Acquired valve diseases Prof. S. Smiyan. EPIDEMOLOGY ARF is mainly a disease of children aged 5–14 years. ARF is mainly a disease of children aged 5–14

Acquired valve diseasesAcquired valve diseases

Prof. S. SmiyanProf. S. Smiyan

EPIDEMOLOGYEPIDEMOLOGY

ARF is mainly a disease of children aged ARF is mainly a disease of children aged 5–14 years.5–14 years.

Initial episodes become less common in Initial episodes become less common in older adolescents and young adults and older adolescents and young adults and are rare in persons aged >30 years.are rare in persons aged >30 years.

There is no clear gender association for There is no clear gender association for ARF, but RHD more commonly affects ARF, but RHD more commonly affects females, sometimes up to twice as females, sometimes up to twice as frequently as males. frequently as males.

ORGANISMORGANISM

Caused by group A Caused by group A streptococcus.streptococcus.

There is a latent There is a latent period of ~3 weeks period of ~3 weeks (1–5 weeks) between (1–5 weeks) between the precipitating the precipitating group A streptococcal group A streptococcal infection and the infection and the appearance of the appearance of the clinical features of clinical features of ARF. ARF.

PATHOGENESISPATHOGENESIS

Rheumatic fever affect the peri-Rheumatic fever affect the peri-arteriolar connective tissue and can arteriolar connective tissue and can occur after an untreated Group A occur after an untreated Group A streptococcal pharyngeal infection. streptococcal pharyngeal infection.

It is believed to be caused by It is believed to be caused by antibody antibody cross-reactivity. This cross-. This cross-reactivity is a reactivity is a Type II hypersensitivityreaction and is termed reaction and is termed molecular molecular mimicrymimicry

http://en.wikipedia.org/wiki/Cross-reactivity

http://en.wikipedia.org/wiki/Type_II_hypersensitivity

http://en.wikipedia.org/wiki/Type_II_hypersensitivity

Characteristic Characteristic Aschoff bodies, , composed of composed of swollen eosinophilic swollen eosinophilic collagen collagen surrounded by surrounded by lymphocytes and lymphocytes and macrophages can macrophages can be seen on light be seen on light microscopy.microscopy.

http://en.wikipedia.org/wiki/Aschoff_body

http://en.wikipedia.org/wiki/Aschoff_body

In acute RF, these In acute RF, these lesions can be found in lesions can be found in any layer of the heart any layer of the heart and is hence called and is hence called pancarditis. pancarditis.

The inflammation may The inflammation may cause a serofibrinous cause a serofibrinous pericardial exudates pericardial exudates described as “bread-described as “bread-andbutter” andbutter” pericarditis, , which usually resolves which usually resolves without sequelae without sequelae

http://en.wikipedia.org/wiki/Pericarditis

CLINICAL FEATURESCLINICAL FEATURES

Nimishikavi S, Stead L Streptococcal Pharyngitis – Images in Clinical Medicine. NEJM 2005: 352:e10.

Arthritis: This is usually Arthritis: This is usually polyarthritis, sometimes polyarthritis, sometimes flitting from joint to joint flitting from joint to joint (migratory), affecting (migratory), affecting the larger joints more the larger joints more than the smaller ones.than the smaller ones.

Swelling, redness and Swelling, redness and tenderness are the tenderness are the common findings and common findings and occasionally joint occasionally joint effusions. effusions.

Skin lesions : The Skin lesions : The classical erythema classical erythema marginatum—large marginatum—large erythematous lesions erythematous lesions with prominent with prominent margins slightly margins slightly raised.raised.

The red margins take The red margins take longer to fade and so longer to fade and so the lesions sometimes the lesions sometimes look like red ringslook like red rings

Subcutaneous Subcutaneous nodules :nodules : These are These are painless, roundish, firm painless, roundish, firm lumps overlaid by lumps overlaid by normal looking skin normal looking skin

They range from a few They range from a few millimeters to 1.5 cm millimeters to 1.5 cm in diameter, and are in diameter, and are localised over bony localised over bony prominences like the prominences like the elbow, shin and spine. elbow, shin and spine. They sometimes last They sometimes last longer than a month.longer than a month.

