Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and...

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Valvular Heart Disease Hakan Karpuz, MD Dept. of Cardiology Cerrahpasa Medical School

Transcript of Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and...

Valvular Heart Disease

Hakan Karpuz, MDDept. of Cardiology

Cerrahpasa Medical School

Valvular Heart Disease

(part I)

Hakan Karpuz, MDDept. of Cardiology

Cerrahpasa Medical School

Aortic ValveAortic Stenosis

 Aortic Regurgitation

 

Aortic ValveAortic Stenosis

 Aortic Regurgitation

 

Learning Objectives 

Describe the pathophysiology, etiology,

signs and symptoms, natural history, and

treatment of aortic stenosis.

 Aortic Stenosis 

Pathophysiology

Related to pressure changes, Valve obstructed,

LV > pressure, LV hypertrophy,

LA enlarges, Decreased cardiac output

 Etiology

Sub-valvular Supra-valvular

Valvular (most common)

 Aortic Stenosis

 

Etiology

Rheumatic Heart Disease Congenital AV Disease  Bicuspid Aortic Valve

Idiopathic Calcific Aortic Stenosis

 Aortic Stenosis“Valvular”

 

Symptoms

Fatigue Dyspnea on exertion

Angina Exertional Syncope

Heart Failure Sudden Cardiac Death

 Aortic Stenosis“Valvular”

 

Vital Signs Narrow pulse pressure

PMI Displaced

Ascultation

S2Murmur

 Aortic Stenosis“Valvular”

 

ECGHypertrophy

CXR Cardiomegaly 50% of the time

ECHOConfirm, Severity

LHCSeverity, Coronary Artery Disease

 Aortic Stenosis“Valvular”

Aortic Valve Area…formula

don’t forget!the best method is…

don’t forget!the best method is…

 

Natural History 

AsymptomaticFor many years

Duration of symptoms

(until death)

Angina  - 3 yearsSyncope - 2 yearsCHF - 18 months

 Aortic Stenosis“Valvular”

 

Treated Aortic Stenosis40% survived for 5 years

20% survived for 10 years

Sudden Cardiac DeathDecreased cerebral blood flow

Arrhythmias

Natural History 

 Aortic Stenosis“Valvular”

 

Treatment 

Strenous ActivityLimit for symptomatic

Medical treatment of HFACC/AHA guidelines for

preload/afterload reduction&fluid management

 

 Aortic Stenosis“Valvular”

 

Treatment 

Surgical treatmentindications, techniques, outcome

depend on age/cause

Adults: valve replacement

 Aortic Stenosis“Valvular”

Aortic ValveAortic Stenosis

 Aortic Regurgitation

 

Learning Objectives 

Describe the etiology, signs and symptoms,

findings and treatment for aortic insufficiency.

 

Etiology

Valvular DiseaseRheumatic Heart Disease

Infective EndocarditisTrauma

(tear of the ascending aorta)

Bicuspid valve

 Aortic Insufficiency

 

Etiology

Aortic root disease (1/3 of patients)Marfan’s syndrome

Cystic medial necrosisSyphilitic aortitis

Ankylosing spondylitisBehcets syndromeReiter’s syndrome

Systemic Hypertension

 Aortic Insufficiency

 

SymptomsAngina, Palpitations, CHF symptoms

Vital SignsWide pulse pressure

 Pulses

Abrupt distension/quick collapse: Corrigan’s pulseBisferiens pulse 

 Aortic Insufficiency

 

PalpationPMI, Thrill

Auscultation

S2 variable, A2 absentMurmur

Diastolic: patient sitting, leaning forward, on expiration,

diaphragm at Erb’s pointAustin Flint Murmur, De Musset’s

 Aortic Insufficiency

 

Findings  

EKGLVH CXR

Marked enlargement if AI is chronic ECHO

Confirms/severity LHC

Severity/CAD

 Aortic Insufficiency

remember!the best method is…

remember!the best method is…

 

Natural History 

 Aortic Insufficiency

 

Treatment  

Follow clinically (q 6 mos)Asymptomatic with normal LV

Use IE prophylaxis

TreatedSymptomatic with LV function decrease

MedicationsAVR

 Aortic Insufficiency

Valvular Heart Disease

(part II)

Hakan Karpuz, MDDept. of Cardiology

Cerrahpasa Medical School

Mitral ValveMitral Stenosis

 Mitral Regurgitation

 

Mitral ValveMitral Stenosis

 Mitral Regurgitation

 

Learning Objectives 

Describe the etiology, pathophysiology, signs and symptoms, physical exam, and treatment of

mitral stenosis.

