Valvular Disorders & Infecive Endocarditis

1. Valvular Disorders&Infecive Endocarditis

2. Normal Valve Function • Prevent backward flow of blood • Permit forward flow of blood

3. Abnormal valve function • Allows backward flow • Valve is “leaky;” “regurgitant;” “incompetent” • Backwards jet causes turbulence that is audible as murmur • Prevents forward flow • Valve does not open well • Greek stenōsis, a narrowing • Typically causes hypertrophy and dilatation of the cardiac chamber

4. All valvular diseases have characteristic murmurs • Damaged valve disrupts blood flow=turbulence & sound! • Caused by • Rheumatic Heart Disease • Acute conditions (infective endocarditis) • Acute MI • Congenital Heart Defects • Aging

5. Auscultation • Use the diaphragm for high pitched sounds and murmurs • Use the bell for low pitched sounds and murmurs • Sequence of auscultation { Z Pattern } • Apex • Lower left sternal border (LLSB) • Upper left sternal border (ULSB) • Upper right sternal border (URSB)

6. Common Murmurs and Timing Systolic Murmurs • Aortic stenosis • Mitral insufficiency • Mitral valve prolapse • Tricuspid insufficiency Diastolic Murmurs • Aortic insufficiency • Mitral stenosis S1 S2 S1

7. Grading the Intensity of Murmurs • Grade 1 • Murmur heard with stethoscope, but not at first • Grade 2 • Faint murmur heard with stethoscope on chest wall • Grade 3 • Murmur hears with stethoscope on chest wall, louder than grade 2 but without a thrill • Grade 4 • Murmur associated with a thrill • Grade 5 • Murmur heard with just the rim held against the chest • Grade 6 • Murmur heard with the stethoscope held away and in from the chest wall

8. Cardiac Murmurs • Most mid systolic murmurs of grade 2/6 intensity or less are benign • Associated with physiologic increases in blood velocity: • Pregnancy • Elderly • In contrast, the following murmurs are usually pathologic: • Systolic murmurs grade 3/6 or greater in intensity • Continuous murmurs • Any diastolic murmur

9. Innocent MurmursCommon in asymptomatic adults • Characterized by • Grade I – II @ LSB • Systolic ejection pattern - no  with Valsalva • Normal precordium, apex, S1 • Normal intensity & splitting of second sound (S2) • No other abnormal sounds or murmurs • No evidence of LVH S1 S2

10. Characteristic Pathological Murmur • Diastolic murmur • Loud murmur - grade IV or above • Regurgitant murmur • Murmurs associated with a click • Murmurs associated with other signs or symptoms e.g. cyanosis • Abnormal 2nd heart sound – fixed split, paradoxical split or single

11. Valvular Aortic Stenosis • Normal valve area 3-4 cm2 • Failure of valve to open normally during systole, requiring LV to develop excess pressure to overcome increased resistance • Mild AS >1.5 cm2 • Moderate >1.0 cm2 • Severe AS when area ¼ normal • <1 cm2 for large person • <0.75 cm2 for normal person • Causes concentric hypertrophy • Symptoms of exertional chest pain, syncope, dyspnea • Mandate valve replacement to prevent sudden death

12. A.S : Etiology

13. Clinical Presentation of Aortic Stenosis • Cardinal symptoms: • Angina • Syncope • CHF

14. Physical Findings S1 S2 S1 S2 Mild-Moderate Severe

15. Management of Aortic Stenosis • Prognosis in asymptomatic disease excellent • Conservative approach with monitoring for symptoms recommended • Once symptoms occur, AVR needed • Only should be considered: • If other cardiac surgery (such as CABG) planned • Severe LVH or systolic dysfunction • Women contemplating pregnancy

16. Aortic Regurgitation

17. Any conditions resulting in incompetent aortic leaflets Congenital Bicuspid valve Aortopathy Cystic medial necrosis Collagen disorders (e.g. Marfan’s) Acquired Rheumatic heart disease Dilated aorta (e.g. hypertension..) Degenerative Connective tissue disorders E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis ) Syphilis (chronic aortitis) Acute AI: aortic dissection, infective endocarditis, trauma Aortic Regurgitation: Etiology

18. Aortic Regurgitation: Symptoms • Dyspnea, Orthopnea, PND • Chest pain. • Nocturnal angina >> exertional angina

19. Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula Durosier’s sign: femoral retrograde bruits Traube’s sign: pistol shot femorals Hill’s sign:BP Lower extremity >BP Upper extremity by > 20 mm Hg - mild AR > 40 mm Hg – mod AR > 60 mm Hg – severe AR Peripheral Signs of Severe Aortic Regurgitation

20. Aortic Regurgitation: Physical Exam • Widened pulse pressure • Systolic – diastolic = pulse pressure • High pitched, blowing, decrescendo diastolic murmur at LSB • Best heard at end-expiration & leaning forward S1S2 S1

21. Aortic Regurgitation: Natural History Asymptomatic • Normal LV function (~good prognosis) • Abnormal LV function • Progression to cardiac symptoms (25 % ) • Symptomatic (Poor prognosis) • Mortality > 10 % TX: Medical  Surgery BEFORE LV dysfunction