Up to 60% of Up to 60% of patients with ARF patients with ARF progress to RHD.progress to RHD.

The endocardium, The endocardium, pericardium, or pericardium, or myocardium may myocardium may be affected.be affected.

Valvular damage Valvular damage is the hallmark of is the hallmark of rheumatic carditis. rheumatic carditis. The mitral valve is The mitral valve is almost always almost always affected.affected.

http://en.wikipedia.org/wiki/File:Rheumatic_heart_disease,_gross_pathology_20G0013_lores.jpg

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Rheumatic heart disease. Abnormal mitral valve. Thick, fused chordae

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Another view of thick and fused mitral valves in Rheumatic heart disease

It presents with It presents with breathlessness, chest breathlessness, chest pain of pericardial pain of pericardial type, and palpitations type, and palpitations due to tachycardia.due to tachycardia.

a soft mid-diastolic a soft mid-diastolic murmur due to murmur due to thickening of the thickening of the mitral valve, the mitral valve, the Carey-Coombs Carey-Coombs murmur, is the murmur, is the classical picture; classical picture;

Pericardial rub may Pericardial rub may be heard at some be heard at some stage in the stage in the disease. disease.

Sydenham's chorea Sydenham's chorea commonly occurs in the commonly occurs in the absence of other absence of other manifestations, follows a manifestations, follows a prolonged latent period prolonged latent period after group A after group A streptococcal infection, streptococcal infection,

The choreiform The choreiform movements affect movements affect particularly the head particularly the head (causing characteristic (causing characteristic darting movements of the darting movements of the tongue) and the upper tongue) and the upper limbs limbs

They may be generalized They may be generalized or restricted to one side of or restricted to one side of the body (hemi-chorea). the body (hemi-chorea).

Chorea eventually Chorea eventually resolves completely, resolves completely, usually within 6 weeks. usually within 6 weeks.

Jones Criteria (1993)Jones Criteria (1993)

Major manifestations:Major manifestations:Arthritis (70%) – involves large joints simultaneously or in succession; responds dramatically to Arthritis (70%) – involves large joints simultaneously or in succession; responds dramatically to

salicylatessalicylatesCarditis (50%) – includes some or all of the following in increasing order of severity:Tachycardia (out of Carditis (50%) – includes some or all of the following in increasing order of severity:Tachycardia (out of

proportion to the fever) – its absence makes the diagnosis of myocarditis unlikelyproportion to the fever) – its absence makes the diagnosis of myocarditis unlikelyHeart murmur of valvulitis – MR or ARHeart murmur of valvulitis – MR or ARPericarditis – friction rub, pericardial effusion, chest pain, ECG changesPericarditis – friction rub, pericardial effusion, chest pain, ECG changesCardiomegaly – seen on chest X-rayCardiomegaly – seen on chest X-raySigns of CHF – gallop rhythm, distant heart sounds, cardiomegalySigns of CHF – gallop rhythm, distant heart sounds, cardiomegalyValvulitis – murmursValvulitis – murmursMyocarditis – unexplained cardiomegaly or CHF or gallopMyocarditis – unexplained cardiomegaly or CHF or gallopPericarditis – friction rub or pericardial effusionPericarditis – friction rub or pericardial effusionMiscellaneous findings – conduction disturbances in the ECG; 2D echo findingsMiscellaneous findings – conduction disturbances in the ECG; 2D echo findings Erythema marginatum (<10%) – nonpruritic serpiginous or annular erythematous evanescent rashes Erythema marginatum (<10%) – nonpruritic serpiginous or annular erythematous evanescent rashes

most prominent on the trunk and inner proximal portions of the extremities; never on the face most prominent on the trunk and inner proximal portions of the extremities; never on the face (disappear on exposure to cold and reappear after a hot shower or if covered with a blanket)(disappear on exposure to cold and reappear after a hot shower or if covered with a blanket); ; blanches on pressureblanches on pressure

