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8/16/2019 Valvular Update
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Valvular Heart Disease
Hakim Alkatiri
8/16/2019 Valvular Update
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Mitral Stenosis
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• rekaman\Video009.3gp
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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
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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%+ $20!2-
Severity Symptoms
Mild .symptomatic or mild /
Moderate Mild!mod / orthopnea, 3'/, hemoptysis
Severe /yspnea at rest possible pulmonary edema
ery Severe Severe 345 R failure, mar6ed dyspnea at rest
severe fatigue cyanosis
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Mitral Stenosis ! xamination
Inspection
Malar flush3eripheral cyanosis 7severe MS89ugular venous distension 7right ventricular failure8
Palpation3arasternal right ventricular impulse3alpable pulmonary arterial impulse3alpable S1, 32, and occasionally, the diastolic rumble
Auscultation
:ncreased intensity of the first heart soundpening snap
(o;!pitched diastolic rumbling murmur
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Mitral Stenosis ! 5reatment
Meical
•/iuretic ! pulmonary congestion
•3revent embolism ! cause of 1<= deaths, ↑;ith
↑(. si>e and ↑age
anticoagulate all ;ith 3.F?.F, SR in older age
•#ontrol atrial fibrillation
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Mitral Stenosis ! 5reatment
!alloo" Mitral Valvuloplasty
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Mitral Stenosis ! 5reatment
!alloo" Mitral Valvuloplasty
•100= ↑M., final area )2cm2
•Failure rate 1!1-=
•Mortality 0!=•Severe MR 2!10=
•Restenosis )"0= at *years
•#ontraindications ! thrombus, MR, #a@@, other
disease
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Mitral Stenosis ! 5reatment
Mitral Valve #eplaceme"t
•pen mitral valvotomy
•Mitral valve replacement
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Mitral Regurgitation ! .etiology
•Primary
A""ulus annular calcification
Lea$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
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CXR
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Mitral Regurgitation ! 3athophysiology
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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
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Mitral Regurgitasi
• rekaman\MOV007!.3"#
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rekaman\MOV007.3"#
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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
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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
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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
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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
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Mitral Regurgitation ! :ndications for surgery
,( 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 $u"ctio"
•Eguaranteed repair
•345, recent .F
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Mitral Regurgitation ! :ndications for surgery
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Mitral Regurgitation ! 3rolapse
•2!"= population•femalesmales 21
•diagnosis from echocardiography
•subcategory according to leaflet abnormality
•SB prophylaxis normal @ MR or abnormal leaflets
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.ortic Stenosis ! .etiology
•#ongenital 1st!rd decade
alve degeneration and calcification
•Rheumatic ! "th decade
•Bicuspid valve 1=, males$females, -!Ath decades
•5ricuspid valve ! *!+th decades, 1!2= incidence
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.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
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.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
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.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
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.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
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.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 -=
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.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$u"ctio"
•Eimpairment from pressure overload or other cause
•/S may be helpful
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.ortic Stenosis ! .R
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.ortic Regurgitation ! .etiology
#oot .nnuloaoroectasia
Marfans
/issectionSyphillis
.n6ylosing spondylitis
Lea$letndocarditis
Bicuspid valve
Rheumatic heart disease
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Aorta Regurgitasi
• rekaman\Video00$.3gp
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.ortic Regurgitation ! 3athophysiology
Normal
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.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
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#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
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#hronic .ortic Regurgitation ! #linical features
Maybe asymptomatic, (F, angina
LV ecompe"satio"
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#hronic .ortic Regurgitation ! 5reatment
Meical ! ↓afterload
'ifedipine 20mg bd delayed surgery by 2! yrs
/uplicated ;ith small .#: trials
asodilator therapy
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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
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Summary
Summary
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Summary
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%rikuspid regurgitasi
• rekaman\Video0!$.3gp
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