Valvular Heart Disease瓣膜性心臟病

ValvularHeartDiseasesByMohamedSerwahHistory35yearsoldpregnantwomanpresentedtotheERcomplainingofdyspnea,fatigueandhaemoptysissince2days.Shegaveahistoryofrheumaticheartdiseaseinchildhood.Whatdoyouthink????And..Whatshouldwedo?ValvularHeartDiseasesMitralValveMitralStenosisMitralInsufficiencyMitralValveProlapseAorticValveAorticStenosisAorticIncompetenceTricuspidValveTricuspidStenosisTricuspidIncompetencePulmonaryValvePulmonaryStenosisPulmonaryIncompetenceMitralValveStenosisMitralValveStenosis(MVS)UncommonheartconditioninwhichthemitralvalvefailstoopenaswideasitshouldNoimmediateeffectonhealthEventuallyleadstodecreasedoutputbytheheartandheartfailureEtiologicFactorsofMVSAlmostallcasescausedbyrheumaticfeverOthercauses congenital: -Birthdefects -Hardeningofthemitralvalvecomponentsduetoaging -Bloodclots -Conditionsthatcausescarringofthemitralvalve -PureorpredominantMSoccursinapproximately40%ofallpatientswithrheumaticheartdiseaseTwo-thirdsofallpatientswithMSarefemale.SymptomsofMVSShortnessofbreath(dyspnea)FatiguePoundingoftheheartCoughingupbloodIrregularheartrhythmChestpainDifficultyswallowingMitralStenosis:PathophysiologyScarring&fusionofvalveapparatusNormalvalvearea:4-6cm2Mildmitralstenosis:MVA<2-2.5cm2MinimalsymptomsModmitralstenosisMVA>1.5cm2usuallydoesnotproducesymptomsatrestSeveremitralstenosisMVA<1.0cm2

leftatrialpressure

pulmonaryvenouspressure

dyspnea

“Atrial”viewofmitralvalveinpatientwithrheumaticmitralstenosis.MitralStenosis:SymptomsCongestivesymptomsCough,dyspnea,chestpain,orthopnea,PND,pulmonaryedema,hemoptysisLowCardiacOutput:fatigue,…Worsenedbyconditionsthatcardiacoutput(exertion,excitement,etc.)MitralStenosis:PhysicalExamFirstheartsound(S1)isaccentuatedandsnappingOpeningsnap(OS)afteraorticvalveclosureDiastolicThrillLowpitchdiastolicrumblingmurmurattheapexPre-systolicaccentuation(esp.ifinsinusrhythm)S1S2OSS1InvestigationsChestXrayECGEchocardiographyArteriography

Usuallynormalorslightlyenlargedcardio-thoracicratioStraighteningofleftheartborderConvexityofleftheartbordertoenlargedatrialappendage--onlyinrheumaticheartdiseaseenlargementofthetransversediameteroftheheart.LeftatriumcausesdoubleoutlineLeftatrialappendageisdilated,causingaprominenceoftheleftborderUpperlobevesselslargerthanlowerlobevessels,thatis,upperlobeblooddiversion.ECGMSLeftAtrialHypertrophy:bifidandbiphasicMitralStenosis:NaturalHistoryProgressive,lifelongdiseaseSlow&stableintheearlyyearsProgressiveaccelerationinthelateryears20-40yearlatencyfromrheumaticfevertosymptomonsetAdditional10yearsbeforedisablingsymptomsMitralStenosis:ComplicationsAtrialdysrrhythmias:AtrialfibrillationSystemicembolization(10-25%)CongestiveheartfailurePulmonaryhypertensionPulmonaryinfarcts(resultofsevereCHF)HemoptysisPulmonaryinfectionsInfectiveendocarditisTricuspidregurgitationIsstenosissevere?Howcanyouassess?HowCanYouAssessTheSeverityofMS?

