【高血壓英文課件】Valvular-Heart-Disease

ValvularHeartDiseaseDr.RandaAl-HarizyProf.ofInternalMedicineTricuspidValveMITRALSTENOSISAlmostallmitralstenosisisduetorheumaticheartdisease.Itismuchmorecommoninwomen.

Othercausesinclude:Lutembacher'ssyndrome,whichisthecombinationofacquiredmitralstenosisandanatrialseptaldefect,carcinoidtumoursandSLE.

ValvularHeartDiseaseSYMPTOMSUsuallytherearenosymptomsuntilthevalveorificeismoderatelystenosed(i.e.hasanareaof2cm2).Becauseofpulmonaryvenoushypertensionandrecurrentbronchitis,progressivelyseveredyspnoeadevelops.Acoughproductiveofblood-tinged,frothysputumandoccasionallyfrankhaemoptysismayoccur.Rightheartfailureanditssymptomsofweakness,fatigueandabdominalorlowerlimboedema.Atrialfibrillation,givingrisetopalpitations.Atrialfibrillationmayresultinsystemicemboli.

ValvularHeartDiseaseSIGNSFace:mitralfaciesormalarflush.Pulse:asmall-volumepulse,maybeanirregularlyirregularpulse.Jugularveins:Distensionofjugularveinsinrightheartfailure.

Palpation:Thereisatappingimpulsefeltparasternallyontheleftside(palpablefirstheartsound).Asustainedparasternalimpulseduetorightventricularhypertrophymayalsobefelt.Auscultation:loudfirstheartsound,and'openingsnap'.Thisisfollowedbyalow-pitched'rumbling'mid-diastolicmurmurattheapexwithpresystolicaccentuation.

ValvularHeartDiseaseINVESTIGATIONSChestX-ray:smallheartwithanenlargedleftatrium,Pulmonaryvenoushypertension,acalcifiedmitralvalve,signsofpulmonaryoedemaorpulmonaryhypertension.ECG:showsabifidPwaveorAF,featuresofrightventricularhypertrophy(rightaxisdeviationandperhapstallRwavesinV1)Echocardiogram:assessmentofthemitralvalveapparatusandcalculationofmitralvalvearea,alsodeterminesleftatrialandrightventricularsizeandfunction.EstimateofpulmonaryarterypressureCardiaccatheterizationValvularHeartDiseaseTREATMENTMildmitralstenosismayneednotreatmentotherthanprompttherapyofattacksofbronchitis.Antibioticprophylaxisforinfectiveendocarditis.Milddyspnoeaistreatedwithlowdosesofdiuretics.Atrialfibrillationrequirestreatmentwithdigoxinandanticoagulationtopreventatrialthrombusandsystemicembolization.Ifpulmonaryhypertensiondevelops,surgicalreliefofthemitralstenosisisadvised.Surgicaltreatmentincludes;Trans-septalballoonvalvotomy,Closedvalvotomy,OpenvalvotomyorMitralvalvereplacement.ValvularHeartDiseaseCAUSESThemostcommoncauseisrheumaticheartdisease(50%)andaprolapsingmitralvalve.Othercausesinclude;aorticvalvedisease,acuterheumaticfever,myocarditis,dilatedcardiomyopathy,hypertensiveheartdisease,ischaemicheartdisease,infectiveendocarditis,hypertrophiccardiomyopathy,SLE,Marfan'ssyndrome,Ehlers-Danlossyndrome,ruptureofthechordaetendineae(e.g.duetomyocardialinfarction).MITRALREGURGITATIONPATHOPHYSIOLOGYRegurgitationintotheleftatriumproducesleftatrialdilatationbutlittleincreaseinleftatrialpressure.Withacutemitralregurgitationtheleftatrialvwaveisgreatlyincreasedandpulmonaryvenouspressurerisestoproducepulmonaryoedema.Sinceaproportionofthestrokevolumeisregurgitated,thestrokevolumeincreasestomaintaintheforwardcardiacoutputandtheleftventriclethereforeenlarges.