Subcutaneous nodules (2-10%) – particularly seen in recurrent cases; hard, painless, nonpruritic, freely Subcutaneous nodules (2-10%) – particularly seen in recurrent cases; hard, painless, nonpruritic, freely movable swellings 0.2-2 cm in diameter; found symmetrically, singly or in clusters on the movable swellings 0.2-2 cm in diameter; found symmetrically, singly or in clusters on the extensor surfaces of large & small joints, over the scalp or along the spine; last for weeksextensor surfaces of large & small joints, over the scalp or along the spine; last for weeks

Sydenham’s chorea (15%) – occurs more often in prepubertal girls; consist of choreic movements Sydenham’s chorea (15%) – occurs more often in prepubertal girls; consist of choreic movements (spontaneous purposeless movements followed by motor weakness),hypotonia, emotional (spontaneous purposeless movements followed by motor weakness),hypotonia, emotional lability, hyperactivity, separation anxiety, obsessions & compulsions; may be related to lability, hyperactivity, separation anxiety, obsessions & compulsions; may be related to dysfunction of BG & cortical neurons; increased titers of “antineuronal antibodies” in >90%dysfunction of BG & cortical neurons; increased titers of “antineuronal antibodies” in >90%

Jones Criteria (1993)Jones Criteria (1993)

Minor manifestations:Minor manifestations:

1.1. Arthralgia – not considered a minor Arthralgia – not considered a minor manifestation if arthritis is presentmanifestation if arthritis is present

2.2. Fever – at least 38.8 CFever – at least 38.8 C

3.3. Elevated acute phase reactants Elevated acute phase reactants (CRP and ESR)(CRP and ESR)

4.4. Prolonged PR interval on the ECGProlonged PR interval on the ECG

EVIDENCE OF ANTECEDENT GROUP A EVIDENCE OF ANTECEDENT GROUP A STREPTOCOCCAL INFECTIONSTREPTOCOCCAL INFECTION

1.1. History of sore throat/scarlet fever History of sore throat/scarlet fever unsubstantiated by lab. data is not unsubstantiated by lab. data is not adequate evidence of recent infection.adequate evidence of recent infection.

2.2. A negative rapid strep antigen detection A negative rapid strep antigen detection test should be confirmed by a conventional test should be confirmed by a conventional throat culture.throat culture.

3.3. Streptococcal antibody tests are the most Streptococcal antibody tests are the most reliable lab.evidence. The onset of the reliable lab.evidence. The onset of the clinical manifestations coincide with the clinical manifestations coincide with the peak of the streptococcal antibody peak of the streptococcal antibody response.response.

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Jones Criteria (Revised) for Guidance in the Diagnosis of Rheumatic Fever*

Major Manifestation Minor Manifestations

Supporting Evidence of Streptococal Infection

Carditis Polyarthritis

Chorea Erythema Marginatum

Subcutaneous Nodules

Clinical Laboratory

Increased Titer of Anti-Streptococcal Antibodies ASO (anti-streptolysin O), others Positive Throat Culture for Group A Streptococcus Recent Scarlet Fever

Previous rheumatic fever or rheumatic heart disease Arthralgia Fever

Acute phase reactants: Erythrocyte sedimentation rate, C-reactive protein, leukocytosis Prolonged P-R interval

*The presence of two major criteria, or of one major and two minor criteria, indicates a high probability of acute rheumatic fever, if supported by evidence of Group A streptococcal nfection.

