Valvular Update

8/16/2019 Valvular Update

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Valvular Heart Disease

Hakim Alkatiri



Mitral Stenosis



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Mitral Stenosis

Causes •rheumatic fever •congenital abnormality, calcification, myxoma

Natural history•RF age 12•murmur 1st heard 20 yrs later •symptoms in !"th decade



Mitral Stenosis ! #linical features

Severity MVA (cm²) LAP (mm Hg) CO

Mild $2%0 &10!12 '(Moderate 1%1!2%0 )10!1* '(

Severe &1%0 $1+

,ery Severe &0%+ $20!2-

Severity Symptoms

Mild .symptomatic or mild /

Moderate Mild!mod / orthopnea, 3'/, hemoptysis

Severe /yspnea at rest possible pulmonary edema

ery Severe Severe 345 R failure, mar6ed dyspnea at rest

severe fatigue cyanosis



Mitral Stenosis ! xamination

Inspection

Malar flush3eripheral cyanosis 7severe MS89ugular venous distension 7right ventricular failure8

Palpation3arasternal right ventricular impulse3alpable pulmonary arterial impulse3alpable S1, 32, and occasionally, the diastolic rumble

Auscultation

:ncreased intensity of the first heart soundpening snap

(o;!pitched diastolic rumbling murmur



Mitral Stenosis ! 5reatment

Meical

•/iuretic ! pulmonary congestion

•3revent embolism ! cause of 1<= deaths, ↑;ith

↑(. si>e and ↑age

anticoagulate all ;ith 3.F?.F, SR in older age

•#ontrol atrial fibrillation




!alloo" Mitral Valvuloplasty




!alloo" Mitral Valvuloplasty

•100= ↑M., final area )2cm2

•Failure rate 1!1-=

•Mortality 0!=•Severe MR 2!10=

•Restenosis )"0= at *years

•#ontraindications ! thrombus, MR, #a@@, other

disease




Mitral Valve #eplaceme"t

•pen mitral valvotomy

•Mitral valve replacement



Mitral Regurgitation ! .etiology

•Primary

A""ulus annular calcification

Lea$let myxomatous degeneration

rheumatic deformity

infectious perforation

Chorae myxomatous degeneration

spontaneous rupture

rheumatic shortening

infectious destructionPapillary infarction

ischemic lengthening

•%u"ctio"al

( dilatation and 3M displacement



CXR



Mitral Regurgitation ! 3athophysiology



Mitral Regurgitation ! #linical findings

Acute dyspnoea, orthopnoeano cardiomegaly, short murmur, S

Chro"ic variable symptoms

cardiomegaly, murmur, 32 loud, S

&ua"ti$icatio"

•echocardiography, angiography•serial studies, ( function



Mitral Regurgitasi

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Mitral Regurgitation ! utcome in

#hronic MR

ariable course ! diagnosis to symptoms 1A years

Symptomatic severe ! survival = at - years

mortality )-= per year

( dysfunction most important factor



Mitral Regurgitation ! 5reatment

•/iuretics ↓( filling 3, ↓p oedema

•asodilators ↑for;ard S

•:.B3

Acute

Chro"ic

'o 6no;n effective therapy

•asodilators ! theoretical ris6s

•5reat complications



Mitral Regurgitation ! Surgery

Optio"s•alve repair

•MR ;ith chordal preservation

•MR ;ith destruction M apparatus

Outcome

•Mortality +0!<"= v "0!A0= at -!10years•alve function

•entricular function



Mitral Regurgitation ! :ndications for surgery

'o randomised trialsCC

'( Symptomatic )ith "ormal LV $u"ctio"

•prognosis ;orse once 'D4. class :: symptoms

*( Symptomatic )ith a+"ormal LV $u"ctio"

• :f severe ( impairment ! poor outloo6

•F & 0= Emedical Rx better




,( Asymptomatic )ith a+"ormal LV $u"ctio"

• E .symptomatic

•/etection of ( dysfunction is the 6ey

F&A0=, (S/ $ "-mm, (S$--ml?m2

-( Asymptomatic )ith "ormal LV $u"ctio"

