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Valvular Heart Disease. Vincent E. Friedewald, M.D. Classification of Heart Disease. Congenital Coronary Electrical Endomyocardial Pericardial Valvular. The Cardiac Valves. Cardiac Valve Anatomy. Valvular Heart Disease. Acute and Chronic are Different Diseases . Aortic Stenosis.

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valvular heart disease

Valvular Heart Disease

Vincent E. Friedewald, M.D.

classification of heart disease
Classification of Heart Disease

Congenital

Coronary

Electrical

Endomyocardial

Pericardial

Valvular

valvular heart disease5
Valvular Heart Disease

Acute and Chronic

are

Different Diseases

aortic stenosis types

Aortic StenosisTypes

Valvular

Subvalvular

Supravalvular

aortic valve stenosis9
Aortic Valve Stenosis

Bicuspid

Rheumatic

Degenerative

degenerative aortic stenosis14
Degenerative Aortic Stenosis

Risk Factors

Elevated LDL-cholesterol

Diabetes mellitus

Systemic arterial hypertension

Cigarette smoking

aortic valve stenosis symptoms

Aortic Valve StenosisSymptoms

Often Asymptomatic

Angina pectoris

Dyspnea

Fatigue

Syncope

aortic valve stenosis16
Aortic Valve Stenosis

Signs

ARTERIAL PULSE, GEN – RISE, SLOW

ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED

ARTERIAL PULSE, GEN – DOWNSLOPE GRADUAL

ARTERIAL PULSE, GEN – PULSE PRESSURE, NARROW

ARTERIAL PULSE, GEN – SHUDDER

ARTERY, CAROTID – THRILL

HEART, LV APEX – IMPULSE, PRESYSTOLIC

HEART, LSB MID – MURMUR, DIASTOLIC

HEART, LSB MID – MURMUR, SYSTOLIC

aortic valve stenosis signs cont
Aortic Valve StenosisSigns (cont)

HEART, LV APEX – CLICK, SYSTOLIC

HEART, LV APEX – IMPULSE, SUSTAINED

HEART, RSB UPPER – MURMUR, SYSTOLIC

HEART, RSB UPPER – CLICK, SYSTOLIC

HEART, SOUND A2 – ABSENT OR REDUCED

HEART, SOUND S1 – SOFT

HEART, SOUND S2 – SINGLE

HEART, SOUND S2 – SPLIT REVERSED (PARADOXICAL)

NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

aortic valve stenosis symptoms18
Aortic Valve StenosisSymptoms

FATIGUE

BREATHING – DIFFICULT WITH EFFORT (DYSPNEA)

CHEST, ANT – PAIN, NONPLEURITIC (ANGINA PECTORIS)

CHEST, ANT – PALPITATIONS

CONSCIOUSNESS – LOSS, SUDDEN (SYNCOPE)

CONSCIOUSNESS – LOSS, SUDDEN EFFORT (EFFORT SYNCOPE)

DIZZINESS – EFFORT

aortic valve stenosis medical rx
Aortic Valve StenosisMedicalRX

No drugs alter course – only valve repair/replacement

Antibiotic Prophylaxis

? Statins

For symptoms (if not candidate for valve replacement) – after-load reduction, i.e., nitroglycerine, used with caution to avoid BP fall

aortic valve stenosis surgical rx
Aortic Valve StenosisSurgical Rx

Valvotomy

Replacement

Artificial

Bioprosthesis

Minimally-invasive transfemoral

aortic valve stenosis complications
Aortic Valve StenosisComplications

Atrial fibrillation

Aortic Dissection

Heart failure

Infective endocarditis

Myocardial infarction

Sudden death

aortic regurgitation etiologies
Aortic RegurgitationEtiologies

Primary aortic valve disease

Aortic root abnormalities (Dissection, Syphilis)

Connective tissue disorders (Marfan’s)

Infective endocarditis

Inflammatory disorders (SLE)

Tumors

aortic regurgitation symptoms
Aortic RegurgitationSymptoms

BREATHING – DIFFICULT , NOCTURNAL

BREATHING – DIFFICULT WITH EFFORT

CHEST, ANT – PAIN, NONPLEURITIC (ANGINA)

CHEST, ANT – PALPITATIONS

HEAD, GEN – PAIN

SWEATING – NOCTURNAL

aortic regurgitation signs
Aortic RegurgitationSigns

ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW

ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED

ARTERIAL PULSE, GEN – DOUBLE

ARTERIAL PULSE, GEN – FALL, RAPID

ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE

ARTERIAL PULSE, GEN – RISE, RAPID

ARTERY, CAROTID – THRILL

ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING

aortic regurgitation signs cont
Aortic RegurgitationSigns (cont)

HEAD – BOBBING

HEART, LSB MID – MURMUR, DIASTOLIC

HEART, LSB MID – THRILL, DIASTOLIC

HEART, LV APEX – IMPULSE, INF DISPLACEMENT

HEART, LV APEX – IMPULSE, LAT DISPLACEMENT

HEART, LV APEX – IMPULSE, DIFFUSE

HEART, LV APEX – MURMUR, DIASTOLIC

HEART, RSB UPPER – MURMUR , SYSTOLIC

HEART, RSB UPPER – MURMUR, DIASTOLIC

aortic regurgitation signs cont33
Aortic Regurgitation Signs (cont)

