بسم هللا الرحمن الرحيم Part-1: Valvular Heart Disease

Dr. Faisal Alatawi

Consultant cardiologist

Assistant professor

Medical College - Taibah University

Objectives:

• To know basic anatomy ,aetiology and pathophysiology of Mitral stenosis ,Mitral regurgitation , Aortic stenosis and aortic regurgitation.

• To know the clinical picture ( symptoms and signs of VHD)

• To know most common findings of ECG, Chest X-ray and echocardiography of different types of valvular lesions.

• To introduce basic management of Valvular lesions

Mitral Stenosis: Aetiologies

• Rheumatic :almost all cases in adults

• Mitral Annular calcification (rare in old )

• Congenital ( rare )

P

Normal MVA

4-6 cm2

Symptoms

MVA < 2 cm2

Severe

MVA < 1 LV

LA AOR

Mitral valve area ( MVA)

PATHOPHYSIOLOGY

• 1-Restriction of flow

across stenotic MV

increases LA pressure

• 2-Increase LA pressure

leads to LA dilatation,

pulmonary congestion

and subsequently

pulmonary hypertension

Symptoms of mitral Stenosis

• Dyspnea :due to pulmonary congestion

• Fatigue :due to decrease cardiac out put

• Inability to tolerate tachycardia ( exercise , stress ,pregnancy ,AF):due to decease time of LV filling ( diastolic time) , which lead to quick elevation of LA pressure and pulmonary congestion

Physical Exam

• Auscultation:

–Opening snap ( pliable valve )

–Mid diastolic rumbling murmur)

image from Davidson text book 21 ed

Management Mitral Stenosis

Medical Therapy – to relief symptoms

• Diuretics decrease congestion

• Digoxin, Beta and Ca Channel Blockers for heart rate control

• Anticoagulation to prevent LA thrombus formation in AF

Images are from Cath lab digest website and wikipedia

Management Mitral Stenosis

Surgical Therapy

• Open Commisurotomy ( valve repair)

• Mitral Valve Replacement

Mitral Regurgitation

Mitral regurgitation (MR) is a common valvular disorder that can arise from abnormalities of any part of the mitral valve apparatus

This image from up to date

•Rheumatic

•MV Prolapse

•Endocarditis

Aetiology

( Dr Edward collection , Mayo clinic )

Mitral Regurgitation : pathophysiology

• In chronic severe MR , there is volume overload on both LA and LV , by time both will dilate

• Cardiac out put decrease because more than 50% of stroke volume will go to LA during systole

• In Acute MR , no time for LA to dilate so diastolic pressures rise quickly and pulmonary edema may develop suddenly

Mitral Regurgitation :Symptoms

Severe MR :remain asymptomatic until there is LV dysfunction , PHTN , or AF

– Fatigue and weakness ( low COP)

–Palpitation ( AF or flutter)

–Dyspnea and orthopnea ( pulm. congestion)

–Right sided HF ( secondary to pulmonary hypertension )

Physical Exam

•Irregular pulse( AF) •Displaced hyperdynamic apex ( cardiomegaly ) •Systolic thrill •Soft first heart sound •Apical pansystolic murmur

Investigation of MR

This plain chest radiograph from a patient with known mitral regurgitation

demonstrates cardiomegaly with left atrial (black arrow) and left ventricular

enlargement (red arrow), as well as mild pulmonary venous redistribution,

all features characteristic of mitral regurgitation.

Chest X-ray

Source : up to date

Mitral Regurgitation: Investigation

Echocardiography Diagnostic tool for valvular lesions , see MR movie

Management

• In moderate or severe MR with mild symptoms and no LV dysfunction , after load reduction with ACE I of no proven benefit .

• Definite therapy of severe MR is mitral valve surgery ( repair is better than replacement )

Management

• Mitral valve clip : MV repair by catheter

– New approach for patients with severe MR who cant tolerate surgery for different reasons

Image:http://www.hivehealthmedia.com/mitraclip-approach-

managing-valvular-heart-diseases/, Movie :from our echo lab

Aortic Stenosis

Aortic Stenosis :Aetiologies

• Congenital :

–valvular ( Bicuspid)

–Subvalvular ( membrane)

–Supravalvular

• Rheumatic( developing countries)

• Degenerative ( in old )

Normal AVA 3-4 cm2

Aortic Stenosis

Aortic Stenosis :pathophysiology

Outflow

obstruction

Death

Hypertrophy Diastolic dysfunction

Myocardial Ischemia

Systolic dysfunction

Aortic Stenosis : symptomes

• Angina : Increase oxygen demand due to LVH

• Syncope with effort: due to fixed cardiac out put

• Heart failure :diastolic dysfunction

Investigations

• ECG: LVH

• ECHO: See Movie

• CXR

• Coronary angiography if CAD is suspected before AV surgery

Aortic Stenosis

Operation with aortic valve replacement

Improves symptom & prognosis

Bioprosthetic vs Mechanical AVR

Transcatheter Aortic Valve Implantation , TAVI

Lenard Conradi, Hendrik et al

Interv Cardiol. 2010;2(4):513-523.