Recommendations of the American Heart Association

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TreatmentTreatment Step IStep I - primary prevention - primary prevention

(eradication of streptococci)(eradication of streptococci) Step IIStep II - anti inflammatory treatment - anti inflammatory treatment

(aspirin,steroids)(aspirin,steroids) Step IIIStep III- supportive management & - supportive management &

management of complications management of complications Step IVStep IV- secondary prevention - secondary prevention

(prevention of recurrent attacks)(prevention of recurrent attacks)

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STEP I: Primary Prevention of Rheumatic Fever (Treatment of Streptococcal Tonsillopharyngitis)

Agent Dose Mode Duration

Benzathine penicillin G 600 000 U for patients Intramuscular Once

27 kg (60 lb) 1 200 000 U for patients >27 kg

or Penicillin V Children: 250 mg 2-3 times daily Oral 10 d (phenoxymethyl penicillin) Adolescents and adults:

500 mg 2-3 times daily

For individuals allergic to penicillin

Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d Estolate (maximum 1 g/d)

or Ethylsuccinate 40 mg/kg/d 2-4 times daily Oral 10 d

(maximum 1 g/d)

Recommendations of American Heart Association

Arthritis only Aspirin 75-100mg/kg/day,give as 4divided doses for 6weeks(Attain a blood level 20-30 mg/dl)

Carditis Prednisolone 2-2.5mg/kg/day, give as twodivided doses for 2weeksTaper over 2 weeks &while tapering addAspirin 75 mg/kg/dayfor 2 weeks.Continue aspirin alone100 mg/kg/day foranother 4 weeks

Step II: Anti inflammatory treatmentClinical condition Drugs

Bed rest Bed rest Treatment of congestive cardiac Treatment of congestive cardiac

failure: failure: --digitalis,diureticsdigitalis,diuretics Treatment of chorea:Treatment of chorea:

- -diazepam or haloperidoldiazepam or haloperidol Rest to joints & supportive splintingRest to joints & supportive splinting

3.Step III: Supportive management & management of complications

STEP IV : Secondary Prevention of Rheumatic Fever (Prevention of Recurrent Attacks)

Agent Dose Mode

Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular

or

Penicillin V 250 mg twice daily Oral

or

Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral 1.0 g once daily for patients >27 kg (60 lb)

For individuals allergic to penicillin and sulfadiazine

Erythromycin 250 mg twice daily Oral

*In high-risk situations, administration every 3 weeks is justified and recommended


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Duration of Secondary Rheumatic Fever Prophylaxis

Category Duration

Rheumatic fever with carditis and At least 10 y since last residual heart disease episode and at least until (persistent valvar disease*) age 40 y, sometimes lifelong

prophylaxis

Rheumatic fever with carditis 10 y or well into adulthood, but no residual heart disease whichever is longer (no valvar disease*)

Rheumatic fever without carditis 5 y or until age 21 y,

whichever is longer

*Clinical or echocardiographic evidence.


Overview of ValvesOverview of Valves

Mitral Stenosis

Etiology:Etiology: predominant cause: predominant cause:

rheumatic fever rheumatic fever rare causerare cause Pathology: Pathology: thickening, shortening, thickening, shortening,

adhering, calcium depositing, adhering, calcium depositing, and scarringand scarring

four forms of fusion: (1) four forms of fusion: (1) commissural, (2) cuspal, commissural, (2) cuspal, (3)chordal, (4)combined(3)chordal, (4)combined

two types of shape: fish-two types of shape: fish-mouth shaped, funnel-mouth shaped, funnel-shapedshaped

Mitral StenosisMitral Stenosis

Pathophysiology:Pathophysiology:

