Valvular Heart Disease

Hakim Alkatiri

Mitral Stenosis

Mitral Stenosis
Causes
rheumatic fever
congenital abnormality, calcification, myxoma
Natural history
RF age 12
murmur 1st heard 20 yrs later
symptoms in 3-4th decade

Mitral Stenosis - Clinical features

Severity

MVA (cm)

LAP (mm Hg)

CO

>2.0

<10-12

NL

1.1-2.0

~10-17

NL

Severe

<1.0

>18

Very Severe

<0.8

>20-25

Mild
Moderate

Severity

Symptoms

Mild

Asymptomatic or mild DOE

Moderate

Mild-mod DOE; orthopnea, PND, hemoptysis

Severe

Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest;

severe fatigue; cyanosis

Mitral Stenosis - Examination

Inspection
Malar flush
Peripheral cyanosis (severe MS)
Jugular venous distension (right ventricular failure)
Palpation
Parasternal right ventricular impulse
Palpable pulmonary arterial impulse
Palpable S1, P2, and occasionally, the diastolic rumble
Auscultation
Increased intensity of the first heart sound
Opening snap
Low-pitched diastolic rumbling murmur

Mitral Stenosis - Treatment

Medical
Diuretic - pulmonary congestion
Prevent embolism - cause of 19% deaths, with
LA size and age
anticoagulate all with PAF/AF, SR in older age
Control atrial fibrillation

Mitral Stenosis - Treatment

Balloon Mitral Valvuloplasty

Mitral Stenosis - Treatment

Balloon Mitral Valvuloplasty
100% MVA, final area ~2cm2
Failure rate 1-15%
Mortality 0-3%
Severe MR 2-10%
Restenosis ~40% at 7years
Contraindications - thrombus, MR, Ca++, other
disease

Mitral Stenosis - Treatment

Mitral Valve Replacement
Open mitral valvotomy
Mitral valve replacement

Mitral Regurgitation - Aetiology

Primary
Annulus
Leaflet

Chordae

Papillary

annular calcification
myxomatous degeneration
rheumatic deformity
infectious perforation
myxomatous degeneration
spontaneous rupture
rheumatic shortening
infectious destruction
infarction
ischemic lengthening

Functional
LV dilatation and PM displacement

CXR

Mitral Regurgitation - Pathophysiology

Mitral Regurgitation - Clinical findings

Acute

dyspnoea, orthopnoea
no cardiomegaly, short murmur, S3

Chronic

variable symptoms
cardiomegaly, murmur, P2 loud, S3
Quantification

echocardiography, angiography
serial studies, LV function

Mitral Regurgitation - Outcome in

Chronic MR
Variable course - diagnosis to symptoms 16 years
Symptomatic severe - survival 33% at 5 years
mortality ~5% per year
LV dysfunction most important factor

Mitral Regurgitation - Treatment

Acute
Diuretics LV filling P, p oedema
Vasodilators

forward SV

IABP
Chronic
No known effective therapy
Vasodilators - theoretical risks
Treat complications

Mitral Regurgitation - Surgery

Options
Valve repair
MVR with chordal preservation
MVR with destruction MV apparatus
Outcome
Mortality 80-94% v 40-60% at 5-10years
Valve function
Ventricular function

Mitral Regurgitation - Indications for surgery

No randomised trials!!
1. Symptomatic with normal LV function
prognosis worse once NYHA class II symptoms

2. Symptomatic with abnormal LV function

If severe LV impairment - poor outlook
EF < 30% ?medical Rx better

Mitral Regurgitation - Indications for surgery

3. Asymptomatic with abnormal LV function
? Asymptomatic
Detection of LV dysfunction is the key
EF<60%, LVESD > 45mm, LVESV>55ml/m2
4. Asymptomatic with normal LV function
?guaranteed repair
PHT, recent AF

Mitral Regurgitation - Indications for surgery

Mitral Regurgitation - Prolapse

2-4% population
females:males 2:1
diagnosis from echocardiography
subcategory according to leaflet abnormality
SBE prophylaxis; normal + MR or abnormal leaflets

