VALVULAR HEART DISEASE

Dr.Alexandru Nechita

Valvular heart disease

MITRAL STENOSIS AORTIC STENOSIS MITRAL REGURGITATION AORTIC REGURGITATION TRICUSPID REGURGITATION TRICUSPID STENOSIS PULMONARY STENOSIS PULMONARY REGURGITATION MIXED LESIONS

MITRAL STENOSIS
Definition: The incapacity of the mitral valve to open completely in diastole, due to comisural fusion, cusps thickenning and remodeling of the subvalvular structures

MITRAL STENOSIS

Etiology: Rheumatic fever, most of the patients, other etiologies are very rare:
Congenital, MS+atrial septal defect=Lutembacher syndrome. Mitral valve annular calcification,elderly. Other causes of LV inflow obstr.:atrial myxoma, LA ball thrombus, cor triatriatum.

MITRAL STENOSISPathology
Posterior cusp

Fusion of the comissures, cusps or chords. Contracture and thickening of the cusps. Shortening and fusion of the chordae tendinae. Funnel shaped orifice.

Mitral annulus Anterior cusp Chordae tendinae Papillary muscles

Pathophysiology

Obstruction between LA and LV. Pressure gradient. Elevated LA pressure. LA pressure increases at elevated HR. Pulmonary vascular resistance elevated. Pulmonary hypertension Right ventricular hypertrophy, enlargement. Systemic venous congestion.

Mitral stenosisClassification

Large: more than 2 sqcm. Medium: 1,5-2sqcm. Severe:<1sqcm.

Mitral stenosisSymptoms.

Hemoptysis us hypertension

Exertional dyspnea. Fatigue. Presyncope, syncope. Cough, wheezing. Paroxysmal nocturnal dyspnea. Orthopnea. Hemoptysis. Hoarsenes(Ortner syndrome)

-rupture of alveo

-pulmonary infa

-ruptured of dila

-chronic bronchi

Mitral stenosis-Physical fi n d i n g s

Mitral facies. Tachypnea. Turgid jugulars. Jugular pulse. Pulmonary rales, pleural fluid. Diastolic thrill. Sustained RV lift.

Mitral stenosis -auscultaion

- FFT
ENHANCED SOUND 1

- TA
AORTIC COMP OF S 2

-TA.
OPENING SNAP

PRESYSTOLIC MURMUR

S1

A2,P2

OS

S1 PRESYSTOLIC MURMUR

Mitral stenosis -auscultation

Mitral senosis auscultation

Mitral stenosisc o m p l i c a t i o ns

Atrial fibrillation/flutter. Embolism: Systemic:cerebral, coronary, preipheral; pulmonary. Acute pulmonary edema. RV heart failure. Infective endocarditis. Chest pain/angina.

Aortic stenosis
Definition: obstruction to blood outrflow from the LV to the aorta. Causes: 1. Congenital. 2. Acquired:- Degenerative - Rheumatic Rare causes: Infective endocarditis, Paget bone disease, SLE, RHeumtatoid involvement, Irradiation.

Pathophysiology

Obstruction in LV outflow. Gradient LV-Ao. LV pressure rises,. LV wall stress increases. LV dysfunction develops LV hypertophy develops. LV filling pressure increaqses. LV systolic failure develops

Aortic stenosisclassification

Aortic stenosis-symptoms

Angina pectoris. Syncope. Exertional presyncope Pulmonary edema.

AS- CLINICAL FINDINGS

Peripheral pulse: parvus et tardustaking longer time to reach the peak pressure, peak is reduced. Heart size increased in heart failure. Palpable G4(S4). Aortic thrill at the base of the heart.

AS-auscultation

Systolic ejection click(bicuspid) Paradoxically split S2. Systolic ejection murmur. In older patients ejection murmur is atypical, heard at the apex as seagull sound Gallavardin phenomenon. Ejection murmur decreased when LV failure occurs.

AORTIC REGURGITATION
Definition: incomplete closure of the aortic cusps in diastole and regurgitation of blood from the aorta to the left ventricle. Aortic regurgitation can be: acute or chronic.

AORTIC REGURGITATIONEtiology

Aortic root dilatation. Congenital biscuspid valve. Previous infective endocarditis Rheumatic Other congenital Connective tissue disease: Marfan,osteogenesis imperfecta,Ehlers-Danlos syndrome. Autoimmune dis.:ankylosing spondylitis, rheumatoid arthirtis,SLE.Aortitis and arteritis Syphilis

AORTIC REGURGITATIONPathology

Dilatation of the annulus results in AR. Valves can show thickening, shortening, comisural lesions, calcification, . LV is dilated and hypertrophied. LV dysfunction develops.

