Valvular

Heart
Disease

Vincent E.
Friedewald, M.D.

Classification of
Heart Disease
Congenital
Coronary
Electrical
Endomyocardial
Pericardial
Valvular

The Cardiac Valves

Cardiac Valve
Anatomy

Valvular Heart
Disease
Acute and Chronic
are
Different Diseases

Aortic
Stenosis

Aortic Stenosis
Types
Valvular
Subvalvular
Supravalvular

Aortic
Valve
Stenosis

Aortic Valve
Stenosis
Bicuspid
Rheumatic
Degenerative

Aortic Valve Stenosis

Age Relationship

Bicuspid Aortic
Stenosis

Rheumatic Aortic
Stenosis

Degenerative
Aortic Stenosis

Degenerative Aortic
Stenosis
Risk Factors
Elevated LDL-cholesterol
Diabetes mellitus
Systemic arterial
hypertension
Cigarette smoking

Aortic Valve
Stenosis
Symptoms
Often
Asymptomatic
Angina pectoris
Dyspnea
Fatigue
Syncope

Aortic Valve
Stenosis
Signs
ARTERIAL PULSE, GEN RISE, SLOW
ARTERIAL PULSE, GEN AMP, ABSENT OR
REDUCED
ARTERIAL PULSE, GEN DOWNSLOPE
GRADUAL
ARTERIAL PULSE, GEN PULSE
PRESSURE, NARROW
ARTERIAL PULSE, GEN SHUDDER
ARTERY, CAROTID THRILL
HEART, LV APEX IMPULSE, PRESYSTOLIC
HEART, LSB MID MURMUR, DIASTOLIC
HEART, LSB MID MURMUR, SYSTOLIC

Aortic Valve
Stenosis
Signs (cont)

HEART, LV APEX CLICK, SYSTOLIC

HEART, LV APEX IMPULSE, SUSTAINED
HEART, RSB UPPER MURMUR, SYSTOLIC
HEART, RSB UPPER CLICK, SYSTOLIC
HEART, SOUND A2 ABSENT OR REDUCED
HEART, SOUND S1 SOFT
HEART, SOUND S2 SINGLE
HEART, SOUND S2 SPLIT REVERSED
(PARADOXICAL)
NECK, SUPRATERNAL NOTCH THRILL,
SYSTOLIC

FATIGUE

Aortic Valve
Stenosis
Symptoms

BREATHING DIFFICULT WITH EFFORT

(DYSPNEA)
CHEST, ANT PAIN, NONPLEURITIC (ANGINA
PECTORIS)
CHEST, ANT PALPITATIONS
CONSCIOUSNESS LOSS, SUDDEN
(SYNCOPE)
CONSCIOUSNESS LOSS, SUDDEN EFFORT
(EFFORT SYNCOPE)
DIZZINESS EFFORT

Aortic Valve
Stenosis
Untreated Prognosis

Aortic Valve
Stenosis
Chest X-Ray

Aortic Valve
Stenosis
ECG

Aortic Valve
Stenosis
Echo

Stenosis
AV Pressure
Gradient

Aortic Valve
Stenosis
Medical RX

No drugs alter course only valve

repair/replacement
Antibiotic Prophylaxis
? Statins
For symptoms (if not candidate
for valve replacement) afterload reduction, i.e.,
nitroglycerine, used with
caution to avoid BP fall

Aortic Valve
Stenosis
Surgical Rx
Valvotomy
Replacement

Artificial
Bioprosthesis
Minimally-invasive
transfemoral

Aortic Valve
Replacement
Transfemoral

Aortic Valve
Stenosis
Complications

Atrial fibrillation
Aortic Dissection
Heart failure
Infective endocarditis
Myocardial infarction
Sudden death

Aortic
Regurgitation
(Insufficiency
)

Aortic
Regurgitation
Etiologies
Primary aortic valve disease
Aortic root abnormalities
(Dissection, Syphilis)
Connective tissue disorders
(Marfans)
Infective endocarditis
Inflammatory disorders (SLE)
Tumors

Aortic Regurgitation
Symptoms
BREATHING DIFFICULT , NOCTURNAL
BREATHING DIFFICULT WITH EFFORT
CHEST, ANT PAIN, NONPLEURITIC
(ANGINA)
CHEST, ANT PALPITATIONS
HEAD, GEN PAIN
SWEATING NOCTURNAL

Aortic Regurgitation
Signs
ARTERIAL PRESSURE, GEN DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN SYSTOLIC, ELEVATED
ARTERIAL PULSE, GEN DOUBLE
ARTERIAL PULSE, GEN FALL, RAPID
ARTERIAL PULSE, GEN PULSE PRESSURE, WIDE
ARTERIAL PULSE, GEN RISE, RAPID
ARTERY, CAROTID THRILL
ARTERY, FEMORAL SOUND, DIASTOLIC
BOOMING

Aortic Regurgitation
Signs (cont)
HEAD BOBBING
HEART, LSB MID MURMUR, DIASTOLIC
HEART, LSB MID THRILL, DIASTOLIC
HEART, LV APEX IMPULSE, INF DISPLACEMENT
HEART, LV APEX IMPULSE, LAT
DISPLACEMENT
HEART, LV APEX IMPULSE, DIFFUSE
HEART, LV APEX MURMUR, DIASTOLIC
HEART, RSB UPPER MURMUR , SYSTOLIC
HEART, RSB UPPER MURMUR, DIASTOLIC

Aortic Regurgitation
Signs
(cont)
HEART, RSB UPPER THRILL, SYSTOLIC
HEART, SOUND A2 ABSENT OR REDUCED
HEART, SOUND S1 SOFT
HEART, SOUND S2 SPLIT REVERSED
HEART, SOUND S3 LV
MOUTH, UVULA PULSATIONS
NAILS PULSATIONS
NECK, SUPRATERNAL NOTCH THRILL,
SYSTOLIC

