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Valvular Heart
DiseaseVincent E.
Friedewald, M.D.
Classification of Heart Disease
CongenitalCoronaryElectrical
EndomyocardialPericardial
Valvular
The Cardiac Valves
Cardiac Valve Anatomy
Valvular Heart Disease
Acute and Chronicare
Different Diseases
Aortic Stenosis
Aortic StenosisTypes
ValvularSubvalvular
Supravalvular
Aortic Valve
Stenosis
Aortic Valve StenosisBicuspid
RheumaticDegenerative
Aortic Valve StenosisAge Relationship
Bicuspid Aortic Stenosis
Rheumatic Aortic Stenosis
Degenerative Aortic Stenosis
Degenerative Aortic Stenosis
Risk FactorsElevated LDL-
cholesterolDiabetes mellitusSystemic arterial
hypertensionCigarette smoking
Aortic Valve Stenosis
Symptoms
Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope
Aortic Valve StenosisSigns
ARTERIAL PULSE, GEN – RISE, SLOW ARTERIAL PULSE, GEN – AMP, ABSENT OR
REDUCED ARTERIAL PULSE, GEN – DOWNSLOPE
GRADUAL ARTERIAL PULSE, GEN – PULSE
PRESSURE, NARROW ARTERIAL PULSE, GEN – SHUDDER ARTERY, CAROTID – THRILL HEART, LV APEX – IMPULSE,
PRESYSTOLIC HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – MURMUR, SYSTOLIC
Aortic Valve Stenosis
Signs (cont)HEART, LV APEX – CLICK, SYSTOLIC HEART, LV APEX – IMPULSE, SUSTAINED HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – CLICK, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SINGLE HEART, SOUND S2 – SPLIT REVERSED
(PARADOXICAL) NECK, SUPRATERNAL NOTCH – THRILL,
SYSTOLIC
Aortic Valve Stenosis
SymptomsFATIGUE BREATHING – DIFFICULT WITH EFFORT
(DYSPNEA) CHEST, ANT – PAIN, NONPLEURITIC (ANGINA
PECTORIS)CHEST, ANT – PALPITATIONS CONSCIOUSNESS – LOSS, SUDDEN
(SYNCOPE) CONSCIOUSNESS – LOSS, SUDDEN EFFORT
(EFFORT SYNCOPE) DIZZINESS – EFFORT
Aortic Valve Stenosis
Untreated Prognosis
Aortic Valve Stenosis
Chest X-Ray
Aortic Valve Stenosis
ECG
Aortic Valve Stenosis
Echo
Aortic Valve Stenosis
AV Pressure Gradient
Aortic Valve Stenosis
Medical RXNo drugs alter course – only
valve repair/replacementAntibiotic Prophylaxis? StatinsFor symptoms (if not candidate
for valve replacement) – after-load reduction, i.e., nitroglycerine, used with caution to avoid BP fall
Aortic Valve Stenosis
Surgical RxValvotomyReplacement
ArtificialBioprosthesisMinimally-
invasive transfemoral
Aortic Valve ReplacementTransfemoral
Aortic Valve Stenosis
ComplicationsAtrial fibrillationAortic Dissection
Heart failureInfective endocarditisMyocardial infarction
Sudden death
Aortic Regurgitation (Insufficiency
)
Aortic Regurgitation
EtiologiesPrimary aortic valve diseaseAortic root abnormalities
(Dissection, Syphilis)Connective tissue disorders
(Marfan’s)Infective endocarditisInflammatory disorders (SLE)Tumors
Aortic RegurgitationSymptoms
BREATHING – DIFFICULT , NOCTURNAL BREATHING – DIFFICULT WITH EFFORT CHEST, ANT – PAIN, NONPLEURITIC
(ANGINA)CHEST, ANT – PALPITATIONS HEAD, GEN – PAIN SWEATING – NOCTURNAL
Aortic RegurgitationSigns
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED ARTERIAL PULSE, GEN – DOUBLE ARTERIAL PULSE, GEN – FALL, RAPID ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE ARTERIAL PULSE, GEN – RISE, RAPID ARTERY, CAROTID – THRILL ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING
HEAD – BOBBING HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – THRILL, DIASTOLIC HEART, LV APEX – IMPULSE, INF
DISPLACEMENTHEART, LV APEX – IMPULSE, LAT
DISPLACEMENT HEART, LV APEX – IMPULSE, DIFFUSE HEART, LV APEX – MURMUR, DIASTOLIC HEART, RSB UPPER – MURMUR , SYSTOLIC HEART, RSB UPPER – MURMUR, DIASTOLIC
Aortic RegurgitationSigns (cont)
Aortic Regurgitation
Signs (cont)HEART, RSB UPPER – THRILL, SYSTOLIC HEART, SOUND A2 – ABSENT OR
REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SPLIT REVERSED HEART, SOUND S3 LV MOUTH, UVULA – PULSATIONS NAILS – PULSATIONS NECK, SUPRATERNAL NOTCH – THRILL,
SYSTOLIC
Aortic Regurgitation – ChronicChest X-Ray
Aortic RegurgitationEcho
Aortic Regurgitation
Medical Rx Vasodilators to
reduce systolic BPAntibiotic prophylaxis
Aortic Regurgitation
Surgical Rx
Aortic valve replacement
Mitral Regurgitation (Insufficiency)
Mitral RegurgitationEtiologies
Congenital deformities Degenerative, i.e., myxomatous
Endomyocardial fibroelastosisMitral annular calcificationPapillary muscle dysfunction
– ischemic heart diseaseRheumatic
Mitral RegurgitationEtiologies (cont)Ergotamine toxicityCarcinoid syndromeRadiation RxSLEDiet-drug therapy
Mitral RegurgitationPapillary Muscles
Mitral RegurgitationLeaflet Prolapse (MVP Syndrome)
Mitral Regurgitation
Calcified Annulus
Mitral Regurgitation
SymptomsBREATHING – DIFF, EFFORTFATIGUE SKIN, GEN – TEMPERATURE, COOL
SWEATING – EXCESSIVE
Mitral RegurgitationSigns
ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN - FALL, RAPID ARTERIAL PULSE, GEN - RISE, RAPID CHEST, ANT LEFT - BULGE HEART, LV APEX - IMPULSE, FORCEFUL HEART, LV APEX - IMPULSE, DIFFUSE
Mitral RegurgitationSigns (cont)
HEART, LV APEX - IMPULSE, SUSTAINED
HEART, LV APEX - MURMUR, DIASTOLIC
HEART, LV APEX - MURMUR, SYSTOLIC
HEART, SOUND P2 - LOUD HEART, SOUND S3 LV SKIN, GEN - TEMPERATURE, COOL
Mitral Regurgitation2-D Echo
Mitral RegurgitationDoppler Echo
Mitral RegurgitationComplications
Atrial fibrillationPulmonary
hypertensionLV dysfunctionInfective
endocarditis
Mitral RegurgitationMedical Rx
Antibiotic prophylaxis
ACEIs (functional form of MR)
Beta-blockers (functional form of MR)
Mitral RegurgitationSurgical Rx
Mitral repairMitral valve
replacement
Mitral Stenosis
Mitral StenosisIncreased LA
Pressure
Mitral StenosisEtiologiesRheumaticRare:
CongenitalChest radiationLeft atrial myxomaMucopolysaccharidosisSevere mitral annular
calcification
Mitral StenosisSymptoms
ABDOMEN, GEN – PAIN BREATHING – DIFF, NOCTURNALBREATHING – DIFF, EFFORTBREATHING – DIFF, RECLINING FLATBREATHING – DIFF, RESTINGBREATHING – RAPIDCHEST, ANT – PAIN, NONPLEURITIC CHEST, ANT – PALPITATIONS COUGH – CHRONIC, NONSPECIFIC FATIGUE SPUTUM – BLOODY
Mitral StenosisSigns
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW ARTERIAL PULSE, GEN – AMP, ABSENT OR
REDUCED BREATH SOUNDS, GEN – WHEEZES EXTREMITIES, LOWER BILATERAL - EDEMA HEART RATE – RAPID HEART, LSB LOWER – IMPULSE, SYSTOLIC
Mitral StenosisSigns (cont)
HEART, LSB LOWER – MURMUR, DIASTOLIC HEART, LSB MID – PERCUSSION, DULLNESS HEART, LV APEX – MURMUR, DIASTOLIC HEART, LV APEX – OPENING SNAP, MITRAL HEART, LV APEX – THRILL, DIASTOLIC HEART, RSB – SOUND, SYSTOLIC EJECTION HEART, RSB UPPER – MURMUR, DIASTOLIC HEART, SOUND P2 – LOUD
Mitral StenosisSigns (cont)
HEART, SOUND P2 – PALPABLE HEART, SOUND S1 – SOFT HEART, SOUND S1 – LOUD LIVER – ENLARGEDSKIN, CHEEKS – COLOR, PINK PURPLESKIN, GEN – COLOR, BLUEVENOUS PULSE, JUGULAR - A WAVE,
LARGEVENOUS PULSE, JUGULAR – ELEVATED
Mitral StenosisChest X-ray
Mitral StenosisEcho
Mitral StenosisLA Thrombus
Mitral StenosisECG
Mitral Stenosis Complications
Atrial fibrillationInfective EndocarditisPeripheral embolismPulmonary
hypertension
Mitral StenosisMedical RX
Antibiotic prophylaxisAnticoagulation for
Atrial fibrillationPrior embolic eventDocumented LA
thrombusArrhythmia control
Mitral StenosisSurgical RX
Invasive valvuloplastyPercutaneous valvotomy
Valve replacement
Mitral StenosisInvasive
Valvuloplasty
Mitral StenosisSurgical RX –
Valvuloplasty with Balloon Catheter
Valvular Heart Disease
Follow upAntibiotic prophylaxis
New symptomsChange in symptomsChange in physical
findingsEchocardiography/other
imaging
Thank you!