Valvular heartDr. Hesham K. Rashid, MD

Ass. Professor of Cardiology

Benha University

Mitral stenosis Etiology :

1. Rheumatic heart2. Rare congenital 3. Lutembacher’s syndrome (MS + ASD).4. Senile calcify mitral valve .

Hemodynamic effects:1. Increase LA pressure that leading to

its dilatation2. Lung congestion.3. Reactive pulmonary arteriolar

vasoconstriction: - Decrease pulmonary

congestion. - Initiate pulmonary hypertension.4. LA dilatation produce AF & pressure

symptoms

Clinical picture:Symptoms:1. Mild cases may be asymptomatic.2. Moderate to severe cases present with

symptoms of pulmonary congestive symptoms

3. Palpitation (irregular) AF.4. Manifestation of pulmonary hypertension - low cardiac output. - right hypochondrial pain & GIT upset. - bilateral edema of lower limb . 5. Pressure symptoms: hoarseness of voice ,

dysphagia , and dyspnea

Signs :1. Apex is normal in position & slapping

(hypokinitic ) in character. 2. Palpable first heart sound3. Accentuated first heart sound.4. Opening snape after second heart

sound 5. Diastolic rumbling murmur at the apex6. Severe cases with pulmonary

hypertension manifestation of low cardiac out put can be seen as peripheral cyanosis – malar flash at the cheeks

1. Chest X- ray :show straight left border of the heart due to LA dilatation(mitralization )& double contour.

Investigations

2. Echocardiography :show thick leaflets dilated LA & can calculate mitral valve area

Complications :

1. Atrial fibrillation 2. LA thrombus & systemic

embolizations3. Infective endocarditis.4. Recurrence of rheumatic activity5. Pulmonary hypertension

Management :A- Medical treatment in minimal

symptomatic patients:- Diuretic to relieve lung congestion - Control rate of AF and give also oral

anticoagulant.- Prophylaxis against recurrence by LA

penicillin.- Prophylaxis against infective

endocarditis.- Follow up the patient by

Echocardiography.

B- surgical treatment :

- Open commissurotomy.- Closed commissurotomy.- Valve replacement.

C- percutaneous balloon mitral valvloplasty

Percutaneous balloon mitral valvuloplasty

Mitral regurgitation

Etiology :1. Rheumatic fever causing : - fibrosis & deformity of valve leaflets. - shortening of chordae tendinae .2. Dilatation of the LV & mitral valve ring

(functional)3. Dysfunction of papillary muscles: due to

ischemia , infarction.4. Less common causes as: - congenital abnormalities. - endocarditis. - HOCM - Mitral valve prolapse (degenerative disease )

Heamodynamic effect :1. Regurgitated jet from LV to LA during

systole leading to LA dilatation.2. Transmission of large volume from LA to

LV produce hyperdynamic heart.3. LV dilated and ending by failure if the

regurge is severe & prolonged.4. LV failure leading to pulmonary

congestion and if this is prolonged , pulmonary hypertension occurs

5. Atrial fibrillation may occur due to LA dilatation

Clinical picture: symptoms:1. For many years , patients with mild or

moderate mitral regurge are asymptomatic or complain only of palpitation.

2. Symptoms of pulmonary congestion appear due to LV failure .

3. Symptoms of low cardiac output may occur due to pulmonary hypertension

Signs :1. Hyperdynamic apex and may be

displaced outward and downwards.2. Systolic thrill at the apex.3. Pansystolic murmur at the apex &

propagated to the axilla4. Faint first heart sound.5. Third heart sound at the apex.6. Signs of LV failure as bilateral basal

crepitation.

DD : the causes of pansystolic murmur :1. Mitral regurge.2. Tricuspid regurge.3. VSD.

DD :from other causes of systolic murmur;

1. Mitral regurge.2. Aortic stenosis.

Investigations:1.Plain chest X-ray: - LV enlargement . - signs of pulmonary congestion.2.ECG: - P mitral. - LV dilatation.3.Echocardiography: - determine degree of regurge. - LV dimensions . - EF

Complications:1. LV failure.2. Pulmonary hypertension.3. AF.4. Thrombus formation.5. Rheumatic activity.6. Infective endocarditis.

A - Medical treatment:1. Prophylaxis against endocarditis.2. Prophylaxis against rheumatic activity3. ACE inhibitor .4. Diuretic in case of lung congestion5. Patient with AF : - digitalis to control rate. - oral anticoagulant

B- Surgical treatment : for symptomatic severe regurge - Mitral valve repair :in case of wide annulus , rupture chordae. - Mitral valve replacement : for destructive valve

Aortic regurge Etiology :1. The vast majority due to : rheumatic fever

.2. Rare causes : - Congenital heart disease. - Infective endocarditis. - Trauma. - Dissecting aneurysm. - Ankylosing spondylitis. - Syphilis. - Marfan syndrome.

Hemodynamic effect

(1) -Very low diastolic pressure.(2) -High systolic pressure.(3) -Wide pulse pressure (peripheral signs)(4) -LV dilatation & hypertrophy.(5) -LV failure.

C/P: Symptoms:

1. Mild & moderate case may be complaint from palpitation for a long time.

2. Manifestations of LV failure as dyspnea , orthopenia ,PND

3. Angina in severe cases only

Signs :1. High systolic pressure & very low

diastolic pressure2. Peripheral pulse has the following

characters: - High volume. - marked arterial pulsations in the

neck(corrigan´s) - water hummer pulse -pistol shot femoral. 3. Hyperdynamic apex & is displaced

outward and downward4. Long early diastolic murmur immediately

after second heart sound at second aortic area .

Investigations

1- Plain chest X-ray.2- ECG.3- Echocardiography

Complications :

1. Infective endocarditis. 2. Recurrence of rheumatic activity .3. Left ventricular failure.

Treatments :A- Medical treatment : - long acting penicillin - prophylaxis against endocarditis. - on severe LV failure use digitalis .

Diuretic , ACEIB- Surgery : aortic valve replacement on severe

symptomatic cases before LV failure.

Aortic stenosis

Causes :1. Rheumatic : it is more common in males2. Congenital : bicuspid aortic valve.3. Senile sclerosis : in old age. The valvular aortic stenosis should be

differentiated from other causes of LV outflow obstructions as:

A) Sub-aortic membrane.B) HOCM.C) Supra-valvular stenosis.

Hemodynamic effect

1.Mild stenosis may be asymptomatic

2.Severe cases cause LVH & end by failure due to pressure overload .

3.Low cardiac output.

4.Myocardial ischemia.

Symptoms :

1. Mild case asymptomatic.2. Low cardiac output.3. Myocardial ischemia4. Manifestation of left ventricular failure

late.5. Sudden death in severe case due to

arrhythmia

•Signs:

1.Plateau pulse2.Low pulse

pressure.3.Sustained apex.4.Systolic thrill.5.Ejection systolic

murmur6.Soft delayed

aortic component

Investigations

1.Plain X-ray : - calcifications. - Post stenotic

dilatation. - Signs of HF at

end stage

2. ECG: - signs of LVH & strain. - Arrhythmias

3. Echocardiography: - degree of stenosis - LVH - LV dimensions & function

Treatment :1. Medical : - prophylaxis against rheumatic

activity & infective endocarditis in rheumatic cases.

- Anti-failure treatment at end stage HF.

2. Surgical : aortic valve replacement .3. Balloon aortic dilatation in severe child

cases