HEART, RSB UPPER – THRILL, SYSTOLIC

HEART, SOUND A2 – ABSENT OR REDUCED

HEART, SOUND S1 – SOFT

HEART, SOUND S2 – SPLIT REVERSED

HEART, SOUND S3 LV

MOUTH, UVULA – PULSATIONS

NAILS – PULSATIONS

NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

aortic regurgitation
Aortic Regurgitation

Medical Rx

Vasodilators to reduce systolic BP

Antibiotic prophylaxis

aortic regurgitation surgical rx
Aortic Regurgitation Surgical Rx

Aortic valve replacement

mitral regurgitation etiologies
Mitral RegurgitationEtiologies

Congenital deformities

Degenerative, i.e., myxomatous

Endomyocardial fibroelastosis

Mitral annular calcification

Papillary muscle dysfunction – ischemic heart disease

Rheumatic

mitral regurgitation etiologies cont
Mitral RegurgitationEtiologies (cont)

Ergotamine toxicity

Carcinoid syndrome

Radiation Rx

SLE

Diet-drug therapy

mitral regurgitation symptoms
Mitral Regurgitation Symptoms

BREATHING – DIFF, EFFORT

FATIGUE

SKIN, GEN – TEMPERATURE, COOL

SWEATING – EXCESSIVE

mitral regurgitation signs
Mitral RegurgitationSigns

ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED

ARTERIAL PULSE, GEN - FALL, RAPID

ARTERIAL PULSE, GEN - RISE, RAPID

CHEST, ANT LEFT - BULGE

HEART, LV APEX - IMPULSE, FORCEFUL

HEART, LV APEX - IMPULSE, DIFFUSE

mitral regurgitation signs cont
Mitral RegurgitationSigns (cont)

HEART, LV APEX - IMPULSE, SUSTAINED

HEART, LV APEX - MURMUR, DIASTOLIC

HEART, LV APEX - MURMUR, SYSTOLIC

HEART, SOUND P2 - LOUD

HEART, SOUND S3 LV

SKIN, GEN - TEMPERATURE, COOL

mitral regurgitation complications
Mitral RegurgitationComplications

Atrial fibrillation

Pulmonary hypertension

LV dysfunction

Infective endocarditis

mitral regurgitation medical rx
Mitral RegurgitationMedical Rx

Antibiotic prophylaxis

ACEIs (functional form of MR)

Beta-blockers (functional form of MR)

mitral regurgitation surgical rx
Mitral RegurgitationSurgical Rx

Mitral repair

Mitral valve replacement

mitral stenosis etiologies
Mitral StenosisEtiologies

Rheumatic

Rare:

Congenital

Chest radiation

Left atrialmyxoma

Mucopolysaccharidosis

Severe mitral annular calcification

mitral stenosis symptoms
Mitral StenosisSymptoms

ABDOMEN, GEN – PAIN

BREATHING – DIFF, NOCTURNAL

BREATHING – DIFF, EFFORT

BREATHING – DIFF, RECLINING FLAT

BREATHING – DIFF, RESTING

BREATHING – RAPID

CHEST, ANT – PAIN, NONPLEURITIC

CHEST, ANT – PALPITATIONS

COUGH – CHRONIC, NONSPECIFIC

FATIGUE

SPUTUM – BLOODY

mitral stenosis signs
Mitral StenosisSigns

ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW

ARTERIAL PRESSURE, GEN – LOW

ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW

ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED

BREATH SOUNDS, GEN – WHEEZES

EXTREMITIES, LOWER BILATERAL - EDEMA

HEART RATE – RAPID

HEART, LSB LOWER – IMPULSE, SYSTOLIC

mitral stenosis signs cont
Mitral StenosisSigns (cont)

HEART, LSB LOWER – MURMUR, DIASTOLIC

HEART, LSB MID – PERCUSSION, DULLNESS

HEART, LV APEX – MURMUR, DIASTOLIC

HEART, LV APEX – OPENING SNAP, MITRAL

HEART, LV APEX – THRILL, DIASTOLIC

HEART, RSB – SOUND, SYSTOLIC EJECTION

HEART, RSB UPPER – MURMUR, DIASTOLIC

HEART, SOUND P2 – LOUD

mitral stenosis signs cont58
Mitral StenosisSigns (cont)

HEART, SOUND P2 – PALPABLE

HEART, SOUND S1 – SOFT

HEART, SOUND S1 – LOUD

LIVER – ENLARGED

SKIN, CHEEKS – COLOR, PINK PURPLE

SKIN, GEN – COLOR, BLUE

VENOUS PULSE, JUGULAR - A WAVE, LARGE

VENOUS PULSE, JUGULAR – ELEVATED

mitral stenosis complications
Mitral Stenosis Complications

Atrial fibrillation

Infective Endocarditis

Peripheral embolism

Pulmonary hypertension

mitral stenosis medical rx
Mitral StenosisMedical RX

Antibiotic prophylaxis

Anticoagulation for

Atrial fibrillation

Prior embolic event

Documented LA thrombus

Arrhythmia control

mitral stenosis surgical rx
Mitral StenosisSurgicalRX

Invasive valvuloplastyPercutaneous valvotomy

Valve replacement

valvular heart disease follow up
Valvular Heart DiseaseFollow up

Antibiotic prophylaxis

New symptoms

Change in symptoms

Change in physical findings

Echocardiography/other imaging