•Eguaranteed repair

•345, recent .F



Mitral Regurgitation ! 3rolapse

•2!"= population•femalesmales 21

•diagnosis from echocardiography

•subcategory according to leaflet abnormality

•SB prophylaxis normal @ MR or abnormal leaflets



.ortic Stenosis ! .etiology

•#ongenital 1st!rd decade

alve degeneration and calcification

•Rheumatic ! "th decade

•Bicuspid valve 1=, males$females, -!Ath decades

•5ricuspid valve ! *!+th decades, 1!2= incidence



.ortic Stenosis ! 3athophysiology

( pressure overload → ( hypertrophy → diastolic( dysfunction

Systolic function usually preserved except late in

diseaseSystolic function improves ;ith .R

utcome is dependent on symptoms



.ortic Stenosis ! #linical features

Symptoms

•'one

•/, di>>iness

•4F, syncope, angina./ami"atio"

•3ulse ! ↓amplitude, delay

•Sustained apex

•S2! soft and single → paradoxical splitting

•SM ! loud → late pea6 → soft



.ortic Stenosis ! Severity

.chocariography

Mea"graie"t(mmHg)

Pea0 Aovelocity

AVA(cm*)

Normal 1%0!2%0 $2%-

Mil &20 2%-!2%< $1%*

Moerate 20!"0 %0!"%0 1%0!1%*

Severe $"0 $"%0 &1%0



.ortic Stenosis ! utcome

Symptoms

•2!year survival & -0=

Asymptomatic

•Generally good prognosis•3ea6 velocity $"%0m?s → 2yr event!free survival 21=

•3rogression of$ 0%m?s per year ! ;orse



.ortic Stenosis ! 5reatment

Meical

•'oneCCC

•/iuretics v (F

• .#: contraindicated

!alloo" aortic valvuloplasty

• .verage M. improvement 0%+cm2 → 1%0cm2

•Restenosis &A?12 in -0=

•'o improvement in mortality

•3rocedural mortality -=



.ortic Stenosis ! .R

:ndicated only if symptomatic

•Mortality 0%A!-=

•Survival A*!+-= at - yrs, *0= at 10yrs

•2yr survival "x greater than medical treatment

LV ys$u"ctio"

•Eimpairment from pressure overload or other cause

•/S may be helpful



.ortic Stenosis ! .R



.ortic Regurgitation ! .etiology

#oot .nnuloaoroectasia

Marfans

/issectionSyphillis

.n6ylosing spondylitis

Lea$letndocarditis

Bicuspid valve

Rheumatic heart disease



Aorta Regurgitasi

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.ortic Regurgitation ! 3athophysiology

Normal



.cute .ortic Regurgitation ! #linical features

'o time for ( to enlarge

↑total S, ↓f;d S, ↑ ↑(/3

Huiet S1 7presystolic M closure8,

short murmur

1reatme"t

•Medical therapy ineffective

• .R if symptoms?signs (F



#hronic .ortic Regurgitation ! #linical features

↑total S, maintained f;d S, R runoff in diastole

→ ↑systolic B3, ↓diastolic B3

→Volume a" pressure overloa

xamination ! hyperdynamic circulation, ;ide pulse

pressure, dilated (, /M duration important



#hronic .ortic Regurgitation ! #linical features

Maybe asymptomatic, (F, angina

LV ecompe"satio"



#hronic .ortic Regurgitation ! 5reatment

Meical ! ↓afterload

'ifedipine 20mg bd delayed surgery by 2! yrs

/uplicated ;ith small .#: trials

asodilator therapy



ACC / AHA Practice Guidelines 2006

Indications for AVr/R

Class 2

1% .R is indicated for Symptomatic patients ;ith

severe .R irrespective of ( systolic function%2% .R is indicated for asymptomatic patients ;ith

chronic severe .R and ( systolic dysfunction 7 F

-0 = or less8 at rest%

.R is indicated for patiens ;ith chronic severe .R;hile undergoing #.BG or surgery on the aorta or

other heart valves%

ACC / AHA Practice Guidelines 2006

Indications for AVr/R

Class 2

1% .R is indicated for Symptomatic patients ;ith

severe .R irrespective of ( systolic function%2% .R is indicated for asymptomatic patients ;ith

chronic severe .R and ( systolic dysfunction 7 F

-0 = or less8 at rest%

.R is indicated for patiens ;ith chronic severe .R

;hile undergoing #.BG or surgery on the aorta or

other heart valves%

S mmar



Summary

Summary



Summary



%rikuspid regurgitasi

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