Valvular heart disease

1. Valvular heart disease Richard Schilling St Mary’s Hospital London

2. Valve disease • Aetiology • Clinical findings • Investigations • Management

3. Mitral stenosis Aortic stenosis Pulmonary stenosis Tricuspid stenosis Prosthetic stenosis Mitral regurgitation Aortic regurgitation Pulmonary regurgitation Tricuspid regurgitation Prosthetic regurgitation Mitral valve prolapse Heart Valve lesions

4. Valve Rheumatic fever Endocarditis Mitral valve annulus Dilation Calcification Chordae tendinae Rupture Lengthening Papillary muscle ischaemia dilation Mitral regurgitation - Aetiology

5. Mitral regurgitation – pathophysiology •  LV emptying •  LA pressure (if acute, pulmonary odema) •  LV filling •  LVedd • LV stretch  failure 

6. Mitral regurgitation – Clinical • Symptoms appear late • SOB • Fatigue • Right heart failure • Signs • Full volume pulse • Pan systolic murmur radiating to apex • Right heart failure • Pulmonary hypertension

7. Mitral Regurgitation • Investigations • ECG p mitrale • Xray large heart, calcified mv annulus, pulmonary odema • Echocardiogram large LA, abnormal valve, MR • LV angio MR, large LA

10. Mitral Regurgitation • Heart Failure • Decrease afterload • Replacement • Anticoagulation • Antibiotic prophylaxis

11. Mitral Stenosis - Aetiology • Rheumatic fever • Congenital

12. Mitral Stenosis - pathophysiology •  LA pressure •  Pulmonary pressure • R Heart failure •  LV function

13. Mitral Stenosis – Symptoms/Signs • SOB • Haemoptysis • Embolisation • Mitral Facies • AF, thready pulse •  JVP • RV heave

14. Mitral Stenosis – Symptoms/Signs • Opening snap • Rumbling diastolic murmur • Presystolic murmur

16. Mitral stenosis - Investigations • ECG – AF • Xray – Pulmonary congestion, large LA and R heart • Echo – tight valve, high inflow large LA

17. MS ECG

18. MS x-ray

19. MS echo

20. MS Treatment • Antibiotic prophylaxis • Anticoagulation (AF) • Digoxin (AF) • Mitral Valvuloplasty • Surgical Replacement

21. Mitral Valvuloplasty

22. Aortic Stenosis - aetiology • Congenital – bicuspid valve • Acquired • Rheumatic • Senile/degenerative

23. Aortic Stenosis – pathophysiology • LVH •  Cardiac output on exercise • LV dilatation and failure

24. Aortic stenosis – symptoms/ signs • Asymptomatic • Angina • Heart Failure • Syncope • Sudden Death

25. Aortic stenosis – symptoms/ signs • Slow rising pulse • LV heave • Ejection systolic murmur radiating to carotids

26. Aortic Stenosis - investigations • ECG – LVH • Echo – LVH, calcified valve, high doppler velocity • Angio – Ao valve gradient

27. AS ECG

28. Congenital AS

29. Echo AS

30. Doppler/Pressure Aortic stenosis

31. Aortic stenosis - treatment • Antibiotic prophylaxis • Surgical replacement before heart failure

32. Aortic valve replacement

33. Aortic Regurgitaiton- aetiology • Aortic valve • Rheumatic fever • Infective endocarditis • Bicuspid vlave • Aortic dilation • Age related • Marfans • Dissection

34. Aortic regurg - pathophysiology • Increased Lved volume • Increased stroke volume • LV dilatation • LV failure

35. AR – symptoms/signs • Often asymptomatic • Chest pounding • Prominent pulse • Heart failure

36. AR – symptoms/signs • deMusset’s sign • Collapsing pulse • Displaced apex beat • Early diastolic murmur

37. Auscultation AR

38. AR investigations • ECG – LVH • X-ray – abnormal aorta, large heart • Echo – AR, LV dilation, dissection • Angiogram – AR, LV dilation

39. AR - xray

40. AR - Echo

41. AR - treatment • Antibiotics • Vasodilators • Replacement – when LV begins to dilate or fail

42. When to replace the aortic valve?

43. When to replace the mitral valve • When symptoms significant • Before LV failure • Before significant pulmonary hypertension

44. Right heart valves • Low pressure • Tricuspid regurg (drug addicts) • Pulmonary stenosis (congenital)