MITRALREGURGITATIONSYMPTOMSMitralregurgitationcanbepresentformanyyearsbeforeanysymptomsoccur.Theincreasedstrokevolumeissensedasa'palpitation'.Dyspnoeaandorthopnoeadevelopowingtoleftventricularfailure.Fatigueandlethargydevelopbecauseofthereducedcardiacoutput.Inthelatestagesofthediseasethesymptomsofrightheartfailurealsooccurandeventuallyleadtocongestivecardiacfailure.Cardiaccachexiamaydevelop.Thromboembolismislesscommonthaninmitralstenosis,butsubacuteinfectiveendocarditisismuchmorecommon.

MITRALREGURGITATIONSIGNSLaterallydisplaced(forceful)diffuseapexbeatandasystolicthrill(ifsevere).Softfirstheartsound.Pansystolicmurmur,radiatingwidelyovertheprecordiumandintotheaxilla.Prominentthirdheartsound.Thesignsrelatedtoatrialfibrillation,pulmonaryhypertension,andleftandrightheartfailuredeveloplaterinthedisease.MITRALREGURGITATIONINVESTIGATIONSChestX-ray:leftatrialandleftventricularenlargement.ThereisanincreaseintheCTR,andvalvecalcificationisseen.ECGshowsthefeaturesofleftatrialdelay(bifidPwaves)andleftventricularhypertrophyasmanifestedbytallRwavesinleadsIandV6anddeepSwavesintheright-sidedprecordialleadsV1andV2.Atrialfibrillationmaybepresent.Echocardiogram:dilatedleftatriumandleftventricle.Theremaybespecificfeaturesofchordalorpapillarymusclerupture.Cardiaccatheterization.

MITRALREGURGITATIONTREATMENTMildmitralregurgitationintheabsenceofsymptomscanbemanagedconservativelybyfollowingthepatientwithserialechocardiograms.ProphylaxisagainstendocarditisisrequiredAnyevidenceofprogressivecardiacenlargementgenerallywarrantsearlysurgicalinterventionbyeithermitralvalverepairorreplacement.Inpatientswhoarenotconsideredappropriateforsurgicalintervention,managementusuallyinvolvestreatmentwithACEinhibitors,diureticsandpossiblyanticoagulants.

MITRALREGURGITATIONCAUSESCongenitalaorticvalvestenosis.Rheumaticfever;Inrheumaticheartdiseasetheaorticvalveisaffectedinabout40%ofcasesandthereisusuallyassociatedmitralvalvedisease.

Calcificvalvulardiseaseisthecommonestcauseofaorticstenosisandmainlyoccursintheelderly.

AORTICSTENOSISPATHOPHYSIOLOGYObstructedleftventricularemptyingleadstoincreasedleftventricularpressureandcompensatoryleftventricularhypertrophy.Inturn,thisresultsinrelativeischemiaoftheleftventricularmyocardium,andconsequentangina,arrhythmiasandleftventricularfailure.

AORTICSTENOSISSYMPTOMSThereareusuallynosymptomsuntilaorticstenosisismoderatelysevere(whentheaorticorificeisreducedtoone-thirdofitsnormalsize).Atthisstage,exercise-inducedsyncope,anginaanddyspnoeadevelop.Whensymptomsoccur,theprognosisispoor-onaverage,deathoccurswithin2-3yearsiftherehasbeennosurgicalintervention.