Aortic Regurgitation Etiologies • Abnormalities of the Leaflets

• Rheumatic • Congenital ( Bicuspid) • Degenerative ( old) • Endocarditis

• Dilation of the Aortic Annulus –Aortic Aneurysm / Dissection

• Chronic uncontrolled HTN • Inheritable (Marfans) • Inflammatory (Syphyllis, Giant Cell

Arteritis)

Aortic Regurg – pathophysiology

Chronic AR

There is time for LV and LA to dilate

symptoms appear after long time ,

when LV function deteriorate

LA

LV

Acute AR

No time for LV to dilate

Acute elevation of LV

diastolic pressure

Leads to acute elevation

of LA pressure and

patient will come in acute

pulmonary oedema

LA

LV

Aortic Regurgitation :symptoms

• Shortness of breath secondary to pulmonary venous congestion

• Angina due to decreased coronary flow

• Palpitation

• Fatigue due to decreased cardiac out put

Aortic Regurgitation

Physical Exam

• Bounding Pulses

• Hyperdynamic LV apical impulse

• Diastolic Decrescendo Blowing Murmur

• Apical Rumble – “Austin Flint Murmur”

Aortic Regurgitation:Diagnosis

–ECG – LA dilatation, LVH

–Echocardiography

–Cardiac Cath – look at the coronaries ( in patients with CAD risk factors)

Treatment of Aortic Regurg

Medical Therapy of asymptomatic • Serial Check ups with echo

• Vasodialators (Nifedipine, ACE-I , benefit is unproven )

Treatment of Symptomatic Aortic Regurg

Aortic Valve Replacement

Bioprosthetic vs Mechanical AVR

Tricuspid valve regurgitation (TR )

• Mild TR: very common, normal

• > mild TR: mostly functional secondary to dilatation of right ventricle( RV).

• RV dilatation mostly due to left sided cardiac lesions and pulmonary hypertension

• Rheumatic fever can affect TV and cause TR

Clinical picture

• In sever TR :Right sided HF

• JVP: prominent V wave

• Pansystolic murmur increase during inspiration

Management

• Diuretics : spiranolacton , furosemid

• Digoxin , ACE I for RV function

• TV repair in severe TR with symptoms or with left sided valve surgery

Part II :Heart Failure

Prepared by Dr Hussein M Ismail, MD Cardiology

ILOs

1. To demonstrate definition of cardiac failure, and the magnitude of the problem.

2. To demonstrate knowledge of the pathophysiology of cardiac failure.

3. To demonstrate knowledge of signs and symptoms of cardiac failure.

4. To demonstrate knowledge of the investigations of cardiac failure.

5. To demonstrate knowledge of the different option of treatment of cardiac failure.

6. To demonstrate knowledge of the actions of drugs (including unwanted effects) on cardiac muscle and vascular smooth muscle

Congestive Heart Failure (HF): definitions

HF is the state in which the heart is unable to pump blood at a rate sufficient with the requirements of the tissues or can do so only from high pressures. (Braunwald 8th Edition, 2001)

Magnitude of the problem of HF

World-wide, there are about 23 million people with HF.

Prevalence of HF in Scotland the is high at 7.1 in 1000, rising to 90 in 1000 among patients over 85 years.

5.8 million Americans have HF, with 670,000 new diagnoses each year.

One in every five patients dies from heart failure with in the first year from diagnosis. (CDC)

Causes of heart failure

• Main causes are:

1.Ischemic heart disease

2.Cardiomyopathy

3.Hypertension

4.Valvular heart disease

(Kumar

2009)

Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.

Pathologic

remodeling

Low ejection

fraction Death

Symptoms:

Dyspnea

Fatigue

Edema

Chronic

heart

failure

•Neurohormonal stimulation

•Myocardial toxicity

Sudden

Death

Pump

failure

Coronary artery

disease

Hypertension

Cardiomyopathy

Valvular disease

Myocardial

injury

Pathologic Progression of CV Disease

Diabetes Causes of heart failur

e

Compensatory Mechanisms

Two main systems:

1.Renin-Angiotensin-

Aldosterone system.