normal cross-sectional area: normal cross-sectional area: 4-6 cm4-6 cm22

mild MS: <2 cmmild MS: <2 cm22, LAP, LAP↑↑→→LAHLAH

---compensated period---compensated period

moderate MS: <1.5 moderate MS: <1.5 cmcm22, PVP, PVP↑, PCWP↑, ↑, PCWP↑,

→→interstitial edema interstitial edema

severe MS: <1.0 severe MS: <1.0 cmcm22,PAP,PAP↑↑→→RVoverloadRVoverload

→→RV failure RV failure →→TR TR →→PR PR

Mitral StenosisMitral Stenosis Clinical Manifestations (MVAClinical Manifestations (MVA<1.5cm<1.5cm22)) 1. Symptom: dyspnea, hemoptysis, cough, 1. Symptom: dyspnea, hemoptysis, cough, hoarseness (ortnerhoarseness (ortner’’s syndrome)s syndrome) 2. Signs:2. Signs: -Mitral faces-Mitral faces -Diastolic thrill at apex-Diastolic thrill at apex -S1-S1↑(flexible), OS(↑(flexible), OS(Opening snapOpening snap), ), Diastolic Diastolic

rumbling murmur at apex,rumbling murmur at apex, -P2↑, splitting, Graham-Steel -P2↑, splitting, Graham-Steel

murmur(PR),TRmurmur(PR),TR

Mitral StenosisMitral Stenosis Laboratory ExaminationLaboratory Examination

- ECG: - ECG:

1) left atrial enlargement: P 1) left atrial enlargement: P wave (II,Vwave (II,V11) )

2) Af; 2) Af;

3) right ventricular hypertrophy 3) right ventricular hypertrophy

- X-film: change in cardiac - X-film: change in cardiac silhouette, silhouette,

Kerley B linesKerley B lines

- Echocardiography: M-mode, - Echocardiography: M-mode, Two-Two-

dimensional, Doppler dimensional, Doppler

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Physical examPhysical examthe murmurthe murmur

"Tapping" sensation over area of expected PMI. "Tapping" sensation over area of expected PMI. Accentuated S1Accentuated S1 Opening snap.Opening snap. Mid-diastolic murmur (rumble) low in pitch.Mid-diastolic murmur (rumble) low in pitch. S2-OS interval of 70 msec is seen in severe MS.S2-OS interval of 70 msec is seen in severe MS. Best heard after exercise, left lateral recumbency. Best heard after exercise, left lateral recumbency. Bell chest piece lightly applied. Bell chest piece lightly applied. Pulmonary HTN and RVF occur later in MS. Pulmonary HTN and RVF occur later in MS. Low Low

sensitivitysensitivity P mitrale:P mitrale:

Lead II broad and bifid > 0.12 secLead II broad and bifid > 0.12 sec Lead V1 broad and deep negative Lead V1 broad and deep negative

component of biphasic P wave, longer than component of biphasic P wave, longer than 0.04 sec and 1 mm in depth.0.04 sec and 1 mm in depth.

If pulmonary hypertension is present, tall If pulmonary hypertension is present, tall peaked P waves, right axis deviation, or peaked P waves, right axis deviation, or right ventricular hypertrophy appears.right ventricular hypertrophy appears.

Atrial fib.Atrial fib. Atrial flutter.Atrial flutter.

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CXRCXR

Straight left heart border. Straight left heart border. Large left atrium. Large left atrium. Sharply indenting esophagus. Sharply indenting esophagus. Elevation of left mainstem bronchus. Elevation of left mainstem bronchus. Large right ventricle and pulmonary artery Large right ventricle and pulmonary artery

if pulmonary hypertension is present. if pulmonary hypertension is present. Calcification occasionally seen in mitral Calcification occasionally seen in mitral

valve. valve.

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2D echocardiogram2D echocardiogram

Estimates the severity of MSEstimates the severity of MS Measure the pressure gradient Measure the pressure gradient

between LA to LV.between LA to LV. Define the etiology.Define the etiology.

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SurgerySurgery

Indications for intervention focus on:Indications for intervention focus on: Episode of pulmonary edema,Episode of pulmonary edema, Decline in exercise capacity, Decline in exercise capacity, Evidence for pulmonary hypertension. Evidence for pulmonary hypertension.

