Valvular Heart Disease

1. Valvular Heart Disease Vincent E. Friedewald, M.D.

2. Classification of Heart Disease Congenital Coronary Electrical Endomyocardial Pericardial Valvular

3. The Cardiac Valves

4. Cardiac Valve Anatomy

5. Valvular Heart Disease Acute and Chronic are Different Diseases

6. Aortic Stenosis

7. Aortic StenosisTypes Valvular Subvalvular Supravalvular

8. Aortic Valve Stenosis

9. Aortic Valve Stenosis Bicuspid Rheumatic Degenerative

10. Aortic Valve StenosisAge Relationship

11. Bicuspid Aortic Stenosis

12. Rheumatic Aortic Stenosis

13. Degenerative Aortic Stenosis

14. Degenerative Aortic Stenosis Risk Factors Elevated LDL-cholesterol Diabetes mellitus Systemic arterial hypertension Cigarette smoking

15. Aortic Valve StenosisSymptoms Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope

16. 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

17. 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

18. 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

19. Aortic Valve StenosisUntreated Prognosis

20. Aortic Valve StenosisChest X-Ray

21. Aortic Valve StenosisECG

22. Aortic Valve Stenosis Echo

23. Aortic Valve StenosisAV Pressure Gradient

24. 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

25. Aortic Valve StenosisSurgical Rx Valvotomy Replacement Artificial Bioprosthesis Minimally-invasive transfemoral

26. Aortic Valve ReplacementTransfemoral

27. Aortic Valve StenosisComplications Atrial fibrillation Aortic Dissection Heart failure Infective endocarditis Myocardial infarction Sudden death

28. Aortic Regurgitation (Insufficiency)

29. Aortic RegurgitationEtiologies Primary aortic valve disease Aortic root abnormalities (Dissection, Syphilis) Connective tissue disorders (Marfan’s) Infective endocarditis Inflammatory disorders (SLE) Tumors

30. Aortic RegurgitationSymptoms BREATHING – DIFFICULT , NOCTURNAL BREATHING – DIFFICULT WITH EFFORT CHEST, ANT – PAIN, NONPLEURITIC (ANGINA) CHEST, ANT – PALPITATIONS HEAD, GEN – PAIN SWEATING – NOCTURNAL

31. 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

32. 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

33. 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

34. Aortic Regurgitation – ChronicChest X-Ray

35. Aortic RegurgitationEcho

36. Aortic Regurgitation Medical Rx Vasodilators to reduce systolic BP Antibiotic prophylaxis

37. Aortic Regurgitation Surgical Rx Aortic valve replacement

38. Mitral Regurgitation (Insufficiency)

39. Mitral RegurgitationEtiologies Congenital deformities Degenerative, i.e., myxomatous Endomyocardial fibroelastosis Mitral annular calcification Papillary muscle dysfunction – ischemic heart disease Rheumatic

40. Mitral RegurgitationEtiologies (cont) Ergotamine toxicity Carcinoid syndrome Radiation Rx SLE Diet-drug therapy

41. Mitral RegurgitationPapillary Muscles

42. Mitral RegurgitationLeaflet Prolapse (MVP Syndrome)

43. Mitral Regurgitation Calcified Annulus

44. Mitral Regurgitation Symptoms BREATHING – DIFF, EFFORT FATIGUE SKIN, GEN – TEMPERATURE, COOL SWEATING – EXCESSIVE

45. 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

46. 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

47. Mitral Regurgitation2-D Echo

48. Mitral RegurgitationDoppler Echo

49. Mitral RegurgitationComplications Atrial fibrillation Pulmonary hypertension LV dysfunction Infective endocarditis

50. Mitral RegurgitationMedical Rx Antibiotic prophylaxis ACEIs (functional form of MR) Beta-blockers (functional form of MR)