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Valvular Heart Disease (VHD)Chapter 9

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Pathophysiology•The primary causes for disease of the heart valves include rheumatic fever (resulting in rheumatic heart disease [RHD]), valves with congenital abnormalities, infection, and aging.•Limiting Factors:

– heart valve(s) involved (i.e., mitral, aortic, tricuspid, and/or pulmonary); condition of the valve (e.g., narrowing, or stenosis;–or not closing properly, regurgitation or insufficient–severity of the valve lesions; and–presence of coronary artery disease, myocardial dysfunction

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Overview of Heart Valves

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Overview of Heart Dynamic Flow

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PathophysiologyConditions –

–Mitral Stenosis–Mitral Regurgitation–Mitral Valve Prolapse–Aortic Stenosis–Aortic Regurgitation–Tricuspid Stenosis–Tricuspid Regurgitation–Pulmonic Stenosis–Pulmonic Regurgitation

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Mitral Stenosis–blood flow is obstructed across the mitral heart valve–emptying of the left atrium is impeded–resistance is increased across the mitral valve, which decreases ventricular filling.–decreased ventricular filling causes a decreased left ventricular stroke volume and cardiac output.–there is an elevation of the left atrial pressure, which may result in pulmonary hypertension.–When the left atrium becomes chronically overloaded, the atrial conduction fibers are stretched promote atrial fibrillation (thus an increased risk of atrial thrombus formation)

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Mitral Stenosis (MS)•predominant cause of MS is rheumatic fever•rheumatic MS includes thickening and shortening of the chordae tendineae, calcification of the valve leaflets, and fusion of the commissures (the borders where the leaflets meet).•Patients may present:

•Dyspnea•Hemoptysis•CP (angina)•Infective endocarditis

•Echo (transesophageal [ TEE ] ) is helpful in the diagnosis

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Mitral Regurgitation (MR)

Mitral regurgitation (MR) occurs when the leaflets of the mitral valve do not close properly.

Annular Dilation is the most common cause of MR, complicated with congestive heart failure

•Other factors involved:•congenital abnormalities,•mitral valve prolapse, •chordae tendineae rupture

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Symptoms of MR

Depend on the severity and the rate of development of the MR.

• mild MR produces no symptoms. • moderately severe MR can lead to increased left atrial and left ventricular volumes. This can manifest itself to pulmonary venous congestion, elevation of pulmonary artery pressures, and dyspnea.

Echocardiography (TEE) helps to determine whether or not left ventricular dysfunction or pulmonary hypertension has developed. Angiography can also be used for determining the severity of MR.Patients with MR need to be monitored for symptoms of ventricular dysfunction, dilation, or pulmonary hypertension.

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Mitral Valve ProlapseMitral valve prolapse (MVP) is a bowing of the mitral valve leaflets into the left atrium during ventricular systole. It is the most prevalent form of VHD.

Symptoms•is most often asymptomatic.•physical examination may identify MVP by the presence of a mid-systolic "click" and/or

murmur.•Can be confirmed with echocardiography 3-D echocardiography is now possible

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Aortic StenosisAortic stenosis (AS) is a narrowing of the aortic valve leaflets. It is commonly caused by gradual fibrosis and calcification of the aortic valve, thus the valve cannot open or close properly.•AS is accompanied by dyspnea, angina, and / or syncope, or combinations of the above. As AS progresses ventricular hypertrophy and dysfunction ensue. There is an increased risk of myocaridal ischemia, reduced Cardiac Output and poor coronary perfusion•Echocardiography can help to determine the severity of AS.

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•People with symptomatic/progressed AS are not candidates for exercise programs. The danger of sudden death is present, particularly during exercise.

•Clients with mild or moderate AS may have a normal exercise capacity. Exertional hemodynamics must be assessed

•Angina, dyspnea, and fatigue are common symptoms with exercise.

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Aortic Regurgitation

Aortic regurgitation (AR) occurs when the leaflets of the aortic valve do not close properly.•Valvular disease may develop in the setting of RHD, infective endocarditis, trauma, congenital lesions, or connective tissue-related diseases (ex. Marfan’s Syndrome)

•Long- standing hypertension (HTN) or aging can cause dilation of the aortic root, resulting in mild AR.

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Aortic Regurgitation• Mild AR may be tolerated with only mild dypsnea•Progressed AR presents fatigue, dypsnea, arrhythmias, and angina

•Strenuous exercise (e.g., isometric exercises) should be avoided in AR if weakening of the aortic wall is present.

•People with mild to moderate AR can pursue normal exercise activities.

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Tricuspid Stenosis

Tricuspid stenosis (TS) is a rare condition resulting from narrowing of the tricuspid valve. It is almost always secondary to RHD.

