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Valvular Heart Disease

Valvular Heart Disease. Jay L. Rubenstone, D.O., F.A.C.C. Normal Structure Mitral Valve. Cross sectional Area 4-6cm ² Anterior and Posterior Leaflets Chordae Tendineae  Papillary Muscles. Mitral Stenosis Etiology & Pathology. Rheumatic Fever- 99% Other Congenital Carcinoid Lupus

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Valvular Heart Disease

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  1. Valvular Heart Disease Jay L. Rubenstone, D.O., F.A.C.C

  2. Normal StructureMitral Valve • Cross sectional Area 4-6cm² • Anterior and Posterior Leaflets • Chordae Tendineae  Papillary Muscles

  3. Mitral StenosisEtiology & Pathology • Rheumatic Fever- 99% • Other • Congenital • Carcinoid • Lupus • Amyloid • Infective Endocarditis • Mucopolysaccharide Disease

  4. Stenotic Pathology • Etiology & Pathology • Commissural 30% • Cuspal 15% • Chordal 10% • Mixed Remaining • Valve becomes funnel shaped or “fish mouthed” • Thickened immobile leaflets or chordal structures

  5. Stenotic Pathology • Debate: • Smoldering rheumatic process or • Constant blood flow trauma leading to valve fibrosis and thickening

  6. Pathophysiology • Mild MS- orifice <2 cm² • Critical MS- <1 cm² • A-V pressure gradient >20mmHg • Increased LA Pressure • Increase Pulmonary Venous + Capillary Pressures • Increase Pulmonary Artery Systolic Pressure • Decrease RV Function (when PAS>30-60mmHg)

  7. Pathophysiology • Pulmonary HTN • Passive Backward Transmission Of Incr. LA pressure Pulmonary Arteriolar Constriction Organic Obliterative Changes in Pulmonary Vascular Bed RV Failure

  8. History • Exertional Dyspnea • Cough/Wheezing • Orthopnea/PND/CHF • Hemoptysis-Rupture of Pulmonary Vein-Bronchial Vein Shunts

  9. History • Chest Pain-Increase RV Pressures or Unknown Etiology • Systemic Emboli (LA clots) • Increased LA size, Decreased C.O., Atrial Fib, IE • Significantly decreased w/anticoagulation

  10. Physical Exam • Auscultation • O.S. • Diastolic Rumble • Assoc Murmur of MR • Loud S1-thickened leaflets • Increased P2-pulmonary hypertension • Decreased B/P if C.O. decreased • Prominent a wave if sinus rhythm present

  11. Physical Exam • Mitral Facies-pink, purple facial patches due to decrease CO and systemic vasoconstriction • Hepatomegally • Edema • Ascites • Hydrothorax With Right Heart Failure

  12. Diagnosis • ECG • Left Atrial Abnormality • P wave becomes bifid and greater than 0.12 sec in duration in V1 and Lead II • RVH- right axis deviation • R wave > S wave in V1

  13. Diagnosis • Chest X-ray • Dilated LA, RA, RV • Elevated Left Main stem Bronchus • Interstitial Edema • Echo- Cornerstone of Diagnosis • Thickened Calcified Leaflets • Doming of Leaflets on Opening • Bernoulli equation

  14. Diagnosis • Cardiac Catherization • Gorlin Equation

  15. Natural History • Asymptomatic for 15-20yrs following Rheumatic Fever • Additional 5-10 yrs for progression from mild to severe stenosis • Stenosis progression approximately .09 cm²/yr

  16. Natural History • Presurgical Survival Rates • NYHA Class II 80%-10yrs • Class III 38%-10yrs, 62% 5yrs • Class IV 15%-5yrs

  17. Management-Medical • Endocarditis Prophylaxis • Activity Limitation • Diuretics- Decrease Na Intake • Heart Rate Control for A-fib or Sinus Rhythm • Anticoagulation

  18. Percutaneous Balloon Angioplasty • Moderate-Severe MS • Mild MS- if Pulmonary Artery Pressures or Wedge Pressure Elevate with Exercise

  19. Valve Replacement • Indications • Combined MS/MR • <1.5 cm²-NYHA III or IV • <1 cm² • Class II if Pulmonary Artery Pressure >70mmHg • Mortality • 3-8% • Valve Type-Prosthetic or Bioprosthetic

  20. Mitral Regurgitation • Etiology • Rheumatic Heart Disease • Infective Endocarditis • Collagen Vascular Disease • Cardiomyopathy • Ischemic Heart Disease • Mitral Valve Prolapse-most common cause for valve surgery in US

  21. Pathophysiology • Decreased Impedance to Ventricular Emptying • Determinants of Regurgitant Flow • Instantaneous Size of MV Orifice • Dependent on Preload, After load, LV Contractility, LV Size • LA-LV Pressure Gradient dependent on Systemic Vascular Resistance, LV Pressure, & LV Size

  22. Pathophysiology • LV Compensation • Increased End Diastolic Volume • Increased Wall Tension • Increased Preload • Increased LV Emptying • Normal Ejection Fraction should be Super Normal >65% to maintain forward cardiac output and B/P

  23. Pathophysiology • LV Decompensation • Increase End Systolic Volume • Increased End Diastolic Volume • Leads to Annulus Dilatation (MR begets MR) • Decreased Ejection Fraction and Stroke Volume

  24. Pathophysiology • Ejection Fraction in Mitral Regurgitation • >65% normal in compensated MR • 50-65% mild impairment • 40-50% moderate-severe impairment • <35% advanced impairment As ejection fraction decreases operative risk increases.

  25. History • Shortness of Breath • Exertional Dyspnea • Congestive Heart Failure • Right Heart Failure • Significant symptoms in chronic MR usually do not develop until LV decompensation occurs.

  26. History • Medical Treatment Survival • 80% 5yr • 60% 10yr • 30-45% 5yr if MR severe

  27. Diagnosis • Physical Exam • Holosystolic Murmur • Increase Carotid Impulse • ECG • LA abnormality • LVH • RVH • Chest X-ray • Increase LA, LV, RV, Interstitial Edema

  28. Diagnosis • Echo • Transesophageal superior to transthoracic • Evaluation of Chamber Sizes, Regurgitant Jet, Leaflets

  29. Management of Acute MR • Medical • After load Reduction (Nitropresside & Intra aortic balloon pump) • Decrease impedance to LV ejection • Decrease regurgitant volume into left atrium • Inotropic Support (Dobutamine)-if LV function reduced

  30. Management of Acute MR • Surgical Intervention • Progressive LV Failure or Hemodynamic Deterioration • CHF • Hypertension • Valve Disruption

  31. Management of Chronic MR • Medical • Digoxin • Diuretics* • After load Reduction • Anticoagulation in A-fib • Endocarditis Prophylaxis

  32. Management of Chronic MR • Surgical • Indications • Asymptomatic Class I • EF < 60% or LV Systolic Diameter >45mm • Severe MR Class II, III, or IV • generally considered for surgery unless EF <30% • Valve Repair vs. Replacement

  33. Mitral Valve Prolapse • Systolic Click-Murmur Syndrome • Barlow’s Syndrome • Billowing Mitral Valve Syndrome • Floppy Valve Syndrome • Myxomatous Valve Syndrome • Parachute Valve

  34. Mitral Valve Prolapse • Over diagnosed • 2.4% of population • Females>Males 2:1 • Severe MR- Elderly Male>Young Female

  35. MVP Etiology • Primary Valvular most frequent • Connective Tissue Diseases • Hyperthyroidism • Myotonic Dystrophy • Periarteritis Nodosa • Von Willebrands

  36. MVP Pathology • Myxomatous Proliferation and Degeneration of Valve Leaflets • Increased Quantity of Acid Mucopolysaccharide in Middle Layer of Valve Tissue

  37. MVP History • Most are asymptomatic throughout life • Chest pain, fatigue, anxiety • Orthostasis-questionable autonomic dysfunction • Arrhythmia-SVT, PACs, PVCs • Symptoms of MR if present

  38. Physical Examination • Body type • Asthenic, low weight body habitus, straight back syndrome • Auscultation • Systolic click- multiple, non-ejection (after carotid upstroke) due to tensing of elongated chordae and prolapsing valve

  39. Physical Examination • Auscultation • Murmur- mid to late crescendo progressing to holosystolic if MR becomes severe • Click and murmur move closer to S1 during strain phase of valsalva, sudden standing, and Amyl Nitrate

  40. Diagnosis • ECG and Chest X-ray • Normally unremarkable • Echo • Billowing of one or both leaflets into the left atrium during systole at least 2mm • Parasternal long axis view for diagnosis • Associated MR • Leaflet thickness

  41. Natural History • Progressive MR in 15% over 10-15 yrs • Infective Endocarditis • Cerebral Emboli-tearing of endothelial covering of myxomatous valve with platelet activation • Sudden Cardiac Death-V fib, increased Q-T interval (not well established)

  42. MVP Management • Endocarditis prophylaxis if MR present • Holter monitor-beta blocker for ectopy? • Aspirin if focal neurological events present • MR-treat like any other MR, valves usually amenable to repair • *MVP is usually a benign disease*

  43. Aortic ValveNormal Structure • Valve sits at the base of Aortic Root • Three Leaflets (cusps)-non coronary, right coronary, left coronary • Cusps give rise to ostea of right coronary artery and left main coronary artery • Normal cross-sectional area 3-4cm²

  44. Aortic Stenosis Etiology and Pathology • Valvular • Supravalvular • Subvalvular • Hyperthrophic Cardiomyopathy

  45. Congenital Aortic Stenosis • Unicuspid • Presents less than one year of age • Bicuspid • Adult Presentation • Chronic turbulent flow • Leads to fibrosis, rigidity, calcification • Tricuspid • Leaflets of unequal size

  46. Acquired Aortic Stenosis • Rheumatic • Rare • Usually mitral valve also involved • Degenerative or Senile • Most common cause of adult AS • Most common cause of valve replacement • Years of normal mechanical stress leads to calcium deposits on leaflets • Inflammatory or Infectious component?? • >age 65 2% frank AS, 30% Aortic Sclerosis

  47. Is this atherosclerotic disease? • Degenerative A.S. accelerated in diabetes and hyperlipidemia. • Associated with tobacco use and HTN. • Potentially treated with HMGcoA agents?

  48. Hemodynamics • Critical (Surgical) AS • Peak systolic pressure gradient > 50mmHg in the presence of normal cardiac output • Valve area <0.7-0.8cm² • Moderate AS • 1-1.5cm² • Mild AS • 1.5-2cm² • Aortic Sclerosis

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