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Rheumatic heart disease

Rheumatic heart disease. Mitral stenosis. Valvular heart disease. Rheumatic Age related congenital. Mitral valve. Stenosis Regurgitation Prolapse. Mitral stenosis. 2/3 females Usually rheumatic Rarely congenital 40% of all RHD . Structural defects.

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Rheumatic heart disease

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  1. Rheumatic heart disease Mitral stenosis

  2. Valvular heart disease • Rheumatic • Age related • congenital

  3. Mitral valve • Stenosis • Regurgitation • Prolapse

  4. Mitral stenosis • 2/3 females • Usually rheumatic • Rarely congenital • 40% of all RHD

  5. Structural defects • Diffusely thickened –fibrous tissue /calcified deposits • Mitral commisures fuse • Corde tendinae fuse /shorten • Narrowing of the apex of funnel shaped valves

  6. Calcification of slender valves immobilises the leaflet and narrows the orifice –thrombus formation –arterial thrombus from calcified Valves

  7. Pathophysiology • Normal mv –dia -4-6 cm2 • <2 cm 2-atrial to ventricular flow is maintained by increased av pressure gradient –the hallmark of ms • <1 cm2 –LAP should be atleast 25mm hg is required to maintain normal output .

  8. Increased Lap --------increased pulm pressure ------increased capillary pressure -----decreased pulm compliance -------exertionaldyspnoea. • Increased heart rate –decreased transvalvular gradient ----increased LAP • Lv diastolic pressure in normal in ms • Co is normal at rest ---at exercise –decreased co.

  9. $ • Clinical /hemodynamic Features –influenced by • Passive backward transmission of LAP • Pulmonary arteriolar constriction • Intertitial edema • Organic obliterative changes in the pul vascular bed • Phtn----Tr------rt sided failures---bornheimeffect

  10. symptoms • Carditis---ms-----2 decades, • Dyspnoea on exertion ----4 th decade—progressive worsening to death---2-5 yrs • Doe ,orthopnoea ,pnd,arrthmia-premature atraial complex,paroxysysmal tachycardia,flutter,fibrilation • Haemoptysis –increased pulm venous pressure

  11. Recurrantpulm embolism • Pulm infection • Endocarditis • Chest pain -10% • Thrombus formation in the left atrium-af—appendages of LA • Pedunculated thrombus –ball valve thrombi • -syncope-angina –changing ascultatory signs

  12. On examination • Malar flush-pinched blue facies • JVP-a wave prominence –af –a wave absent • Palpation-tapping apical impulse ,s1 loud,palpable ,s2 p2 loud • Diastolic thrill • Auscultation-s1 accentuated /snapping –delayed –mv doesn’t close till LVP>LAP • Qs prolongation ,p2 loud

  13. A2-p2-os -0.05-0.12 • P2-os –severity of ms • Intensity of s1/os –pliability of leAFLET • MDM after os • Duration correlates with ms severity • S1-closure of mitral /tricuspid valve

  14. Intensity of s1 • Pos of mv at onset of vent systole • Rate of increase in LAP • Degree of structural damage of the valve • Amt of tissue bet heart and sthetoscope

  15. S1 loud –diastole is shortened by tachycardia • S1 split -10-30 msec • S1 –m1t1-----prolonged in rbbb • t1m1 –severe ms ,left atrial myoma lbbb

  16. Mitrl regurgitation

  17. etiology • Chronic rhd –severe mr- 1/3 • Seen in males mostly • Rheumatic process-rigidity,deformity,retraction of the valve cusps-commisural fusion • Congenital-endocardial cushion defects • Fibrosis of papillary muscles in MI • Ischeamia –paplillary dysfn

  18. Lv dilated in DCM • HOCM-ant displace ment of the ant leaflet • Mitral prolapse –MR • Acute MR-inf endocarditis

  19. pathophysiology • Clinical pic depends on p-v relation ship of LA AND PUL -VENOUS BED • Increased LAP-Increased pulm edema • Effective forward pressure of lv decreases • Inc-LA volume –due to atrial compliance • Low cardiac out put • Atrial fibrillation

  20. SYMPTOMS • FATIGUE • Doe • Orthopnea • Pnd • Haemoptysis • Sys embolism • Rh f-jvp inc,tr,phtn,hep congestion

  21. Physical examination • Sys thrill-left apex • Hyperdynmic apical impulse • Laterally displaced • Palpable p2 • Parasternal heave

  22. auscultation • S1-absent/softor buried in systolic murmur • Decreased co-aorta closes early-a2 early-wide spliting of s2 • Os –indicates ms • Gallop rhythm • Pansystolic murmur

  23. lab • Ecg –sinus rhythm ,prominent p waves ,af lvh • Echo • Cxr-kerley b lines

  24. management • Medical • Dec exertion • Dec NA intake • Diuretics • Digitalis/vasodilators-inc co • Ace inhibitors /hydralazine • Surgical-valve replacement

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