Symptoms:•Fatigue and lower extremity edema•Distended neck veins•Echo preferred for diagnosis

•Often people with TS are not candidates for testing or rehabilitation until after valve surgery.

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Tricuspid RegurgitationTricuspid regurgitation (TR) occurs when the leaflets of the tricuspid valve do not close properly. TR is often caused by dilation of the right ventricle and tricuspid annulus.

Signs / Symptoms•If pulmonary arterial pressure is elevated, fatigue, dilated neck veins, and peripheral edema develop. •Echo effective in accurate diagnosis of severity of TR

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Pulmonic StenosisPulmonic stenosis (PS) is a narrowing or tightening of the pulmonary valve. It is most often congenital, or RHD.

Signs / Symptoms•Usually asymptomatic•People with PS may present with:

–heart failure,–exertional dyspnea–syncope, –or chest pain (caused by the inability to increase pulmonary blood flow during exercise)

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Pulmonic Regurgitation

Pulmonic regurgitation (PR) occurs when the leaflets of the pulmonary valve do not close properly. Caused by Pulmonary Hypertension.

PR itself does not present symptoms, the underlying pulmonary hypertension does. Pulmonary HTN can include symptoms of fatigue, pre-syncope, and dypsnea.

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Effects on the Exercise ResponseMild VHD usually present few restrictions to exercise, problems arise as the severity of the disease progresses (see pg. 87-88 for the following):

•Mitral Stenosis - Mitral stenosis: In severe cases, tachycardia and atrial fibrillation are common. Cardiac output can be blunted during exercise, leading to exercise-induced hypotension. Abnormal exertional hemodynamics, especially in the presence of PPH, cause increased MVO2 demand, chest pain, and ST-segment depression.

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Effects on the Exercise Response•Mitral Regurgitation - Expect normal hemodynamic responses to exercise with mild to moderate MR. With severe MR, exercise capacity is limited as a result of reduced CO and hypotension.

•Aortic Stenosis - With mild asymptomatic AS, the exercise response may be quite normal. Exercise is generally contraindicated in severe, symptomatic AS because of the following factors: compensatory concentric left ventricular hypertrophy (LVH); diastolic dysfunction; CHF; inadequate MVO2 supply; and exertional syncope, dyspnea, and angina.

•Aortic Regurgitation - Asymptomatic patients with low to mild AR and good LV function should have normal responses to exercise. As the disease progresses, systolic dysfunction may severely limit exercise tolerance.

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Effects of Exercise Training•The mechanical function of a valve will not improve with exercise. However, the working capacity of the skeletal muscles can be improved.•Significant mitral stenosis may cause limitation to exercise because demands of the exercising muscle may be greater than the cardiac output available. •People with severe aortic stenosis should avoid vigorous physical activity because there is an increased risk of syncope or sudden death.

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Recommendations for Exercise Testing(see Table 11.1, p.89, next slide)

A cardiac examination should be performed prior to exercise testing to rule out AS and determine if exercise testing is contraindicated.

•Severe AS is an absolute contraindication to exercise.•Severe TS, TR, and PS are also contraindications toexercise. Indications for terminating exercise testing include:

– ECG changes (>2 mm ST-segment depression or elevation, – T-wave inversion with significant ST change, and serious dysrhythmias. – Abnormal changes in blood pressure (SBP > 250 mmHg or DBP > 115 mmHg).

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Recommendations for Exercise Programming

•Before an exercise program begins, the upper training rate and description of any symptoms should be documented from a diagnostic exercise test. •The severity of the stenosis must be established•Patients with significant PS or severe AS should refrain

from weight training•For patients who are unable to undergo surgery of the heart valves, the primary goal is to improve the working capacity of the skeletal muscles.

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Recommendations for Exercise Programming

Dynamic low-moderate intensity physical activity in individuals with mild VHD.

See special considerations for (p. 89):

•Mitral Stenosis - Physical activity and exercise are recommended in asymptomatic mild MS. The decision to start, modify, or stop exercise should be guided by signs and symptoms of exertional intolerance.

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Recommendations for Exercise Programming

•Mitral Regurgitation - Asymptomatic patients with MR of any severity who have normal sinus rhythm and LV function and pulmonary artery pressure can exercise without any restrictions.

•Aortic Stenosis - With mild asymptomatic AS, the exercise response may be quite normal. Exercise is generally contraindicated in severe, symptomatic AS because of the following factors: compensatory concentric LVH; diastolic dysfunction; CHF; inadequate MVO2 supply; and exertional syncope, dyspnea, and angina.

•Aortic Regurgitation - Asymptomatic patients with low to mild AR and good LV function should have normal responses to exercise. As the disease progresses, systolic dysfunction may severely limit exercise tolerance.

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End of Presentation