Percutaneous mitral balloon valvotomy:Percutaneous mitral balloon valvotomy: Mitral valve area <1.5 cmMitral valve area <1.5 cm22

MVR:MVR: Mitral valve area <1.0 cmMitral valve area <1.0 cm22

Rheumatic mitral stenosisRheumatic mitral stenosis




Diagnosis & Differential diagnosisDiagnosis & Differential diagnosis - Diastolic rumbling murmur at apex - Diastolic rumbling murmur at apex + X-film + ECG + Echo+ X-film + ECG + Echo - relative MS; Austin-Flint murmur;- relative MS; Austin-Flint murmur; left atrial myxoma ; Graham steell murmurleft atrial myxoma ; Graham steell murmur Complication:Complication: Atrial fibrillation; acute pulmonary edema;Atrial fibrillation; acute pulmonary edema; congestive heart failure; thromboembolism; congestive heart failure; thromboembolism; infective endocarditis; pulmonary infective endocarditis; pulmonary

infectiveinfective


Management:Management: - Medical treatment:- Medical treatment: Antibiotics, Diuretics and Digitalis,Antibiotics, Diuretics and Digitalis, Antiarrhythmic drugs, Anticoagulant Antiarrhythmic drugs, Anticoagulant - Percutaneous balloon mitral - Percutaneous balloon mitral

valvuloplastyvalvuloplasty ( PBMV)( PBMV) - Surgical treatment:- Surgical treatment: Closed mitral valvotomyClosed mitral valvotomy Open valvotomyOpen valvotomy Mitral valve replacementMitral valve replacement

Balloon Mitral Balloon Mitral CommissurotomyCommissurotomy

Mitral RegurgitationMitral Regurgitation

Etiology and PathologyEtiology and Pathology

- Abnormalities of valve leaflets: - Abnormalities of valve leaflets:

Rheumatic, infective Rheumatic, infective

- Abnormalities of the mitral annulus:- Abnormalities of the mitral annulus:

dilatation, calcificationdilatation, calcification

- Abnormalities of the chordae tendineae:- Abnormalities of the chordae tendineae:

congenitally, infective, trauma, Rheumaticcongenitally, infective, trauma, Rheumatic

- Involvement of papillary muscle: CAD - Involvement of papillary muscle: CAD


PathophysiologyPathophysiology In systolic period, blood flow from LV In systolic period, blood flow from LV

→→ LA, LA filling pressure LA, LA filling pressure↑; ↑; in diastolic period, LV accepts more in diastolic period, LV accepts more

blood →LV dilation, hypertrophy blood →LV dilation, hypertrophy →LVEDP↑ →LVEDP↑ →LAP↑→PCWP↑→PAP↑→RHF; CO↓→LAP↑→PCWP↑→PAP↑→RHF; CO↓

ChronicChronic AcuteAcute


Clinical ManifestationsClinical Manifestations (1) Symptoms: asymptomatic( gradually,>20 (1) Symptoms: asymptomatic( gradually,>20

years),years), palpitation, fatigue, dyspnea, pulmonary edemapalpitation, fatigue, dyspnea, pulmonary edema (2) Signs:(2) Signs: - apical pulse→left,lower- apical pulse→left,lower - apical beat heavy- apical beat heavy - cardiac dullness enlarged→leftcardiac dullness enlarged→left - pansystolic murmur at apex, radiate to left - pansystolic murmur at apex, radiate to left axilla, subscapularaxilla, subscapular - S1↓,P2↑- S1↓,P2↑

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ECGECG

Left axis deviation.Left axis deviation. Left ventricular Left ventricular

hypertrophy. hypertrophy. P waves broad, tall, or P waves broad, tall, or

notched in standard leads.notched in standard leads. Broad negative phase of Broad negative phase of

diphasic P in V1. diphasic P in V1.

5050 M Chadi AlraiesM Chadi Alraies

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2D echocardiogram2D echocardiogram

Thickened mitral valve in rheumatic Thickened mitral valve in rheumatic disease.disease.

Enlarged left ventricle with above-Enlarged left ventricle with above-normal, normal, or decreased normal, normal, or decreased function. function.