AORTICSTENOSISSIGNSPulse:smallvolumeandisslow-risingorplateauinnature.Precordialpalpation:Theapexbeatisnotusuallydisplacedbecausehypertrophy(asopposedtodilatation)doesnotproducenoticeablecardiomegaly.However,thepulsationissustainedandobvious.Adoubleimpulseissometimesfeltbecausethefourthheartsoundoratrialcontraction('kick')maybepalpable.Asystolicthrillmaybefeltintheaorticarea.AuscultationThemostobviousauscultatoryfindinginaorticstenosisisanejectionsystolicmurmurthatisusually'diamond-shaped'(crescendo-decrescendo).Themurmurisusuallyroughinqualityandbestheardintheaorticarea.Itradiatesintothecarotidarteriesandalsotheprecordium.AORTICSTENOSISINVESTIGATIONSChestX-rayrevealsarelativelysmallheartwithaprominent,dilated,ascendingaorta.Thisoccursbecauseturbulentbloodflowabovethestenosedaorticvalveproducesso-called'post-stenoticdilatation'.Theaorticvalvemaybecalcified.TheCTRincreasesinheartfailure.ECGshowsleftventricular'strain'patterndueto'pressureoverload'(depressedSTsegmentsandTwaveinversioninleadsI,AVL,V5,V6).Echocardiogramreadilydemonstratesthethickened,calcifiedandimmobileaorticvalvecusps.Leftventricularhypertrophymaybeseen.Cardiaccatheterization.AORTICSTENOSISTREATMENTInpatientswithaorticstenosis,symptomsareagoodindexofseverityandallsymptomaticpatientsshouldhaveaorticvalvereplacement.Asymptomaticpatientsshouldbeunderregularreviewforassessmentofsymptomsandechocardiography.Antibioticprophylaxisagainstinfectiveendocarditisisessential.AORTICSTENOSISCAUSESThemostcommoncausesofaorticregurgitationarerheumaticfeverandinfectiveendocarditiscomplicatingapreviouslydamagedvalves.Acuteaorticregurgitation:Acuterheumaticfever,InfectiveendocarditiS,Dissectionoftheaorta,Rupturedaneurysm,Failureofprostheticheartvalve.Chronicaorticregurgitation:Rheumaticheartdisease,Syphilis,Arthritides(Reiter'ssyndrome,Ankylosingspondylitis,Rheumatoidarthritis),Hypertension(severe),Bicuspidaorticvalve,Aorticendocarditis,Marfan'ssyndromeAndOsteogenesisimperfecta.

AORTICREGURGITATIONPathophysiologyAorticregurgitationisrefluxofbloodfromtheaortathroughtheaorticvalveintotheleftventricleduringdiastole.Consequentlytheleftventricularsizemustenlarge.Becauseoftheaorticrun-offduringdiastole,diastolicbloodpressurefallsandcoronaryperfusionisdecreased.Cardiacischaemiadevelops.AORTICREGURGITATIONSYMPTOMSInaorticregurgitation,significantsymptomsoccurlateanddonotdevelopuntilleftventricularfailureoccurs.Aswithmitralregurgitation,acommonsymptomis'poundingoftheheart'becauseoftheincreasedleftventricularsizeanditsvigorouspulsation.Anginapectorisisafrequentcomplaint.Varyinggradesofdyspnoeaoccurdependingontheextentofleftventriculardilatationanddysfunction.Arrhythmiasarerelativelyuncommon.