22. Mitral Stenosis • Almost always rheumatic in origin • >40% of cases of RHD result in mitral stenosis • Women affected more than men (2:1) • Presentation 20-40 years after the initial episode of rheumatic fever • Diastolic murmur • classic presentation is during vaginal delivery. Tachycardia, straining, volume increase cause pulmonary edema • Patients eventually have exertional dyspnea, atrial fibrillation (often with thromboembolism), chest pain • Always look for MS in patient with new Atrial fibrillation

23. Mitral Stenosis Pathophysiology • Normal valve area: 4-6 cm2 • Mild mitral stenosis: • MVA 1.5-2.5 cm2 • Minimal symptoms • Mod mitral stenosis • MVA 1.0-1.5 cm2 usually does not produce symptoms at rest • Severe mitral stenosis • MVA < 1.0 cm2

24. Fatigue Palpitations Cough SOB Orthopnea PND Palpitation A. Fibrillation Systemic embolism Pulmonary infection Hemoptysis Right sided failure Hepatic Congestion Edema Worsened by conditions that  cardiac output. Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy, thyrotoxicosis Mitral Stenosis Symptoms

25. Mitral Stenosis Physical Exam • First heart sound (S1) is accentuated • Opening snap (OS) • Low pitch diastolic rumble at the apex • Pre-systolic accentuation (esp. if in sinus rhythm) S1 S2 OS S1

27. MS Mortality • Minimal symptoms >80% 10 year survival • Limiting symptoms <15% 10 year survival • Untreated patients • 60-70% progressive pulmonary edema • 20-30% systemic embolism • 1-5% endocarditis/infection

28. Mitral Regurgitation • Incompetent mitral valve allows loss of stroke volume back into Left Atrium • Mitral valve prolapse most common cause • Rheumatic disease and endocarditis • Physical Examination • Loud pan-SYSTOLIC murmur, loudest at apex and radiating into axilla • Typically soft S1 • Presence of S3 suggests severe MR

29. Valvular-leaflets Rheumatic Endocarditis Chordae Fused/inflammatory Torn/trauma Degenerative Endocarditis Annulus Calcification, IE (abcess) Papillary Muscles CAD (Ischemia, Infarction, Rupture) LV dilatation & functional regurgitation Trauma Mitral Regurgitation: Etiology

30. MRSymptoms • Dyspnea, Orthopnea, PND • Fatigue • Pulmonary HTN, Right sided failure • Hemoptysis • Systemic embolization in A Fib

31. Mitral Insufficiency: Physical Exam • Mitral regurgitation S1 S2 S1

32. MR Treatment • No medical therapy • Most difficult clinically • By the time symptoms occur, it may be too late • Drop in Ejection Fraction or development of atrial fibrillation enough to justify surgery

33. Mitral Valve Prolapse : Epidemiology • Affects 5-10% of population • Most common cause of isolated severe MR • Females >> males; Ages of 14 - 30years • Strong hereditary component (? Autosomal Dominant) • 2º to failure of apposition/coaptation of the anterior and posterior mitral valve leaflets. • Cause is unknown in a majority of pts

34. Mitral Valve Prolapse: Symptoms • Majority are asymptomatic for entire life • Palpitations • Chest pain (atypical). • Often substernal, prolonged, poorly related to exertion, and rarely resembles typical angina • Syncope

35. Mitral Valve Prolapse: Physical Exam • Most important finding: mid  late systolic click. • Variable murmurs: • high pitched late systoliccrescendo-decrescendo murmur, S1 C S2

36. Mitral Valve Prolapse: Complications • Arrhythmias (Usually PVC, PSVT>>VT) • Transient cerebral ischemic (embolic – rare) • Infective endocarditis (if associated with MR) • Sudden death (rare)

37. Tricuspid Valve Disease • Tricuspid stenosis is rare • Associated with rheumatic heart disease • More common than regurgitation • Result in R. atrial enlargement > inc. systemic venous pressure > atrial fibrillation, peripheral edema, ascites • TR usually occurs secondary to: • Pulmonary hypertension • RV chamber enlargement with annular dilatation • Endocarditis (associated with IV drug use) • Other secondary causes: carcinoid, radiation therapy • Symptoms are manifestations of systemic venous congestion • Ascites & Pedal edema • Echo is diagnostic in most cases • Severe tricuspid regurgitation is difficult to treat and carries a poor overall clinical outcome

38. Other Valve disorders: Pulmonic stenosis Result in R. ventricular hypertension and hypertrophy Fatigue , loud midsystolic murmur Uncommon valve disorders NBTE: Non bacterial thrombotic… Thrombus on valves – Hypercoag., DIC, Malignancy, etc. May cause strokes, sec. bacterial infection. Libman-Sacks: Sterile Immune complex vegetations SLE. Carcinoid Heart Disease: Carcinoid tumour, 5HT, seratonins etc.. Endocardial fibrosis

