Valvular Diseases

1. Valvular Diseases • Causes of valve regurgitation • congenital, senile degeneration, acute and chronic rheumatic carditis, infective endocarditis, syphilitic aortitis • traumatic valve rupture, damage to chordae and papillary muscles (e.g. in MI), dilated valve ring (e.g. dilated CMP) • Causes of valve stenosis • congenital, senile degeneration • rheumatic carditis • Common clinical scenarios • Young people: functional murmurs, MVP, AS • Old people: aortic sclerosis, aortic stenosis

2. Mitral Stenosis • Symptoms • pulmonary congestion: dyspnea, cough, hemoptysis (also due to PE) • chest pain (PH), edema and ascites (RVF) • fatigue (low COP), palpitation (AF), thromboembolic complications • Signs • inspection: mitral facies • palpation: tapping apex (palpable first heart sound), RV heave (PH) • auscultation: loud first heart sound, loud P2 (PH), opening snap, rumbling mid-diastolic murmur, presystolic accentuation • atrial fibrillation, raised pulmonary capillary pressure: crepitations, pulmonary edema, effusion

3. Mitral Stenosis • ECG • LA hypertrophy, RVH, AF • CXR • enlarged LA, pulmonary venous congestion • Echo • thick immobile cusps, reduced valve area, reduced rate of LV diastolic filling • Doppler • pressure gradient across MV, pulmonary artery pressure • Cardiac catheterization • pulomnary wedge pressure, pressure gradient between LA and LV

4. Mitral Stenosis • Medical management • digoxin for AF + BB or CA • diuretics for pulmonary congestion • anticoagulant to reduce the risk of systemic emboli • antibiotic prophylaxis against infective endocarditis • Mitral balloon valvoplasty • significant symptoms • isolated MS • no to trivial MR • mobile non-calcific valve / subvalvular apparatus on echo • LA free of thrombus • Mitral valve surgery • closed mitral valvotomy • open mitral valvotomy • mitral valve replacement: mechanical, bioprosthesis [St. Jude (bi-leaflet), Carpentier-Edwards (porcine), Medtronics (single leaflet, open)]

5. Mitral Regurgitation • Causes • mitral valve prolapse (myxomatous changes) is the most common cause in developed world • damage to cusps: rheumatic valve disease, IE, congenital cleft mitral valve • damage to chordae: rheumatic valve disease, IE, trauma, degenerative • damage to papillary: ischemia, infarction, infiltrative, HCM • damage of annulus: calcification, IE (abscess) • dilation of MV ring: IHD, CMP, acute rheumatic valve • Symptoms • dyspnea, edema, ascites, fatigue, palpitations (AF, increased stroke volume), thromboembolic complications • Signs • jerky pulse (AF), displaced apex (hyperdynamic circulation) • 3rd heart sound, apical pansystolic murmur with or without thrill • signs of pulmonary congestion and pulmonary hypertension

6. Mitral Regurgitation • ECG • LAH, LVH, AF • CXR • enlarged LA, enlarged LV, pulmonary venous congestion • Echo • dilated LA and LV, dynamic LV, structural abnormalities (e.g. MVP) • Doppler • detects and quantifies MR • Cardiac catheterization • dilated LA and LV, MR, assess PH, detect co-existing CAD

7. Mitral Regurgitation • Medical (mild and moderate cases) • diuretics, vasodilators (e.g. ACEI) • digoxin and anticoagulant (for AF) • antibiotic prophylaxis (for IE) • Surgical • MV valvoplasty (repair) • MV replacement • Indications for surgery • worsening symptoms • progressive cardiomegaly • deterioration of LV function: EF < 60%, LVEDD > 55 • Complications of artificial valves • IE, thromboembolic complications, hemolysis, valve dysfunction

8. Mitral Regurgitation • Emergency minor criteria for surgery in isolated severe chronic MR • any symptoms of heart failure or suboptimal exercise tolerance test • flail mitral leaflet • left atrial diameter > 45 mm • paroxysmal atrial fibrillation • abnormal exercise end-systolic volume index or ejection fraction • MVP • asymptomatic, acute MR (ruptured chordae), chronic MR, CHF • mid-systolic click, late systolic murmur or pan-systolic murmur • increased risk for IE, arrhythmias, embolic stroke and TIA (small), sudden death (rare)

9. Aortic Stenosis • Causes • young patient: thick congenital bicuspid valve, unicuspid valve, supravalvular stenosis, subvalvular stenosis (discrete, diffuse) • middle age: thick bicuspid valve, rheumatic disease • old age: thick degenerative valve, calcification of bicuspid valve, rheumatic AS

10. Aortic Stenosis • Symptoms • angina, exertional pre-syncope and dizziness, dyspnea, impaired exercise tolerance, episodes of acute pulmonary edema, sudden death • other signs of LVF (systolic and diastolic dysfunction) • Signs • slow-rising carotid pulse, narrow pulse pressure, thrusting apex beat (LV pressure overload) • ejection systolic murmur, basal crepitations • Severity • indicated by: diamond-shaped murmur, anacrotic pulse, paradoxical S2, S4 (LVH), S3 (LVF) • not indicated by: intensity, presence of thrill