 

Etiology

Rheumatic heart disease (female)

Congenital

Rare:SLE

AmyloidCarcinoid

Rheumatoid Arthritis

 Mitral Valve Stenosis

 

Pathophysiology

Minimum of 2 yrs for severe MS to develop after ARF

Pressure elevates in:

Left atriumPulmonary tree

Right heart

Atrial contraction30% of CO, Atrial fibrillation 

 Mitral Valve Stenosis

 

Dyspnea on exertion Hemoptysis Chest pain

CHF symptoms Hoarseness

Pulmonary Embolism Infective Endocarditis

 Mitral Valve Stenosis

 

Physical Exam 

InspectionJVP

Sternal lift Palpation

Sternal heaveApex

AuscultationAccentuated S1, Opening snap,

Diastolic murmur

 Mitral Valve Stenosis

 

EKGLAE

Pulmonary HTN

CXRLAE

ECHO

Confirm/severity

LHCSeverity/CAD

 Mitral Valve Stenosis

 

Treatment 

MedicalSBE prophylaxisAvoid strenuous exerciseDiureticsAnticoagulants

Rheumatic heart diseaseAtrial fibrillation

Treatment AFDigoxin

 Mitral Valve Stenosis

 

Treatment 

SurgicalAsymptomatic

FollowSymptomatic

Balloon ValvuloplastyOpen commissurotomyValve replacement

Mechanical Bio-prosthetic 

 Mitral Valve Stenosis

 

Mitral Valve Prolapse 

Other terms: Floppy valve, Barlow’s

Etiology Congenital

Marfan’s syndrome RHD

Sequelae of CM or MI Pathophysiology

Valve leaflet has redundant tissue Extra tissue balloons into LA, click sound

 

Mitral Valve Prolapse 

Incidence10-20 % of population

F > MClinical Presentation

AsymptomaticSymptomaticPalpitationsArrhythmias

Atypical Chest Pain

 

Mitral Valve Prolapse 

MVP-Physical Exam/Diagnosis 

Thin, young females Abnormalities

Skeletal Heart

Auscultation Mid-systolic click

 

MVP-Physical Exam/Diagnosis 

EKG Normal Abnormal

Arrhythmias: SVT NSST-T changes

ECHO Confirm the diagnosis R/O other abnormalities

 

MVP-Treatment 

Reassurance  

SBE prophylaxis  

Beta blockers

Mitral ValveMitral Stenosis

 Mitral Regurgitation

 

 

Etiology

Valve leaflets: (Do not close properly/Do not stay closed)

Chronic RHDSLE

TraumaEndocarditis

 Mitral Valve Regurgitation

 

Etiology  

Mitral annulus:Dilation

Calcification

Chordae tendinae:Congenital, Rupture, Endocarditis

 Mitral Valve Regurgitation

 

Etiology

Papillary muscles:Ischemia;Dysfunction

Scarring

Infarction:NecrosisRupture

 Mitral Valve Regurgitation

Annulardilatation

Perforation Degenerativ

 

Pathophysiology

MV and AV are in parallel Amount of MR is dependent on LV

outflow impedence, Increased by aortic stenosis

Symptoms

ChronicAcute

 Mitral Valve Regurgitation

 

Clinical Findings 

Auscultation

S1: DiminishedS2: Wide splitting

Murmur: Holosystolic, Loudest at apex

 Mitral Valve Regurgitation

 

EKGLAE

Atrial fibrillationLVH

CXR

Cardiomegaly: LVH/LAE

ECHO

 Mitral Valve Regurgitation

 

Treatment 

Low sodium diet Preload reduction: Diuretics

Afterload reduction: Vasodilators(Nitroprusside, ACE inhibitors, Hydralazine)

Digoxin SBE prophylaxis

 Mitral Valve Regurgitation

 

Treatment 

Surgical

Symptomatic:Class II, III, IV

Asymptomatic:Monitor Symptoms

Echo

 Mitral Valve Regurgitation

 

 TricuspidStenosis

 

EtiologyRheumatic

Pathophysiology

Pressures elevate in RA

SymptomsFatigue

Right sided symptoms

 Tricuspid Stenosis

 

Physical findingsJVD

Right sided failure sxs

EKGRAE

CXR

ECHO

TreatmentDiet restriction, Diuretics, Surgery

 Tricuspid Stenosis

 

 TricuspidRegurgitation

 

EtiologyValvular:

SBE, RHD, CHDAnnular:

Cor PulmonaleEbstein’s anomaly

Clinical features

SOB/DOE  

 Tricuspid Regurgitation

 

Physical examRight sided failure

Holosystolic murmur

EKGRAE, RVH

CXR

ECHO

 Tricuspid Regurgitation

 

Pulmonary Valve  

 

Pulmonary Valve 

Insufficiency

PHTN Little clinical significance

Treat PHTN  

 

Pulmonary Valve 

Stenosis

Congenital (common) Dyspnea

Physical examSystolic murmurSternal heave

EKG Treat symptoms, valvuloplasty, replacement