4- Marboe Valvular heart disease - Columbia University€¦ · MV 65-70% MV & AV 25% Mitral...
20
12/9/2009 1 Aortic stenosis Aortic valve structure
Transcript of 4- Marboe Valvular heart disease - Columbia University€¦ · MV 65-70% MV & AV 25% Mitral...
12/9/2009
1
Aortic stenosis
Aortic valve structure
12/9/2009
2
Calcification
12/9/2009
3
12/9/2009
4
Aortic insufficiency- aortic dissection
• Hypertension• Hypertension• Connective tissue disorders
Marfan’s: 1 in 5000.70-85% familial - Autosomal dominantFib illi 1 (15 21) 500 di ti tFibrillin-1 (15q21) ~ 500 distinct
mutations
12/9/2009
5
Medial degeneration without atherosclerosis
Mitral stenosis
12/9/2009
6
Acute Rheumatic Fever
Immunologically mediated following 1 6Immunologically mediated, following 1-6 weeks after pharyngitis with Group A Streptococcus in 3% of those infected.
Antibodies against streptococcal M proteins g p pcross-react with similar antigenic determinants in joints, heart, skin, CNS.
Acute Rheumatic Fever: Major manifestations (need 2 for diagnosis)1 Migratory polyarthritis in 75%1. Migratory polyarthritis in 75%2. Carditis in 50%3. Sydenham’s chorea in 10%(involuntary,
rapid, purposeless movements – caudate)4. Erythema marginatum of skin in 10%
(brown/pink with pale center)5. Subcutaneous nodules (0.5 – 2 cm;
extensor surfaces, occur late)
12/9/2009
7
Acute Rheumatic Fever
Minor Manifestations (need 2 plus 1 Major): Previous rheumatic fever, arthralgia, fever, , g , ,increased ESR or CRP, prolonged P-R interval.
With 2 Major or Major/2MinorSupportive evidence of streptococcal
infection: ASO Ab, anti-DNAase B, positive throat culture
Excellent prognosis: 1% mortality - cardiac
Acute Rheumatic Fever
PancarditisPericarditisPericarditisMyocarditis (Aschoff body)Endocarditis with sterile vegetations
12/9/2009
8
Aschoff body of acute rheumatic carditis: a cardiac granuloma
12/9/2009
9
Chronic Rheumatic Heart Disease
Follows Acute Rheumatic Heart Disease by decadesFollows Acute Rheumatic Heart Disease by decades.MV 65-70%MV & AV 25%
Mitral stenosis, aortic stenosis.Arrhythmias (A. fib. with left atrial enlargement).Heart failure.Predisposed to infective endocarditis.
12/9/2009
10
12/9/2009
11
Chronic Rheumatic Heart Disease: “Fishmouth” deformity of the mitral valve
Mitral Valve Prolapse
• Most are asymptomaticMost are asymptomatic• Mid-systolic click• Rarely: chest pain, dyspnea, fatigue, or psychiatric
manifestations• ~3% have complications:
Infective endocarditisInfective endocarditisMitral insufficiencyThrombus formation with embolizationArrhythmia/sudden death (unknown mechanism)
12/9/2009
12
Aortic valve structure
Myxomatous, prolapsing mitral valve
12/9/2009
13
“Myxomatous” mitral valve
12/9/2009
14
Endocarditis
12/9/2009
15
12/9/2009
16
Non-bacterial thrombotic endocarditis (NBTE)
• Small (1-5 mm) sterile masses of fibrin on• Small (1-5 mm) sterile masses of fibrin on lines of closure.
• Hypercoagulable state: patients are often debilitated (“marantic” endocarditis) or may have malignancy (mucinous adenocarcinoma) renal failure sepsisadenocarcinoma), renal failure, sepsis.
• May embolize to brain, kidney, heart.• With bacteremia, may be converted to
infectious endocarditis.
Non-bacterial thrombotic endocarditis (NBTE)
12/9/2009
17
NBTE: No inflammation or organism in thrombus
Rupture of mitral valve papillary muscle causing MR
12/9/2009
18
Heart Valve Prostheses: Complications
• Mechanical: component failure• Mechanical: component failure• Bioprostheses: degeneration with
calcification• Both: Paravalvular leak, endocarditis.
Thrombosis and tissue overgrowthThrombosis and tissue overgrowth are less common in bioprostheses than in mechanical valves.
Bioprosthetic (Hancock)valve: Degeneration and tissue overgrowth
12/9/2009
19
AV prosthesis with thrombus (from aortic side)
12/9/2009
20
Tissue overgrowth of MV prosthesis (from atrial side
Endocarditis of ball valve prosthesis (Starr-Edwards)
