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Valvular heart disease

FIEDLER JIŘÍ 201 8. Valvular heart disease. Normal valve function. Maintain forward flow and prevent reversal of flow. Valves open and close in response to pressure differences (gradients) between cardiac chambers. Abnormal valve function. Valve Stenosis

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Valvular heart disease

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  1. FIEDLER JIŘÍ 2018 Valvularheartdisease

  2. Normal valve function • Maintain forward flow and prevent reversal of flow. • Valves open and close in response to pressure differences (gradients) between cardiac chambers.

  3. Abnormal valve function • Valve Stenosis • Obstruction to blood flow during that phase of the cardiac cycle when the valve is normally open. • Hemodynamic hallmark -“pressure gradient” • Valve Regurgitation, insufficiency, incompetence • Inadequate valve closure → reverse flow of the blood, back leakage • Combined – a single valve can be both stenotic and regurgitant; combinations of valve lesions can coexist • Single disease process • Different disease processes • One valve lesion may cause another • Certain combinations are particularly common(AS & MR, MS & TR)

  4. Valvular heart disease • Common cause of cardiovascular morbidity, 2nd most common indication for heart surgery (after ischemic heart disease) • In the Czech Republic (2012): 8644 heart surgeries, about 46% involved valve intervention • Combined myocardial revascularisation and valve surgery particularly common for some diagnosis – CABG + AVR (common risk factor), CABG + MVR(in ischemic mitral regurgitation)

  5. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  6. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  7. History • Other known heart diseses • Congenital heart disease, bicuspid aortic valve • Ischemic heart disease • Hypertrophic/dilated cardiomyopathy • Rheumatic fever • Aortic diseases – Marfans, Ehlers-Danlos

  8. History • Generally: symptoms of heart failure and low cardiac output • Breathlessness • Chest pain or dyscomfort • Syncope • Fatigue • Periferal or pulmonary oedema • Palpitations

  9. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  10. Physical examination

  11. Physical examination

  12. Physical examination • MURMURS!!! • Periferaloedema • Lungcrackles • Elevated JVP • Displaced apex beat, irregularheart beat… • Hundredsofeponymoussignsfrom past millenium (↓importance in dailyroutine, ↑importanceforpassingexam)

  13. Heart murmurs • Sounds produces by turbulent blood flow (in valve diseseses, artery stenosis, abnormal chamber or AV communication) • Localization,grade,propagation, • timing, quality

  14. Heart murmurs

  15. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  16. ECG • Not specific • Findings might be caused or altered by other concomitant heart disease (hypertensive heart disease, ischemic heart disease) • Left ventricular hypertrophy (aortic valve disease) • Left atrial enlargement (mainy MS, but any left heart valve disease) • Atrial fibrilation • Bundle branch block • Arrytmias (atrial fibrilation, ectopic beats)

  17. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  18. Chest x-ray in valvular disease • Different heart shapes in different valvular heart diseses, ↓specificity, ↓significance • Cardiomegaly, pulmonary congestion • Widened mediastinum • Valve calcifications, prosthetic valves

  19. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  20. Echocardiography • Mainstay ofvalvediseasediagnosisandfollow-up • Allowsreal-timemeasurementofchamberandwalldiameters, ejectionfractionassessmentandfunctionalvalveevaluation • Easilyavaiableandrepeated • Essential in acute valvediseasediagnosis • No radiationharm • Trans-esophagealechocardiographyavaiableforpatientswithpoortransthoracicsonographicwindow

  21. Diagnosis • History • Physical examination • ECG • Chest x-ray • Echocardiography • Invasive evaluation, CT, MRI

  22. Invasive evaluation, CT, MRI • Methods usually used for uncertain cases or repeat cardiac surgery / percutaneous inteventions planning • Angiography to assess regurgitation severity – direct transcatheter contrast medium administration into heart chambers – aortography, ventriculography • Hemodynamic measurment – measuring of intracardial pressures and gradients • CT aortography – method of choice in aortic dissection diagnosis • CMRI – very precise evaluation of cardiac tissues and function, but expensive, low avaiability, long examination time

  23. Aortic stenosis • Most commonindicationforvalveintervention • Causes • Degenerativeaortic stenosis • Bicuspidaorticvalve • Congenitalaortic stenosis, unicuspidaorticvalve • Rheumaticdisease (alwayswithmitralvalveinvolvement) • Infectiveendocarditis (but severe stenosis due to massivevegetationsisextremely rare) • Other rare causes – post radiation, associatedwithsystemicdisease

  24. Rheumatic vs. Degenerative (involves commissures) (spares commissures)

  25. Aortic stenosis • Pathophysiology • Normal aortic valve area (AVA) – 3-4 cm2 • With a decrease of AVA ,apressure gradient develops between the left ventricle and the aorta (increased afterload) • LV function initially maintained by compensatory concentric hypertrophy (but without an adequete increase in vascularization) • When compensatory mechanisms are exhausted, LV function declines.