2.Adrenergic activation.

Types of Heart Failure: Firstly, systolic or diastolic

Systolic heart failure is when the heart becomes weak and the ventricle becomes enlarged. The weakened ventricle is then unable to pump enough blood out during contractions. EF is reduced.

Diastolic heart failure is when the ventricle becomes stiff and does not relax appropriately between contractions. Due to this the ventricles are unable to fully fill with blood so there is less to eject during contractions. (Porth, 2009). EF is normal.

Secondly, Left or Right-side heart failure

• Refers to the ventricle that is primarily affected

• Initially heart failure can affect only one side, but long term heart failure usually affect both ventricles.

• Left sided heart failure is when the left ventricle is unable to move blood from the pulmonary circulation to the arterial circulation. This results in blood pooling in the pulmonary veins.

• Right sided heart failure is when the right ventricle is unable to move un-oxygenated blood from the venous system into the pulmonary system, which results in blood pooling in the systemic vessels. (Porth, 2009).

(Porth, 2009).

Ejection Fraction: Normal 55-65% Calculated by echocardiography

Symptoms and signs of Heart Failure

Symptoms:

1. Dyspnea:

• PND

• Orthorpnea

• Exertional dyspnea.

2. Fatigue

(Hudson, 2009.)

10 Signs: (Kumar, 2009.)

■ Cardiomegaly

■ Third and fourth heart sounds

■ Elevated JVP

■ Tachycardia

■ Hypotension

■ Bi-basal crackles

■ Pleural effusion

■ Ankle oedema

■ Ascites ■ Tender hepatomegaly.

Explain

New York Heart Association (NYHA) classification is used to grade the severity of functional limitations in a patient with

heart failure • class I no limitation of physical activity – ordinary physical activity does not cause symotmes

• class II slight limitation of physical activity – patients are comfortable at rest. Ordinary physical activity results in symptoms

• class III marked limitation of physical activity – although patients are comfortable at rest, less than ordinary activity will lead

to symptoms (

• class IV inability to carry out any physical activity without discomfort – symptoms of congestive cardiac failure are present even at rest.

Explanation of dyspnoea with cardiac failure

1. Orthopnoea: increase venous return.

2. Paroxysmal Nocturnal Dyspnoea: shift of interstitial fluid into the blood vessels and increase in the venous return.

Stages of Heart Failure

Stage A- These patients DO NOT have symptoms or structural heart disease but are considered at high risk.

These patients have: Hypertension, Coronary artery disease, Diabetes, Obesity and a history of cardiomyopathy within the family.

Stage B- These patients DO NOT symptoms of heart failure, but have a structural damage to the heart as Left ventricular (LV) dysfunction, previous myocardial infarction, or asymptomatic valvular disease. (Cunningham, 2006.)

Stage C- These patients have structural heart disease and have or have had symptoms (heart failure) including: dyspnea, fatigue and reduced activity tolerance.

Stage D- These patients are in end stage heart failure. They have severe symptoms, even during rest despite maximum medical treatment, and have frequent hospitalizations or need specialized interventions at home. (Cunningham, 2006.)

Stages of Heart Failure (cont.)

Investigations

• ■ Blood tests:

– Full blood count

– Liver biochemistry

– Creatinine, urea and electrolytes

– Cardiac enzymes in acute heart failure

– BNP or N-terminal portion of proBNF (NPproBNP)

– Thyroid function.

Investigations (cont.)

• ■ Electrocardiogram: for ischaemia, hypertension or arrhythmia.

• ■ Echocardiography:

– Ejection fraction (Systolic function)

– Diastolic function

– Regional wall motion

– Cardiac chamber dimension

– Valvular heart disease, and cardiomyopathies.

Ejection Fraction: Normal 60-70% Calculated by echocardiography

Treatment (non-pharmacological)

– Health education on regular weight checking and compliance to medications.

• Salt restriction .

ACE inhibitors

Angiotensin receptor blockers

b Blockers

Digoxin

Aldosterone antagonists

Hydralazine and nitrates

Drug Therapy for Chronic HF (cont.)

Resources

• 1. Davidson’s .Principles & Practice of medicine, 22nd Edition.

• 2. Michael DS, Tracy RH .The world epidemiology of acute rheumatic fever and rheumatic heart disease, clinical epidemiology 2011:3 67-84.

• 3. Guidelines on the management of valvular heart disease (version 2012), European Heart Journal (2012) 33, 2451–2496 .

Thanks