39. Valvular Disease • Rheumatic fever • Regurgitation frequently present acutely • Long term predominant effect is stenosis • Endocarditis causes regurgitation • Patients with valve disease should take antibiotics prior to dental work to prevent endocarditis • All patients with symptomatic valvular disease (i.e. dyspnea, chest pain, syncope) need to be evaluated for surgical correction • Some asymptomatic subjects also need correction “before it’s too late”

40. Valvular DiseaseGeneral Principles • Left sided valvular disease more prone to cause serious hemodynamic problems • Regurgitation causes volume overload- eccentric hypertrophy (dilatation) • Stenotic lesions cause pressure overload on proximal chamber- concentric hypertrophy (thickened walls) • Stenotic lesions cause symptoms sooner than regurgitant lesions but respond to therapy better

41. Common Murmurs and Timing Systolic Murmurs • Aortic stenosis • Mitral insufficiency • Mitral valve prolapse • Tricuspid insufficiency Diastolic Murmurs • Aortic insufficiency • Mitral stenosis S1 S2 S1

42. Marfan Syndrome Tall, long extremities Associated with: aortic root dilitation, MV prolapse Acromegaly Large stature, coarse facial features, “spade” hands Associated with: Cardiac hypertrophy Turner Syndrome Web neck, hypertelorism, short stature Associated with: Aortic coarctation, pulmonary stenosis Pickwickian Syndrome Severe obesity, somnolence Associated with: Pulmonary hypertension Fredreich ataxia Lurching gait, hammertoe, pes cavus Associated with: hypertrophic cardiomyopathy Duchenne muscular dystrophy Pseudohypertrophy of the calves Cardiomyopathy Ankylosing spondylitis Straight back syndrome, stiff (“poker”) spine Associated with: AI, CHB (rare) Lentigines (LEOPARD syndrome) Brown skin macules that do not increase with sunlight Associated with: HOCM, PS General Appearance

43. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) Small capillary hemangiomas on the face or mouth Associated with: Pulmonary arteriovenous fistula Lupus Butterfly rash on face, Raynaud phenomenon- hands, Livedo reticularis Associated with: Verrucous endocarditis, Myocarditis, Pericarditis Pheochromocytoma Pale diaphoretic skin, neurofibromatosis- café-au-lait spots Associated with: Catecholamine-induced secondary dilated CM Sarcoidosis Cutaneous nodules, erythema nodosum Associated with: Secondary cardiomyopathy, heart block Tuberous Sclerosis Angiofibromas (face; adenoma sebaceum) Associated with: Rhabdomyoma Myxedema Coarse, dry skin, thinning of lateral eyebrows, hoarseness of voice Associated with: Pericardial effusion, LV dysfunction General Appearance- 2

44. Prosthetic Valve Complications • Common complications include: • Structural valve deterioration • Valve thrombosis • Embolism • Bleeding • Endocarditis • Endocarditis prophylaxis required for patients with all types of prosthetic valves • Suspect valve dysfunction in: • Acute CHF in the immediate postoperative period • New cardiac symptoms • Embolic phenomena • Hemolytic anemia • New murmurs • TEE is the diagnostic procedure of choice • Postoperative TTE should be done 2-3 months after surgery

45. 2007: Who gets Prophylaxis? Only patients with the highest risk of adverse outcomes (heart failure, surgery, death) from endocarditis: 1. Prosthetic cardiac valve 2. Previous Infective Endocarditis 3. Cardiac transplant recipients who develop cardiac valvulopathy 4. Congenital Heart Disease

46. Which categories of Congenital Heart Disease? • Unrepaired cyanotic CHD • Tetralogy of Fallot, Transposition of Great Arteries, including palliative shunts and conduits • Completely repaired congenital heart defect with prosthetic material or device during 1st 6 months after surgery • Repaired CHD with residual defects at or near a prosthetic patch/device (which inhibit endothelialization)

47. Dental Procedures • “If it bleeds, give prophylaxis” • High-risk pts undergoing all dental procedures that involve manipulation of gingival tissues OR periapical region of teeth OR perforation of oral mucosa • i.e. biopsies, suture removal, placing orthodontic bands • NO PROPHYLAXIS: • X ray, anesthetic injections, fluoride treatments • Shedding of deciduous teeth • Placement/adjustment of removable prosthodontic or orthodontic appliances

48. Prophylaxis for Dental Procedures • Goal: cover Strep Viridans • Single dose, 30-60 min prior to procedure

49. Summary: IE prophylaxis • Need high-risk pt PLUS high-risk procedure • High-risk pts: 1. Prosthetic cardiac valve 2. Previous IE 3. Cardiac transplants w/ valvulopathy 4. Congenital Heart Disease • High-risk procedures: • Dental: “If it bleeds, give prophylaxis” • Respiratory: Consider if pt will be cut or biopsied

50. No Prophylaxis • Endotracheal intubation • Cardiac cath/stent • Pacer/ICD implantation • EGD, Colonoscopy • Barium Enema • TEE • Incision/Bx of surgically scrubbed skin • Circumcision • Vaginal delivery • Hysterectomy