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CARDIOVASCULAR SYSTEM Rheumatic heart disease and valvular disease

CARDIOVASCULAR SYSTEM Rheumatic heart disease and valvular disease. Lecture 4. RHEUMATIC HEART DISEASE. Rheumatic fever is a post-streptococcal immune-mediated inflammatory disease affect heart and extra-cardiac sites e.g. joints, skin, brain….

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CARDIOVASCULAR SYSTEM Rheumatic heart disease and valvular disease

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  1. CARDIOVASCULAR SYSTEMRheumatic heart disease and valvular disease Lecture 4

  2. RHEUMATIC HEART DISEASE • Rheumatic fever is a post-streptococcal immune-mediated inflammatory disease affect heart and extra-cardiac sites e.g. joints, skin, brain…. • The incidence and mortality of rheumatic fever has declined over the past 30 years (due to improved socioeconomic condition and rapid diagnosis and treatment of strep. pharyngitis).

  3. Pathogenesis of rheumatic heart disease • An acute attack of streptococcal pharyngitis(group A beta-hemolytic streptococci). • Within 2-4 weeks after this attack anti-streptococcal antibodies are formed and attack the heart and the extra-cardiac sites.

  4. Strep throat Antibody production Antibody cross-reaction with heart pericarditis vegetations Aschoff body

  5. Pathogenesis of rheumatic heart • The disease passes into two phases; • A. Acute phase: • acute rheumatic pancarditis(inflammation of endocardium, myocardium and pericardium) • Myocarditis : the heart muscle itself . • Pericarditis: the pericardial, or exterior, heart surface. • Endocarditis:endocardial, or interior, heart surface.

  6. Pathogenesis of rheumatic heart B.Chronic phase: Acute changes may resolve completely or progress to scarring and development of chronic valvular deformities many years after the acute disease.

  7. CHRONIC RHEUMATIC HEART DISEASE • Chronic scarring of the valves constitutes the most important long-term problem of rheumatic fever, and usually becomes clinically manifest decades after the acute process. • Left sided valves (mitral and aortic) are more commonly involved than the right. • Other cardiac complications: • Bacterial endocarditis. • Arrhythmia. • Chronic heart failure.

  8. Valvular Heart Disease • Aortic Stenosis • Mitral Stenosis • Aortic Regurgitation • Mitral Regurgitation

  9. Aortic Stenosis Overview: • Normal Aortic Valve Area: 3-4 cm2 • Symptoms: Occur when valve area is 1/4th of normal area. • Types: • Supravalvular • Subvalvular • Valvular

  10. Etiology of Aortic Stenosis • Congenital • Rheumatic • Degenerative Patients under 70: >50% have a congenital cause Patients over 70: 50% due to degenerative

  11. Pathophysiology of Aortic Stenosis • A pressure gradient develops between the left ventricle and the aorta. • LV function initially maintained by compensatory pressure hypertrophy • When compensatory mechanisms exhausted, LV function declines. This will lead to : 1.Syncope 2.Angina: (increased myocardial oxygen demand; demand/supply mismatch) 3.Dyspnea: on exertion due to heart failure (systolic and diastolic) 4.Sudden death

  12. Mitral Stenosis Overview: • Definition: • Obstruction of LV inflow that prevents proper filling during diastole. • Normal MV Area: • 4-6 cm2 • Transmitral gradients and symptoms begin at areas less than 2 cm2 • Rheumatic carditisis the predominant cause • Prevalence and incidence: • decreasing due to a reduction of rheumatic heart disease.

  13. Etiology of Mitral Stenosis • Rheumatic heart disease: 77-99% of all cases • Infective endocarditis: 3.3% • Mitral annular calcification: 2.7%

  14. Narrowing of mitral valve Pathophysiology of MS  left atrial pressure  blood flow to left ventricle  pulmonary pressure • COP pulmonary congestion Fatigue Left ventricular atrophy • O2/CO2 exchange • (fatigue, dyspnea) Right-sided failure

  15. Aortic Regurgitation Definition: Aortic regurgitation (AR) is the diastolic flow of blood from the aorta into the left ventricle (LV). Regurgitation is due to incompetence of the aortic valve or any disturbance of the valvular apparatus resulting in the diastolic flow of blood into the left ventricular chamber. Endocarditis is the main cause

  16. Acute Aortic regurgitation

  17. Treatment of Acute Aortic regurgitation • True Surgical Emergency. • Positive inotrope: (eg, dopamine, dobutamine) • Vasodilators: (eg, nitroprusside)

  18. Pathophysiology of Aortic regurgitation • Combined pressure AND volume overload • Compensatory Mechanisms: LV dilation. Progressive dilation leads to heart failure

  19. Mitral Regurgitation • Mitral Regurgitation Overview: • Definition: • Backflow of blood from the LV to the LA during systole Mild (physiological) • MR is seen in 80% of normal individuals.

  20. Management of MR • If leads to : Myocardial infarction: Cardiac cath or thrombolytics • Most other cases of mitral regurgitation is treated by: • Diuretics and nitrates • nitroprusside, even in the setting of a normal blood pressure. • Do not attempt to alleviate tachycardia with beta-blockers. Mild-to-moderate tachycardia is beneficial in these patients because it allows less time for the heart to have backfill, which lowers regurgitant volume.

  21. Incomplete closure of mitral valve Pathophysiology of MR Backflow of blood to the left atrium  vol. of blood ejected by left ventricle  Left atrial pressure  COP Left atrial hypertrophy  Pulmonary pressure Right-sided heart failure  Right ventricular pressure

  22. THANK YOU…

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