  26. Aortic stenosis • Presentation • Anginapectoris(increased myocardial oxygen demand; demand/supply mismatch) • Dyspnea on exertion due to heart failure (systolic and diastolic) • Syncope (exertional) • Sudden death - whenasymptomaticwithpreservedleftventricleejctionfraction, thesuddendeath risk isabout 1%/y, whensymptomatic, however, the mortality increases to up to 50%/y

  27. Aortic stenosis • Physical finding • Systolic crescendo-decrescendo murmur with maximum at right sternal border, 2nd-3rd intercostal space , propagated to the carotic arteries – the loundness of the murmur is not directly correlated to severity of stenosis • Slow rising carotid pulse (pulsus tardus) & decreased pulse amplitude (pulsus parvus) • Heart sounds- soft and split second heart sound, S4 gallop due to LVH…

  28. Aortic stenosis • Therapy – medical therapy has no prognostic effect • Aortic valve replacement • Standard therapy for patients with low surgical risk or with indication for other procedure • Mechanical/biological prosthesis • TAVI (transcatheter aortic valve implantation) – patiens at unaccaptable surgical risk (elderly, comorbid), becoming a standard therapy option even in intermediate risk patients • Percutaneous aortic balloon valvuloplasty (for congenital stenosis, or as a bridging therapy for unstable patients)

  29. Aortic stenosis • Indicationforreplacement • Severe aortic stenosis (AVA <1 cm2, mean PG > 40mmHg) • Symptomatic • LV systolicfunctiondecreases • Otherindicationforsurgery • Moderate stenosis (AVA 1,5-1 cm2 ) • Withotherindicationforsurgery

  30. Aortic stenosis

  31. Aortic regurgitation • Causes • Chronicaorticregurgitation • Bicuspidaorticvalve • Rheumaticanddegenerative – alwayswithsomedegreeof stenosis • Aorticrootdilation (hypertension, Marfan’s, Ehlers-Danlos, syphyliticaortopathy, bicuspidaortopathy) • Other rare causes (SLE, RA) • Acute aorticregurgiation • Infectiveendocarditis • Aorticdissection

  32. Aortic regurgitation • Pathophysiology of chronic aortic regrgitation • Leakage of blood into LV during diastole due to ineffective coaptation of the aortic cusps • Combined pressure and volume overload • Compensatory Mechanisms: LV dilation, LVH. Progressive dilation and decrese of ejection fraction leads to heart failure • Greatest mass of myocardium in any valve disease – „cor bovinum“ – over 500g

  33. Aortic regurgitation • Presentation • Dyspnea:exertional, orthopnea, and paroxsymal nocturnal dyspnea • Chestpain • Fatigue • Palpitations: due to increased force of contractionorarrytmias

  34. Aortic regurgitation • Physical findings (the ones you might find) • Diastolic blowing murmur at the left sternal border – might be very discrete. Systolic ejection murmur might be present due to increased blood flow across the aortic valve of concomitant valve stenosis • Wide pulse pressure – caused by diastolic regurgitation of blood to LV and fast decrease of diastolic BP – „Corrigan’s pulse“ (160/30 mmHg…) • Heaving and laterally displaced apex beat – due to dilated heart with giant stroke volume

  35. Aortic regurgitation • Physical findings (the ones you might not find…) • Quincke’s sign - pulsations of nail bed • Muller’s sign- pulsation of uvula • De Musset sign -  (head nodding in time with the heart beat) • Duroziez sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope) • Austin Flint murmur (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate

  36. Aortic regurgitation • Acute aortic regurgitation • Caused by a leaflet perforation in infective endocarditis • In aortic dissection due to a change in aortic root geometry – dilation, extensive intimal tear with prolapse into LVOT and coaptation impairment • Presentation of acute aortic regurgitation itself is usually a pulmonary oedema accompanied by symptoms of the causing pathology • True emergency – mostly requires immediate cardiac surgery

  37. Aortic regurgitation • Therapy –surgical • Isolated leaflet pathology - aortic valve replacement • Aortic root pathology - combined aortic root, ascendent aorta and aortic valve replacement – Bentall’s procedure

  38. Aortic regurgitation • Indicationforreplacement • Severe aorticregurgitation (EROA – effectiveregurgitantorifice area >0,3 cm2) • Symptomatic • LV dilates (over 50 mm EDD) orfunctiondecreases (EF < 55%) • Otherindicationforsurgery • Acute • Moderate regurgitation (AVA 1,5-1 cm2 ) • Withotherindicationforsurgery

  39. Mitral stenosis • Causes • Rheumatic heart disease in up to 99% of all cases • Other causes are rare - mitral annular calcification, obstructionwithmassiveendocarditisvegetations, leftatrialmyxoma, post radiation • Nowadays rare in developedcountries, stillprevalent in developingcountriesdue to rheumaticfever

  40. Mitral stenosis • Pathophysiology: • Normal mitral valve area 4-6 cm2 – stenosis becomes severe with MVA < 1cm2 • Increased transmitral pressure gradient: leads to left atrial pressure increase, enlargement and atrial fibrillation → • Development of postcapillary pulmonary hypertension (there is no valve to isolate the increased left atrial pressure from pulmonary veins) → • Right heart failure symptoms - due to pulmonary HT, secondary right ventricle dilation and tricuspid regurgitation

  41. Mitral stenosis • Presentation • Dyspnea • Syncope • Palpitations (atrialfibrilationiscommon) • In advancedcases - rightheartfailuresymptoms – periferaloedema, increased JVP, hepatomegaly, ascites…

  42. Mitral stenosis • Physical finding • Diastolic murmur • Low-pitched diastolic rumble most prominent at the apex. • Heard best with the patient lying on the left side in held expiration • Intensity of the diastolic murmur does not correlate with the severity of the stenosis • Lungcrackles • Pleuraleffusion • Facies mitralis: When MS is severe and the cardiac output is diminished, there is vasoconstriction, resulting in pinkish-purple patches on the cheeks (mightbeseen in terminalheartfailureofany cause)

  43. Mitral stenosis • Percutaneous therapy – PTMV – in caseswithsuitablemorphologyofmitralvalve • Surgical therapy -Mitralvalvereplacement • Medical therapy -Diureticsforoedema, ratecontrol therapy in atrialfibrillation, anticoagulant therapy (even in sinus rhytmwithgreatdilationofleft atrium)

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