Aortic Regurgitation
Chronic
Chest X-Ray

Aortic Regurgitation

Echo

Aortic
Regurgitation

Medical Rx
Vasodilators to
reduce systolic BP
Antibiotic
prophylaxis

Aortic Regurgitation
Surgical Rx
Aortic valve
replacement

Mitral
Regurgitation
(Insufficiency)

Mitral Regurgitation
Etiologies
Congenital deformities
Degenerative, i.e., myxomatous
Endomyocardial fibroelastosis
Mitral annular calcification
Papillary muscle dysfunction
ischemic heart disease
Rheumatic

Mitral Regurgitation
Etiologies (cont)
Ergotamine toxicity
Carcinoid syndrome
Radiation Rx
SLE
Diet-drug therapy

Mitral Regurgitation
Papillary Muscles

Mitral Regurgitation

Leaflet Prolapse
(MVP Syndrome)

Mitral Regurgitation
Calcified Annulus

Mitral Regurgitation
Symptoms
BREATHING DIFF, EFFORT
FATIGUE
SKIN, GEN TEMPERATURE,
COOL
SWEATING EXCESSIVE

Mitral Regurgitation
Signs
ARTERIAL PULSE, GEN - AMP, ABSENT
OR REDUCED
ARTERIAL PULSE, GEN - FALL, RAPID
ARTERIAL PULSE, GEN - RISE, RAPID
CHEST, ANT LEFT - BULGE
HEART, LV APEX - IMPULSE, FORCEFUL
HEART, LV APEX - IMPULSE, DIFFUSE

Mitral Regurgitation
Signs (cont)
HEART, LV APEX - IMPULSE, SUSTAINED
HEART, LV APEX - MURMUR, DIASTOLIC
HEART, LV APEX - MURMUR, SYSTOLIC
HEART, SOUND P2 - LOUD
HEART, SOUND S3 LV
SKIN, GEN - TEMPERATURE, COOL

Mitral Regurgitation
2-D Echo

Mitral Regurgitation
Doppler Echo

Mitral Regurgitation
Complications
Atrial fibrillation
Pulmonary
hypertension
LV dysfunction
Infective
endocarditis

Mitral Regurgitation
Medical Rx
Antibiotic prophylaxis
ACEIs (functional form of
MR)
Beta-blockers (functional
form of MR)

Mitral Regurgitation
Surgical Rx
Mitral repair
Mitral valve
replacement

Mitral
Stenosis

Mitral Stenosis
Increased LA
Pressure

Mitral Stenosis
Etiologies
Rheumatic
Rare:
Congenital
Chest radiation
Left atrial myxoma
Mucopolysaccharidosis
Severe mitral annular
calcification

Mitral Stenosis
Symptoms
ABDOMEN, GEN PAIN
BREATHING DIFF, NOCTURNAL
BREATHING DIFF, EFFORT
BREATHING DIFF, RECLINING FLAT
BREATHING DIFF, RESTING
BREATHING RAPID
CHEST, ANT PAIN, NONPLEURITIC
CHEST, ANT PALPITATIONS
COUGH CHRONIC, NONSPECIFIC
FATIGUE
SPUTUM BLOODY

Mitral Stenosis
Signs
ARTERIAL PRESSURE, GEN DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN LOW
ARTERIAL PRESSURE, GEN SYSTOLIC, LOW
ARTERIAL PULSE, GEN AMP, ABSENT OR
REDUCED
BREATH SOUNDS, GEN WHEEZES
EXTREMITIES, LOWER BILATERAL - EDEMA
HEART RATE RAPID
HEART, LSB LOWER IMPULSE, SYSTOLIC

Mitral Stenosis
Signs (cont)
HEART,
HEART,
HEART,
HEART,
HEART,
HEART,
HEART,
HEART,

LSB LOWER MURMUR, DIASTOLIC

LSB MID PERCUSSION, DULLNESS
LV APEX MURMUR, DIASTOLIC
LV APEX OPENING SNAP, MITRAL
LV APEX THRILL, DIASTOLIC
RSB SOUND, SYSTOLIC EJECTION
RSB UPPER MURMUR, DIASTOLIC
SOUND P2 LOUD

Mitral Stenosis
Signs (cont)
HEART, SOUND P2 PALPABLE
HEART, SOUND S1 SOFT
HEART, SOUND S1 LOUD
LIVER ENLARGED
SKIN, CHEEKS COLOR, PINK PURPLE
SKIN, GEN COLOR, BLUE
VENOUS PULSE, JUGULAR - A WAVE,
LARGE
VENOUS PULSE, JUGULAR ELEVATED

Mitral
Stenosis
Chest X-ray

Mitral Stenosis

Echo

Mitral Stenosis
LA Thrombus

Mitral Stenosis
ECG

Mitral Stenosis
Complications
Atrial fibrillation
Infective Endocarditis
Peripheral embolism
Pulmonary hypertension

Mitral Stenosis
Medical RX
Antibiotic prophylaxis
Anticoagulation for
Atrial fibrillation
Prior embolic event
Documented LA
thrombus
Arrhythmia control

Mitral Stenosis
Surgical RX
Invasive valvuloplasty
Percutaneous
valvotomy
Valve replacement

Mitral Stenosis
Invasive
Valvuloplasty

Mitral Stenosis
Surgical RX
Valvuloplasty with
Balloon Catheter

Valvular Heart
Disease
Follow up
Antibiotic prophylaxis

symptoms
Change in symptoms
New

Change in physical findings

Echocardiography/other imaging

Thank
you!