Theseverityofmitralstenosisisjudgedclinicallyonthebasisofseveralcriteria:Thepresenceofpulmonaryhypertension.Theclosenessoftheopeningsnaptothesecondheartsoundisproportionaltotheseverityofmitralstenosis.Thelengthofthemid-diastolicmurmurisproportionaltotheseverity.Asthevalvecuspsbecomeimmobile,theloudfirstheartsoundsoftensandtheopeningsnapdisappears.PulmonaryHypertensionandMSPulmonaryHTNimpliesthatmitralstenosisissevere.Pulmonaryhypertensionisrecognizedbythefollowing:arightventricularheavealoudP2ofthe2ndheartsound,right-sidedheartfailure:signs----??pulmonaryvalvularregurgitationthatcausesanearlydiastolicmurmurinthepulmonaryareaknownasaGrahamSteelmurmurMitralStenosis:TreatmentMonitoringoftheconditionMedications Endocarditisprophylaxis Diuretics Otherstorelievespecificconditions AnticoagulationifpreviousemboliceventValvesurgery:repair/replacementBalloonvalvotomy -Easiertorecoverfromtheoperation. -Doesnotinvolveopen-heartsurgeryMitralIncompetenceMitralInsufficiency:EtiologyRheumaticetiologyinmales50%>>femalesMayalsooccurasacongenitalanomalyConnectivetissuedisorders:SLEMVPConditionscausingLVenlargement:hypertensiveheartdiseaseischaemicheartdiseaseaorticvalvediseaseMitralInsufficiency:SymptomsFatigueExertionaldyspnea,andorthopnea (moreprominentwithchronic,severeMR)Hemopytsisandsystemembolization (occurlessfrequentlyinMR)SignsofMRSoft1stheartsound,owingtotheincompleteappositionofthevalvecuspsandtheirpartialclosurebythetimeventricularsystolebegins.Laterallydisplaced(forceful)diffuseapexbeatSystolicthrill(ifsevere)ApicalholosystolicmurmurRadiationtotheaxilla.Otherfindings:prominentS3,owingtothesuddenrushofbloodbackintothedilatedleftventricleinearlydiastoleshortmid-diastolicflowmurmurmayfollowthethirdheartsound).MitralInsufficiency:PhysicalExamApicalholosystolicmurmurRadiationtotheaxillaPalpablethrillatcardiacapexS3???Sometimesashortmid-diastolicflowmurmurmayfollowthethirdheartsound).S1(soft)S2S3?S1TreatmentofMRTreatmentProphylacticantibioticsValverepairwithsevereMRorrefractorysymptoms

MitralValveProlapse(MVP)

MVP:IntroductionandEpidemiologyOneofthemostcommonformsofvalvularheartdiseasesDuringprolapsebloodflowsbackwardsfromtheventricletotheatriumMostcommoncauseofisolatedsevereMRAffects5-10%ofpopulationFemales>malesAgesof14and30yearsStronghereditarycomponent(?AutosomalDominance)CausesofMVPMostcasesareprimary,idiopathicinnatureConnectivetissuedisordersMarfansyndromeEhlers-Danlossyndrome(ie,typesI,II,IV)OsteogenesisimperfectaPseudoxanthomaelasticumPolycystickidneydiseaseSticklersyndromeSystemiclupuserythematosusRelapsingpolychondritisPolyarteritisnodosaMuscledisordersDuchennemusculardystrophyFragileXsyndromeMucopolysaccharidosesMyotonicdystrophyCongenitalheartdisease-Atrialseptaldefect(ASD)EbsteinanomalyAcquiredheartdiseasePapillarymuscledysfunction(eg,ischemia,myocarditis)CardiactraumaPostmitralvalvesurgeryRheumaticendocarditisMiscellaneousWolff-Parkinson-WhitesyndromeVonWillebranddiseaseMVP:SymptomsMajority

areasymptomaticforentirelifePalpitationsChestpain,sharpmayresembleIschaemicpain(substernal,prolonged,poorlyrelatedtoexertion)LowbloodpressureSleepdisordersHeadacheDizzinessMVP:PhysicalExamMostimportantfinding:mid

latesystolicclickAcutetensingofthemitralvalvechordaeVariablemurmurs:highpitchedlatesystoliccrescendo-decrescendomurmur,Occasionally“whooping”or“honking”attheapexS1C S2LabTestsforMVPSpecificlabstudiesarenotnecessarytoconfirmMVPBut,Somemaybeindicatedtoexcludeotherdiagnosesinsomepatients.Dyspnea:ABGtoexcludethediagnosisofhyperventilation,hypoxemia,andmetabolicacidosis.Arrhythmia:Serumelectrolytestoexcludeelectrolytedisturbances.Fatigue:Serumhemoglobin,Glucose.Chestpain:CardiacenzymesInvestigations:MVPElectrocardiogram:(ECG)

Usuallynormal.MinorQTprolongation(0.42±0.52)mayoccur.NonspecificSTandT-wavechangeswerepreviouslynoted,buttheymaynotbemorefrequentthaninthegeneralpopulation.Holtermonitor

OutpatientHoltermonitoringortranstelephoniceventrecordingshouldbeconsideredinpatientswithpalpitationsthatareassociatedwithsyncopeornear-syncope.SVTandarrhythmiaoccurin30%ofpatientswithMVP.ECGLefttrialhypertrophyLeftAtrialEnlargement(LAE)Pwaveduration>0.12sinfrontalplane(usuallyleadII)NotchedPwaveinlimbleadswiththeinter-peakduration>0.04s

DiagnosisofMVP:SummaryUsuallygoesundiscoveredduringroutinephysicalexamAmurmurorclickmaybeheardaccidentallyduringaphysicalexamination.AnechocardiogramisthemostusefulexamindeterminingatrueMVPMVP:ComplicationsArrhythmias(PrematureVentricularContractions,SVT>>VT)Transientcerebralischemia(embolic–rare)Infectiveendocarditis(ifassociatedwithMR)Suddendeath(rare)TreatmentoptionsforMVPReassurance

Asymptomaticptsw/osevMRorarrhythmia.Follow-upq2-4years,withECHOPhysicalactivityAntibiotics:takenbeforesomedentalandmedicalproceduresBetablockertreatmentforatypicalchestpainInfectiveendocarditisprophylaxiswithSystolicmurmur&/orTypicalechocardiagraphicfindingsMendefinitely!Women?Noconsensus.Surgery: -Notusuallynecessary -Repairorreplace -ComplicationsAorticStenosis(AS)AorticStenosis(AS)ConditioninwhichthevalvebetweenthelowerleftchamberoftheheartandtheaortabecomenarrowedNarrowing(stenosis)resultsinnotenoughbloodflowtothebody

EtiologicfactorsofAS“Wearandtear”CongenitaldefectRheumaticfeverCertainweightlossmedications!!SymptomsofASLowcardiacoutput:AnginaSyncopeFatigueandshortnessofbreathduringactivityRapidorirregularheartbeatAS:PhysicalSignsThecarotidpulseisofsmallvolumeandisslow-risingorplateauinnaturePrecordialpalpationTheapexbeatisdisplacedifcardiomegaly.Thepulsationissustainedandobvious.Adoubleimpulseissometimesfeltbecausethefourthheartsoundoratrialcontraction('kick')maybepalpable.Asystolicthrillmaybefeltintheaorticarea.Asystolicmurmurisheardovertheprecrdium.AorticStenosis:PhysicalFindings“Diamond”shaped,systoliccrescendo-decrescendo,harsh,orhighpitchedormusicalRadiatestorightsternaledgeandCarotidarteriesDecreased,delay&prolongationofpulseamplitudeIntensityDOESNOTpredictseverityS4(causedbystrongatrialcontractionifLVH)S3(withleftventricularfailure)S1S2S1S2S3Mild-Moderate SevereS4LargeS(V1),LargeR(V5)VentricularStrainsRVLV

AorticStenosis:Prognosis/TreatmentSymptom/SignLiveexpectancyAngina5yearsSyncope2-3yearsCongestiveHeartFailure1-2yearsTreatmentoptionsforASTreatmentofAS:Valvereplacementforsevereaorticstenosis

Medications -StatindrugSurgeryforASRisksassociated -80%diewithin3-5yearsiftheydonothavereplacement -2-5%dieinsameperiodiftheyhavereplacementLifelongconsequencesAorticRegurgitationAorticRegurgitation(AR)AconditioninwhichthelowerleftchamberoftheheartandtheaortamalfunctionsThisconditionallowsbloodtotravelbackintotheheartEtiologicfactorsofARInfectionEnlargedaortaTwoleafletsinsteadofthree(congenitaldefect)RheumaticfeverSymptomsofARDifficultybreathingatnightSwellinginthelegsandsometimestheentirebodyPulsationsintheneckLowCardiacOutputFatigueSyncopeAorticInsufficiency:PhysicalExamWidenedpulsepressure Syst.–diast.=pulsepressureHighpitched,blowing,decrescendo diastolicmurmuratLSB (end-expiration&leaningforward)Signsassociatedwith

pulsepressure:

DeMusset’sSign.headbobbing(headnodding)“Pistolshot” loud‘shot’overfem.arteriesQuincke’sSign pulsationsinthenailbedCorrigan’sPulsewaterhammerpulseS1

S2S1TreatmentoptionsforARSurgery -replacementoftheaorticvalveMedications -nitroglycerin -bloodpressureloweringdrugsTricuspidValveDiseases:TricuspidStenosis(TS)Tricuspidincompetence

TricuspidStenosisPathophysiologyTricuspidvalvestenosisCOoutput,system.venouscongestionhepatomegaly,ascitesanddependentoedema.SymptomsUsually,patientswithtricuspidstenosiscomplainofsymptomsduetoassociatedleft-sidedrheumaticvalvelesions.Others”AbdominalPain(hepatomegaly)AscitesEdemaLLTricuspidStenosisSystemicVenousCongestionCardiacOuputJVPHepatomegally,AscitesLLEdmaFatigueSyncopePathophysiologyofMSClinicalManifestationsofTS(cont.)SignsofTSArrhythmiaaprominentjugularvenousawave(ifSinusrhysm!!!)Presystolicpulsationmayalsobefeltovertheliver.Murmur:rumblingmid-diastolicheardbestatthelowerleftsternaledgelouderoninspiration.Itmaybemissedbecauseofthemurmurofcoexistingmitralstenosis.Atricuspidopeningsnapmayoccasionallybeheard.Hepatomegaly,abdominalascitesanddependentoedemamaybepresent.TS:InvestigationsChestX-ray

Aprominentrightatrialbulge.ElectrocardiogramEnlargedrightatrium:peaked,tallPwaves(>3mm)inleadII.EchocardiogramThickenedandimmobiletricuspidvalve,butthisisnotsoclearlyseenasanabnormalmitralvalve.Cardiaccatheterization Thisdemonstratesadiastolicpressuregradientbetweentherightatriumandtherightventricle. Contrastinjectionwilldemonstratealargerightatrium.TreatmentofTS

Medicalmanagement:diuretictherapyandsaltrestriction.Surgical:Tricuspidvalvotomyisoccasionallypossible,Tricuspidvalvereplacementisoftennecessary.Othervalvesusuallyalsoneedreplacementbecausetricuspidvalvestenosisisrarelyanisolatedlesion.Tricuspidregurgitation

FunctionalFunctionalTRmayoccurwhenevertherightventricledilates:corpulmonalemyocardialinfarctionpulmonaryhypertension.OrganicTRmayoccurin:rheumaticheartdiseaseinfectiveendocarditiscarcinoidsyndromeEbstein'sanomaly(congenitallymalpositionedtricuspidvalve)

TricuspidRegurgitationSymptomshighrightatrialandsystemicvenouspressure.Symptomsofrightheartfailure

PhysicalsignsAtrialfibrillation(common).largejugularvenouswaveLiver:palpablepulsatinginsystole.aRVimpulsemaybefeltattheleftsternaledge,Murmur:Blowingpansystolicbestheardoninspirationatthelowerleftsternaledge.TreatmentofTR

Functionaltricuspidregurgitationusuallydisappearswithmedicalmanagement.Severeorganictricuspidregurgitationmayrequireoperativerepairofthetricuspidvalve(annuloplastyorplication).Veryoccasionally,tricuspidvalvereplacementmaybenecessary.Indrugaddictswithinfectiveendocarditisofthetricuspidvalve,surgicalremovalofthevalveisrecommendedtoeradicatetheinfection.Thisisusuallywelltoleratedintheshortterm.Theinsertionofaprostheticvalveforthisconditionisconsidered

PulmonaryStenosisPulmonaryStenosisEtiology:Congenitalthecommonestcause:+VSDFallot’sOthers:rheumaticfevercarcinoidsyndrome.MultiplecongenitalpulmonaryarterialstenosesareusuallyduetoinfectionwithrubelladuringpregnancyTypesofPSvalvular,subvalvularorsupravalvular..SymptomsandsignsofPS

MildpulmonarystenosismaybeasymptomaticSeverepulmonaryobstructionmaybeincompatiblewithlife.TheobstructiontoRVemptyingRVHRAtrialHypertrophyrightheartfailure..Inlesserdegreesofobstructionfatigue,syncope.PulmonaryStenosis:SignsP2soundisusuallydelayedandsoftaMidsystolicthrillMurmur:harshmid-systolicejectionmurmur,bestheardoninspiration,totheleftofthesternuminthesecondintercostalspace.Otherfindings:pulmonaryejectionsound(maybe)iftheobstructionisvalvular.Arightventricularfourthsoundandaprominentjugularvenousawavearepresentwhenthestenosisismoderatelysevere.Arightventricularheave(sustainedimpulse)maybefelt.PulmonaryStenosis:InvestigationsChestX-rayThechestX-rayusuallyshowsaprominentpulmonaryartery

owingtopost-stenoticdilatation.ECGTheECGdemonstratesbothrightatrialandrightventricularhypertrophy,althoughitmaysometimesbenormaleveninseverepulmonarystenosis.Echocardiogram

Doppleristheinvestigationofchoice.CardiaccatheterizationThepassageofacatheterthroughtherightheartallowsthelevelanddegreeofthestenosistobeestablishedbymeasuringthesystolicpressuregradient.PS:Treatment

Treatmentofseverepulmonarystenosisrequires:pulmonaryvalvotomy(balloonvalvotomyordirectsurgery).PulmonaryRegurgitation

Thisisthemostcommonacquiredlesionofthe