11. Aortic Stenosis • ECG • LVH, LBBB, normal • CXR • enlarged LV, dilated ascending aorta, calcified AV, normal • Echo • calcified AV with restricted opening, thickened LV walls • Doppler • detects AR, estimates gradient • Cardiac catheterization • systolic gradient between LV and aorta, post-stenotic dilation of aorta, detects AR if present, detect presence of CAD

12. Aortic Stenosis • Medical • prophylaxis against IE • anticoagulants if in AF • diuretics for pulmonary congestion (cautiously) • vasodilators are contraindicated • Surgical • mechanical AV replacement: symptomatic with normal COP and valve gradient > 50 • bioprosthesis: symptomatic elderly (disk valve, caged-ball valve, bio-prosthetic valve) • aortic balloon valvoplasty: congenital AS • Mechanical versus bioprosthetic valve • mechanical: durable, large orifice, best in left side, high thromboembolic potential, chronic warfarin therapy • bioprosthetic: not durable, small orifice/functional stenosis, best in tricuspid orifice, low thromboembolic potential, consider in elderly

13. Aortic Regurgitation • Congenital: • bicuspid AV, cystic medial necrosis (Marfan, Ehlers-Danlos, osteogenesisimperfecta, pseudoxanthomaelasticum) • Acquired • rheumatic heart disease, dilated aorta • degenerative, connective tissue disorders (ankylosingspondylitis, rheumatoid arthritis, Reiter, giant-cell arteritis), syphilis (chronic aortitis) • acute AR: infective endocarditis, trauma, dissecting aneurysm

14. Aortic Regurgitation • Symptoms • mild to moderate: asymptomatic, palpitations • severe: dyspnea, orthopnea, PND, chest pain (noctural and exertional angina) if aortic diastolic pressure < 40 • Signs (peripheral) • Quincke sign: capillary pulsation • Corrigan sign: water hammer pulse • Bisferens pulse (AS/AR > AR) • DeMusset sign: systolic head bobbing • Mueller sign: systolic pulsation of uvula • Durosier sign: femoral retrograde bruits • Traube sign: pistol shot femorals • Hill sign: lower extremity BP > upper extremity BP by > 20 mmHg (mild), > 40 mmHg (moderate), > 60 mmHg (severe) • widened pulse pressure • Signs (central) • apex: enlarged, displaced, hyperdynamic (forcible nonsustained), palpable S3, Austin-Flint murmur • diastolic murmur: length correlates with severity (chronic), in acute murmur shortens as DP=LVEDP, mitral pre-closure

15. Aortic Regurgitation • ECG • LVH, T inversion • CXR • cardiac dilation, aortic dilation, pulmonary congestion • Echo • dilated LV, hyperdynamic LV, fluttering AML • Doppler • detects reflux • Cardiac catheterization • dilated LV, AR, dilated aortic root • Assessing severity • more severity with more peripheral signs and larger LV • S3, Austin-Flint murmur, LVH, radiological cardiomegaly

16. Aortic Regurgitation • Medical • diuretics for pulmonary congestion, vasodilators (ACEI) • prophylaxis against IE, treatment of underlying cause (e.g. IE, syphilis) • Surgical • AV replacement: mechanical or bioprosthesis • aortic root replacement: for dilated aortic root (Marfan, syphilis, dissecting aneurysm) if LVEDD > 55, EF > 55%, FS > 27% • Criteria for replacement • symptoms: congestive heart failure, declining exercise tolerance on exercise testing, angina • anatomy: LV dysfunction (EF < 50%), progressive LV dilation or decline in EF on serial studies, severe dilation (LVDD > 75 mm, LVSD > 55 mm, aortic root dimension > 50)

17. Tricuspid Stenosis • Causes • rheumatic: almost always have associated MS (signs of PH), isolated TS is rare, uncorrected TS worsens survival chance for patients undergoing surgery for AV or MV • carcinoid: mainly affects TV and PV • Clinical • similar to MS, JVD, edema, ascites, hepatomegaly • rumbling diastolic murmur with opening snap accentuated with respiration

18. Tricuspid Regurgitation • Causes • functional overload: pulmonary hypertension, RV dilation from infarction or myopathy • structural leaflet abnormalities: infectious endocarditis, congenital (Ebsteinanomaly), acquired (carcinoid, plantain diet, ergot drugs) • Clinical • asymptomatic (tolerated for years), JVD • high-pitch blowing holosystolic murmur varying with respiration (Rivero-Carvallo sign) in xyphoid area • complications: right heart failure, renal failure • Treatment • none to treat underlying condition • diuretics, salt restriction • valve replacement, rings • Markers of severity • large pulsations in neck, pulsatile enlarged liver, widespread edema (anasarca, Michelin tire man), RV S3 (increases with respiration)

19. Pulmonary Stenosis • typically congenital • valvular, supravalvular, subvalvular (infundibular) • RVH • harsh systolic ejection murmur at 2nd left interspace (crescendo-decrescendo), thrill

20. Pulmonary Regurgitation • Causes • PH (most common) • IE, rheumatic disease, carcinoid heart disease • congenital defects, trauma • physiological is normal variant • Assessment • color flow doppler: right atrialenlargement, right ventricular volume overload • typical murmur: low-pitched diastolic murmur heard at left sternal border increasing with inspiration • PH murmur: high-pitched blowing diastolic murmur at left parasternal border (Graham-Steele murmur)