (cm2/m2 BSA): < 0.6Mean Gradient (mmhg): > 40Maximum Jet Velocity (m/s): >4.0Velocity Ratio: