Valvular Heart Disease

1. Valvular Heart Disease ADRIEL E. GUERRERO, MD, FPCP, FPCC Training Officer Section of Cardiology, Dept of Medicine The Medical City

2. Mitral Stenosis

3. Diagnostic Features of MS@ • 2/3 are females; Pure MS are generally rheumatic • History: • Exertional Dyspnea, PND, Orthopnea and Hemoptysis • PE: • Opening snap, loud S1, diastolic rumble at the apex • ECG and Chest Xray: • Evidence of left atrial enlargement with normal left ventricular size; RVH in later stages • 2DECHO

4. Chest Xray MS

5. Common Etiologies of MS • Rheumatic Heart Disease • Congenital Heart disease • Congenital MS • Lutembachers syndrome (MS and ASD) • Mitral Annular Calcification (elderly)

7. Mitral Stenosis@ Pathophysiology Obstruction to LV filling Increase LA pressure RV Failure

8. Natural History of MS • Pulmonary Hypertension • Fibrous thickening of alveolar and pulmo capillary walls • Thrombi and Emboli • Left atrial appendage • Increased: AF, older patients, reduced CO • Pulmonary Infections, IE,

9. Natural History of Mitral Stenosis MS - blue MR - purple

10. Differential Diagnosis of MS • Atrial Septal Defect • RVE and accentuated pulmo markings • Widely split S2 (fixed)VS Opening snap; diastolic flow across the TV • No LAE • Left Atrial Myxoma • Obstructing LA emptying, tumor-plop • Mitral Regurgitation • Systolic murmur; LVH • Aortic Regurgitation (Austin Flint) • Apical middiastolic murmur of AR. Becomes louder on handgrip and decreases with amyl nitrate

11. Treatment of MS • Penicillin Prophylaxis of B-hemolytic Streptococcal Infections to prevent Rheumatic Fever and IE • Sodium restriction, oral diuretics • Oral Anticoagulation (Warfarin) • INR target 2-3.1 (embolization, permanent AF) • Heart Rate Controlling drugs • To lengthen diastolic LV filling • Digitalis in Atrial Fibrillation; Beta-blockers in sinus rhythm • Nondihydropyridine Calcium Antagonists

12. Mitral Valvotomy • Indicated in symptomatic patients with isolated MS (<1.0 cm2/m2) • Ideal for mobile, thin leaflets with no or little calcium without extensive subvalvular thickening and with no or mild MR • Open valvotomy – mortality rate is 2% • 50% of all patients require reoperation by 10 years. • Pregnant – carried out if pulmonary congestion occurs despite intensive medical treatment

13. Mitral Valve Replacement • MS with significant MR • Distorted valves from previous transcatheter or operative manipulation • Operative Mortality is 6% • Long term complications of valve replacement • Overall 10 year survival is 70% • Poor Recovery • Old patients • Marked disability • Depressed Cardiac index

14. Mitral Stenosis

15. Percutaneous Trans-septal Mitral Commissurotomy

16. Star Edwards Caged Ball Valve

17. Medtronic Hall Valve (Bjork-Shiley)

18. St Jude Bileaflet Valve

19. Carpentier Edwards Porcine Valve

20. Carpentier Edwards Pericardial Valve

21. Mitral Regurgitation • Frequent in males • History: • Easy Fatigue then exertional Dyspnea • PE: • Characteristic holosystolic murmur at the apex with radiation to the axilla

22. Common Etiologies of MR • MV leaflet abnormality • Rheumatic heart disease • Myxomatous alteration (including MVP) • Infective Endocarditis • Mitral annulus dilatation of any cause • Dilated Cardiomyopathy • IHD with dilated LV • Ruptured chordae tendinae • Trauma • Myocardial Infarction • Papillary muscle disorder • Ischemic Heart Disease

23. Mitral Regurgitation

24. NORMAL

25. Pathophysiology of Mitral Regurgitation

26. Pathophysiology of Mitral Regurgitation

27. Pathophysiology of Mitral Regurgitation

28. Laboratory Examination • La enlargement; RAE maybe present if pulmonary HPN is severe • Atrial Fibrillation • LVH • ECG • 2DECHO – most accurate non-invasive technique • CXR – LAE and LVE

29. Medical Treatment for MR • Restrict Physical activities • Reduce sodium intake and enhance sodium excretion (diuretics) • Increase forward cardiac output • Vasodilators (ACEI) and digitalis • Anticoagulants and leg binders to decrease likelihood of venous thrombi and pulmonary emboli • Endocarditis prophylaxis

30. Surgical Treatment of MR • Non-surgical candidates: asymptomatic, or exercise limited to strenuous exertion, normal LV function • Surgery for severe MR even if asymptomatic or when LV dysfunction is progressive (declining <60%) and/or LV ESD on echo is >45mm • MV replacement for markedly shrunken, deformed, calcified leaflets • MV repair (reconstruction) with annuloplasty • Lessens problem on long term anticoagulation and thromboembolism • For ruptured chordae, annular dilatation and IE • Not suitable for Mr due to myxomatous degeneration and patients with calcified annulus

31. Natural History of Unoperated MR

32. Late Survival Rates after Surgical Correction in MR (pre-op EF)

33. Mitral Valve Prolapse • Barlow’s syndrome, floppy-valve syndrome, systolic click-murmur syndrome, billowing mitral leaflet syndrome • Excessive or redundant mitral leaflet tissue. Posterior MV leaflet is more affected than the AMVL • May lead to excessive stress on the papillary muscles leading to dysfunction. Rupture of chordae tendineae with progressive annular dilatation and calcification • Ventricular arrythmias

35. Clinical Features • Females (14-30 years old) • Clinical course is often benign • Increased familial incidence – autosomal dominant • Most common cause of isolated severe MR requiring surgical treatment in North America • Arrythmias (PVCs, SVTs, VTs) – palpitations, lightheadedness and syncope. Sudden death is rare • Chest pain substernal, prolonged, unrelated to exertion

36. Mitral Valve Prolapse Mismatch between elongated MV and LV cavity

37. Laboratory Exams • ECG – non specific STTW changes, PVCs • Echo – demonstrates systolic displacement of MVL and quantifies Mitral Regurgitation and LV function

38. Treatment of MVP • IE prophylaxis • Beta-blockers sometimes relieve chest pain • For severe symptomatic MR, MV repair or rarely replacement is indicated • Antiplatelets for patients with TIA, anticoagulation if recurrent TIAs

39. Survival Rates of MVP patients at baseline risk factors Primary Risk Factors Mod-severe MR; EF <50% Secondary Risk Factors Mild-mod MR; LA > 40 Flail leaflet; AF; age > 50

40. Aortic Stenosis • 80% with symptomatic AS are males • Age-related degenerative calcific AS – most common cause of AS in Adults

41. Common Etiologies of AS • Valvular (90% of all cases) • Rheumatic heart disease • Degenerative calcification (elderly) • Bicuspid AV stenosis/ Congenital heart disease • Subvalvular (9%) • Hypertrophic Obstructive Cardiomyopathy (HOCM) • Discrete • Supravalvular (<1%) • Infancy

42. NORMAL AORTIC VALVE

43. Aortic Stenosis - Rheumatic

44. Aortic Stenosis - Degenerative

45. Aortic Stenosis - Bicuspid

46. Pathophysio of AS

47. Pathophysio of AS

48. Aortic Stenosis • History: • Cardinal symptoms • Exertional Dyspnea • Angina Pectoris • Syncope • PE • Carotid upstroke slowly rising and reduced in amplitude in severe cases; Systolic ejection murmur radiating to the carotid arteries

49. Laboratory Exam • LV hypertrophy is the key finding • ECG • 2DECHO – estimate valve area, LV size and function • Cardiac catheterization • Presence or absence of concomittant CAD

50. Natural History of Severe AS • Death most commonly occurs in the 7th and 8th decade • Average time from onset of symptoms to death: • Angina – 3 years • Syncope – 3 years • Heart Failure – 1.5 – 2 years • Sudden death 10-20% in AS patients 60 years old and above