Valvular Heart Disease

1. Valvular Heart Disease

4. Definition • 1. Acquired heart disease • (1) rheumatic (2) calcification • 2. Valvular disease • (1) a group of heart disease • (2) three kind lesions • 3. Susceptible heart valve • Mitral>Aortic>Tricuspid>Pulmonary

5. Mitral Stenosis Mitral Regurgitation Aortic Stenosis Aortic Regurgitation

6. Mitral valve disease

7. Mitral stenosis (MS)

8. Etiology and Pathology • Rheumatic heart disease • Congenital malformation • Senile mitral annulus and subvalvular calcification

9. Etiology 1. MS is nearly always rheumatic 2. Approximately 25% of all patients with rheumatic heart disease have pure MS and additional 40% have combined MS and MR 3. Two-thirds of all patients with rheumatic MS are female 4. The duration from the acute rheumatic attack to the development of MS : 2-3 or 10-25 years

10. Pathology Rheumatic fever results in four form of fusions of the mitral valve apparatus leading to stenosis 1. Commissural2.Cuspal 3.Chordal 4.combined The stenotic mitral valve is typically funnel-shaped, and the orifice is frequently shaped like a “fish mouth” or buttonhole, with calcium deposits in the valve leaflets sometimes extending to involve the valve ring, which may become quite thick

11. Pathophysiology • The cross-sectional area of the mitral valve ring • Normal adults 2-2.5 cm diameter 4 - 6cmsquare • Mild MS ≤2cm² • Moderate MS ≤1.5cm² • Severe MS ≤1.0cm²

13. Pathophysiology mitral stenosis if the valve orifice<2 cm square LA enlargement and pressure elevated PV pressure elevation PA pressure elevation RV & RA pressure elevation right heart failure —RA failure dyspnea RV failure—edema

14. Clinical manifestation

15. Clinical manifestation

16. Diastolic rumble murmur in mitral stenosis

17. Laboratory Examination • X－Ray LA enlargement RV enlargement pulmonary Vein congestion

18. Laboratory Examination • ECG • PⅡ>0.12s (Mitral P wave) • RV1↑(RV enlargement) • Atrial fibrillation

19. Laboratory Examination • Echocardiogram---cornerstone of the diagnosis M-mode :both leaflets move anteriorly like “ city wall ” Two-dimensional (1) determine mitral valve (2) providing information on the pliability and extent of calcification of the valve Doppler :estimating pulmonary arterial pressure

20. Laboratory Examination • Angiography left atrial size thickening and reduced motion of the valve leaflets outline large intraluminal thrombi left ventricular contractile function PCWP and LVP

21. Diagnosis Symptoms Signs (DM) Some examines (echocardiography)

22. DifferentialDiagnosis The Carey-Coombs murmur of acute rheumatic fever Left atrial myxoma pansystolic murmur of tricuspid regurgitation (Austin Flint murmur)

23. Complications Atrial fibrillation Acute pulmonary edema Embolism Right site heart failure Pulmonary infection Subacute infective endocarditis

24. Prognosis • Asymptomatic---15-20 years • Mild disability -severe disability--- 5-10 years • Died because of complications

25. Medical treatment • Completely asymptomatic patients with very mild MS require no treatment,but periodic medical checkups must be hold • With symptom cases :high salt intake and extraordinary physical activity should be avoided • Mild diuretics may be given for pulmonary congestion • Digitalis is not effective for a pure MS,but the drug is essential in the treatment of Af

26. Medical treatment • General therapy • Antibiotic---prophylaxis • Anticoagulant---venous thrombosis • Hemoptysis---reduce pulmonary venous pressure including sedation assumption of the upright position aggressive diuresis • Atrial fibrillation--- digitalis • Right heart failure---diuretics

27. Percutaneous Ballon Mitral Valvuloplasty(PBMV) Pure MS (without MR) and the mitral valve leaflets must be flexible

28. Surgical treatment ■The patients with moderate to severe MS will require surgery ■Three operative approaches are available for the treatment of rheumatic MS: • closed mitral valvotomy using a transatrial or transventricular approach • open valvotomy • mitral valve replacement

29. Mitral Regurgitation

30. Etiology and Pathology • The mitral valve has to close completely during a systolic phase of the ventricles in order to pump out the blood from the left ventricle to the aort via the aortic valve. • The mitral valve close depend on the integrity of mitral structure and function (including leftlets of valve, mitral annulus, tendinous cords, papillary muscle and LV. • Every abnormality may lead to MR.

31. Etiology Chronic MR • Rheumatic heart disease: The leftlets of mitral valve fibrose , thicken, shorten and often accompany MS and aortic valve disease • Mitral valve prolapse • CHD：Chronic ischemia or infarction lead to fibrosis and functional disorder of papillary muscle

32. Etiology Chronic MR • Calcification of mitral ring and subvalvular • Infective endocsrditis • Rupture of chordae tendineae (unknown cause) • LV enlarged significantly

33. Etiology Acute MR • Rupture of chordae tendineae • Endocarditis leads to the leftlets of valve destruction Acute myocardial infarction • Trauma results in rupture of the mitral valve component • Complication of cardiac surgery • Rupture of prosthetic valve

34. Relative incidence of the causes of severe primary MR

35. Pathophysiology • LA↑↑→LV failure →Pulmonary congestion →PAP↑ →Right heart failure • MR→LVEDV↑→LVhypertrophy →LVEDP↑ • In advanced cases of MR, the LV has to work harder to maintain adequate cardiac output by compensating the leakage of the blood to the LA. The LA and LV will enlarge progressively • Eventually, LV failure is the end result

36. Clinical Manifestation Symptom • Many patients with MR may be totally asymptomatic for many years with no progression • Dyspnea • Fatigue • palpitation

37. Clinical Manifestation Physical Signs • Heaving apex impulse • Cardiac sound：S1↓，S3 • Cardiac murmur： • location at the apex • Intensity grade 3-4 or more • Pitch high • Duration holosystolic • Radiation to the axillae and left back

38. Diagnosis and laboratory findings • In mild cases X-ray ECG UCG------ normal • In advanced MR • Enlargements of various heart chambers will be shown on the X-ray, ECG,UCG • Various cardiac arrhythmias will be conformed on ECG

39. Diagnosis • characteristic pan systolic heart murmur at the apex • laboratory findings

40. Laboratory examination • X－Ray LA enlargement LV enlargement pulmonary Veincongestion

41. Laboratory examination • ECG LA enlargement LV enlargement

42. Laboratory examination Echocardiogram

43. Differential diagnosis Tricuspid Regurgitation ventricular septal defect Systolic ejection murmur in left border of sternum

44. Complication Atrial fibrillation Infective endocarditis Embolism Heart failure

45. Medical Therapy • Prevent endocarditis and rheumatic fever • Patients who are asymptomatic and having normal cardiac function needn’t therapy but regular follow-up • In mild cases • (1)reduction of salt intake • (2)avoidance of extraordinary activities • (3)appropriate use of diuretics and digitalis • Complication are cured in patients with complication

46. Surgical treatment • Prosthetic valve replacement • Valvuloplasty of mitral valve

47. Prognosis • Acult MR • Chronic MR

48. Review Questions • 1. What are the clinical manifestation of MS? • 2. What are the clinical manifestation of MR ? • 3. What are the complications of MS?

49. Aortic valve disease

50. Aortic stenosis (AS)