AORTICREGURGITATIONSIGNSPulse:boundingorcollapsing.Signsofhyperdynamiccirculation:Quincke'ssign(capillarypulsationinthenailbeds),DeMusset'ssign(headnoddingwitheachheartbeat),Duroziez'ssign(ato-and-fromurmurheardwhenthefemoralarteryisauscultatedwithpressureapplieddistally-itisasignofsevereaorticregurgitation),pistolshotfemorals.Apexbeat:isdisplacedlaterallyanddownwardsandisforcefulinquality.Auscultation:ahigh-pitchedearlydiastolicmurmurbestheardattheleftsternaledgeinthefourthintercostalspacewiththepatientleaningforwardandthebreathheldinexpiration.Commonlyanejectionsystolicflowmurmur.Theregurgitantjetcanimpingeontheanteriormitralvalvecusp,causingamid-diastolicmurmur(AustinFlint).AORTICREGURGITATIONINVESTIGATIONSChestX-ray:leftventricularenlargementandpossiblydilatationoftheascendingaorta.Theascendingaorticwallmaybecalcifiedinsyphilis,andtheaorticvalvemaybecalcifiedifvalvulardiseaseisresponsiblefortheregurgitation.ECG:appearancesarethoseofleftventricularhypertrophydueto'volumeoverload'-tallRwavesanddeeplyinvertedTwavesintheleft-sidedchestleads,anddeepSwavesintheright-sidedleads.Echocardiogram:vigorouscardiaccontractionandadilatedleftventricle.Theaorticrootmayalsobeenlarged.Cardiaccatheterization.AORTICREGURGITATIONTREATMENTTheunderlyingcauseofaorticregurgitation(e.g.syphiliticaortitisorinfectiveendocarditis)mayrequirespecifictreatment.Thetreatmentofaorticregurgitationusuallyrequiresaorticvalvereplacement.Becausesymptomsdonotdevelopuntilthemyocardiumfailsandbecausethemyocardiumdoesnotrecoverfullyaftersurgery,operationisperformedbeforesignificantsymptomsoccur.Antibioticprophylaxisagainstinfectiveendocarditisisnecessary.AORTICREGURGITATIONMechanicalValvePorcineValveCAUSESThisuncommonvalvelesion,whichisseenmuchmoreofteninwomenthaninmen,isusuallyduetorheumaticheartdisease.Itisfrequentlyassociatedwithmitraland/oraorticvalvedisease.Itisalsoseeninthecarcinoidsyndrome.TRICUSPIDSTENOSISPATHOPHYSIOLOGYTricuspidvalvestenosisresultsinareducedcardiacoutput,whichisrestoredtowardsnormalwhentherightatrialpressureincreases.Theresultingsystemicvenouscongestionproduceshepatomegaly,ascitesanddependentoedema.TRICUSPIDSTENOSISSYMPTOMSUsually,patientswithtricuspidstenosiscomplainofsymptomsduetoassociatedleft-sidedrheumaticvalvelesions.Abdominalpain(duetohepatomegaly)andswelling(duetoascites)andperipheraloedema.TRICUSPIDSTENOSISSIGNSProminentjugularvenousawave.Presystolicpulsationmayalsobefeltovertheliver.Rumblingmid-diastolicmurmur,heardbestatthelowerleftsternaledgeandislouderoninspiration.Atricuspidopeningsnapmayoccasionallybeheard.Hepatomegaly,abdominalascitesanddependentoedemamaybepresent.TRICUSPIDSTENOSISINVESTIGATIONSChestX-ray:prominentrightatrialbulge.ECG:enlargedrightatriummanifestedbypeaked,tallPwaves(>3mm)inleadII.Echocardiogram:thickenedandimmobiletricuspidvalve,butthisisnotsoclearlyseenasanabnormalmitralvalve.Cardiaccatheterization.TRICUSPIDSTENOSISTREATMENTMedicalmanagementconsistsofdiuretictherapyandsaltrestriction.Tricuspidvalvotomyisoccasionallypossible,buttricuspidvalvereplacementisoftennecessary.Othervalvesusuallyalsoneedreplacementbecausetricuspidvalvestenosisisrarelyanisolatedlesion.TRICUSPIDSTENOSISCAUSESFunctionaltricuspidregurgitationmayoccurwhenevertherightventricledilates,e.g.incorpulmonale,myocardialinfarctionorpulmonaryhypertension.Organictricuspidregurgitationmayoccurwithrheumaticheartdisease,infectiveendocarditis,carcinoidsyndrome,Ebstein'sanomaly(acongenitallymalpositionedtricuspidvalve)andothercongenitalabnormalitiesoftheatrioventricularvalves.TRICUSPIDREGURGITATIONSYMPTOMSandSIGNSymptomsofrightheartfailure.Physicalsignsincludealargejugularvenouscvwaveandapalpableliverthatpulsatesinsystole.Usuallyarightventricularimpulsemaybefeltattheleftsternaledge,andthereisablowingpansystolicmurmur,bestheardoninspirationatthelowerleftsternaledge.Atrialfibrillationiscommon.TRICUSPIDREGURGITATIONTREATMENTFunctionaltricuspidregurgitationusuallydisappearswithmedicalmanagement.Severeorganictricuspidregurgitationmayrequireoperativerepairofthetricuspidvalveorvalvereplacement.TRICUSPIDREGURGITATIONCAUSESThisisusuallyacongenitallesion,butitmayrarelyresultfromrheumaticfeverorfromthecarcinoidsyndrome.Congenitalpulmonarystenosismaybeassociatedwithanintactventricularseptumorwithaventricularseptaldefect(Fa