Aortic Stenosis - Aetiology

Congenital 1st-3rd decade

Valve degeneration and calcification
Rheumatic - 4th decade
Bicuspid valve; 1%, males>females, 5-6th decades
Tricuspid valve - 7-8th decades, 1-2% incidence

Aortic Stenosis - Pathophysiology

LV pressure overload LV hypertrophy diastolic
LV dysfunction
Systolic function usually preserved except late in
disease
Systolic function improves with AVR
Outcome is dependent on symptoms

Aortic Stenosis - Clinical features

Symptoms
None
DOE, dizziness
HF, syncope, angina
Examination
Pulse - amplitude, delay
Sustained apex
S2- soft and single paradoxical splitting
ESM - loud late peak soft

Aortic Stenosis - Severity

Echocardiography

Normal

Mean
Peak Ao AVA
gradient velocity (cm2)
(mmHg)
1.0-2.0
>2.5

Mild

<20

2.5-2.9

>1.7

Moderate 20-40

3.0-4.0

1.0-1.7

Severe

>4.0

<1.0

>40

Aortic Stenosis - Outcome

Symptoms
2-year survival < 50%
Asymptomatic
Generally good prognosis
Peak velocity >4.0m/s 2yr event-free survival 21%
Progression of> 0.3m/s per year - worse

Aortic Stenosis - Treatment

Medical
None!!!
Diuretics v LVF
ACEI contraindicated
Balloon aortic valvuloplasty
Average MVA improvement 0.8cm2 1.0cm2
Restenosis <6/12 in 50%
No improvement in mortality
Procedural mortality 5%

Aortic Stenosis - AVR

Indicated only if symptomatic
Mortality 0.6-5%
Survival 67-85% at 5 yrs, 70% at 10yrs
2yr survival 4x greater than medical treatment
LV dysfunction
?impairment from pressure overload or other cause
DSE may be helpful

Aortic Stenosis - AVR

Aortic Regurgitation - Aetiology

Root
Annuloaoroectasia
Marfans
Dissection
Syphillis
Ankylosing spondylitis
Leaflet
Endocarditis
Bicuspid valve
Rheumatic heart disease

Aortic Regurgitation - Pathophysiology

Normal

Acute Aortic Regurgitation - Clinical features

No time for LV to enlarge
total SV, fwd SV, LVEDP
Quiet S1 (presystolic MV closure),
short murmur
Treatment
Medical therapy ineffective
AVR if symptoms/signs LVF

Chronic Aortic Regurgitation - Clinical features

total SV, maintained fwd SV, RV runoff in diastole

systolic BP, diastolic BP
Volume and pressure overload
Examination - hyperdynamic circulation, wide pulse
pressure, dilated LV, EDM duration important

Chronic Aortic Regurgitation - Clinical features

LV decompensation

Maybe asymptomatic, LVF, angina

Chronic Aortic Regurgitation - Treatment

Medical - afterload
Nifedipine 20mg bd delayed surgery by 2-3 yrs
Duplicated with small ACEI trials

Vasodilator therapy

ACC
ACC // AHA
AHA Practice
Practice Guidelines
Guidelines 2006
2006
Indications
Indications for
for AVr/R
AVr/R
Class
ClassII
1.
1. AVR
AVRisisindicated
indicatedfor
for Symptomatic
Symptomaticpatients
patientswith
with
severe
severeAR
ARirrespective
irrespectiveof
ofLV
LVsystolic
systolicfunction.
function.
2.
2. AVR
AVRisisindicated
indicatedfor
for asymptomatic
asymptomatic patients
patientswith
with
chronic
chronicsevere
severeAR
ARand
andLV
LVsystolic
systolicdysfunction
dysfunction((EF
EF
50
50%
%or
or less)
less) at
atrest.
rest.
33 AVR
AVRisisindicated
indicatedfor
forpatiens
patiens with
withchronic
chronicsevere
severeAR
AR
while
whileundergoing
undergoingCABG
CABG or
orsurgery
surgeryon
onthe
theaorta
aortaor
or
other
otherheart
heart valves.
valves.

Summary

Summary