AORTIC REGURGITATIONSymptoms

Pounding of the head or palpitations. Dyspnea on exerton. Orthopnea, paroxysmal nocturanl d ys p n e a . Fatigue and weakness. Angina pectoris.

AORTIC REGURGITATIONperipheral signs

Pulse pressure elevated. Corrigan pulse- celer et altur. Atrerial hyperpulsatility: Musset sign-bobbing of the head with each heartbeat. Traube sign-pistol-shot heard over the femoral artery. Duroziez sign-systolic murmur fem.a.when compressed proximally, diastolic distally. Quincke pulse-capillary pulsations detected pressing a glass over the patients lips. Arterial dance- carotid pulsations. Waterhammer sign-pulsatons of the forearm when pressed. Landolfi sign intermittant pupillary hippus miosis in systole, midriasis in diastole.

AORTIC REGURGITATIONphysical examination

The chest may rock, cardiac impulse may be visible. Diastolic thrill-severe AR. S1 usually soft. Systolic ejection murmur. Early or immediate, blowing descrescendo diastolic murmur, after S2. IN severe AR the murmur is holodiastolic. Austin-Flint murmur of functional mitral stenosis. Signs of left or global heart failure.

Mitral regurgitation
Definition: Clinical syndrome deterined by the incomplete closure of the mitral valve during s y st o l e .

MR-valve structure.

MR- etiology

MR-pathophysiology

A volume of blood is regurgitated from the LV to the LA, leading to LV overload. End diastolic pressure increases, LA preassure is increased, is dilated, pulmonary hypertension can develop. LV is dilated and systolic LV dysfunction appears, wich may be irreversible. Pulmonary arterial hypertension can appear and also RV failure during evolution.

MR-physical examination

Carotid upstroke is brisk. Laterally displaced apical impulse with enlarged LV. Apical thrill-severe MR. Left sternal border lift RV dilation. S1 is included in the murmur, usually normal, may be increased in rheumatic heart disease. S3 gallop-large volume of regurgitation.

MR-physical examination

The hallmark of MR is the systolic murmurmost often holosystolic, is of blowing type, but may be harh in mitral valve prolapse Irradiation to the left axilla and tricuspid focar, but it can irradiate to the base of the heart in ruptured chordae tendinae with posterior valve prolapse MR.

MR in mitral valve prolapse.

MR limited to telesystole. Frequent -5%pop. Especially in young women. Habitus is sometimes characteristic: longiline- asthenic woman with mild chest deformities:pectus excavatum, pectus carinatum. Palpation- bifid apical impulse. Meso or telesystolic click, followed by in a minority of cases by telesystolic murmur.

Tricuspid regurgitation
Definition: incapacity of the tricuspid valve to close completely during systole, resulting in regurgitation of blood from the right ventricle to the right atrium. Tricuspid valve structure: annulus, 3 leaflets, and chordae tendinae. It is larger than the mitral valve-lower pressure-, the annulus dilates in diastole and constricts during systole.

Tricuspid regurgitation -etiology

Primary TV disease:

Congenital:Ebstein anomaly Rheumatic, assoc. with mitral disease. Infective endocarditis. Iatrogenic: pacemaker wire trauma. Degenerative:TV prolapse. RV dilatation Pulmonary hypertension. Cardiomyopathies Segmental RVdysf. Due to ischemia, ARVD,.

Secondary TV disease:

Tricuspid regurgitationsymptoms

TR is not associated with any complaint until the late phases of the disease when RV dysfunction develops resulting in overt rihgt heart failure syndrome. Symptoms: fatigue, right upper quadrant discomfort, dyspepsia due to gut congestion.

Tricuspid regurgitation physical examination

Edema of the lower limbs. Ascites. Jugular congestion Cachexia due to low cardiac output Right parasternal lift. Systolic puplsations of the liver. Auscultation: soft early or holosystolic murmur, augumented with inspiratory effort.

Tricuspid stenosis

Rare condition Etiology: rheumatic in most of the cases. Simptoms and general signs similar to those met in TR. Auscultation: low to medium pitched diastolic rumble with inspiratory accentuation, localized to the lower sternal border.

Pulmonary valve dissease.

Apart from congenital conditions is very rare. Congenital: PV stenosis, Pulmonary atresia, Bicuspid valve, Infundibular(subvalvular pulmonary stenosis), Idiopathic dilatation of the pulmonary artery. Acquired: reheumatic, Infective endocarditis, carcinoid heart disease, pulmonary hypertension, iatrogenic-Ross operation.

Pulmonary stenosis physical examination

Mild stenosis: systolic ejection click+early systolic murmur. Severity progresses the murmur gets louder and peaks later in systole. In mild PS S2 is splitted with dealyed pulmonary component, but with further widening in inspiration Severe PS- SP2 becomes softer, even inaudible, and the murmur encompasses the aortic component.