Regurgitant flow mapped into left Regurgitant flow mapped into left atrium.atrium.

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ManagementManagement

Acute MR:Acute MR: Emergency surgery. Emergency surgery. Stabilization with vasodilators (nitroprusside)Stabilization with vasodilators (nitroprusside) Intra-aortic balloon counterpulsation.Intra-aortic balloon counterpulsation.

Chronic MR:Chronic MR: Afterload reduction: ACEIAfterload reduction: ACEI Anticoagulation in case of atrial fibrillation.Anticoagulation in case of atrial fibrillation.


Diagnosis:Diagnosis: systolic murmur at apex + systolic murmur at apex +

LALA↑,↑, LV LV↑+ Echo↑+ Echo Differential Diagnosis:Differential Diagnosis: relative MR, ventricular relative MR, ventricular

septal defect,septal defect, tricuspid regurgitation, aortic tricuspid regurgitation, aortic

stenosisstenosis Management:Management: - Medical treatment- Medical treatment - Surgical treatment- Surgical treatment

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Aortic stenosis Aortic stenosis EtiologyEtiology

Bicuspid valve.Bicuspid valve. DegenerativeDegenerative CongenitalCongenital RheumaticRheumatic Infective endocarditis.Infective endocarditis.

5656 M Chadi AlraiesM Chadi Alraies

Aortic StenosisAortic Stenosis

Etiology & Pathology:Etiology & Pathology: - Rheumatic AS, Congenital AS,- Rheumatic AS, Congenital AS, Degenerative calcific ASDegenerative calcific AS Pathophysiology:Pathophysiology: - Obstruction to LVOT→ LVH→ LAH→ PVP↑→- Obstruction to LVOT→ LVH→ LAH→ PVP↑→ Pulmonary edema;Pulmonary edema; - LVEF↓→ischemia of - LVEF↓→ischemia of

peripheralperipheral 、、 brainbrain 、、 heartheart


Clinical Manifestations:Clinical Manifestations: - Symptoms: heart failure (fatigue, dyspnea), - Symptoms: heart failure (fatigue, dyspnea), angina pectoris, syncope, sudden angina pectoris, syncope, sudden

deathdeath - Signs: - Signs: Apical impulse↑,to leftApical impulse↑,to left Systolic thrill in AV area,pulse↓Systolic thrill in AV area,pulse↓ Cardiac dullness→leftCardiac dullness→left Ejection sound & SM in AV area, radiateEjection sound & SM in AV area, radiate to neckto neck A2↓ splitting paradoxicallyA2↓ splitting paradoxically

Rheumatic aortic stenosis and Rheumatic aortic stenosis and regurgitationregurgitation


Laboratory Examination:Laboratory Examination:

ECG; X- film; ECG; X- film;

Echocardiography; AngiographyEchocardiography; Angiography Diagnosis & Diagnosis & Differential Diagnosis:Differential Diagnosis:

- murmur + Echo- murmur + Echo

- MI, TI, VSD- MI, TI, VSD

- other murmurs of LVOT obstruction- other murmurs of LVOT obstruction



Complications:Complications:

Sudden death, heart failure, Sudden death, heart failure, arrhythmia, arrhythmia,

infective endocarditis, systemic infective endocarditis, systemic embolismembolism

Management: Management:

- Medical treatment- Medical treatment

- Surgical treatment- Surgical treatment


Aortic RegurgitationAortic Regurgitation

Etiology & PathologyEtiology & Pathology

- Valvular Disease:- Valvular Disease:

rheumatic, congenital, infective rheumatic, congenital, infective

prolapse, ankylosing spondylitis, prolapse, ankylosing spondylitis, degenerative degenerative

- Aortic Root Disease:- Aortic Root Disease:

syphilitic aoritis, Marfan syndrome,syphilitic aoritis, Marfan syndrome,

ankylosing spondylitis, degenerativeankylosing spondylitis, degenerative

- Acute AR: infective, trauma, aortic dissection- Acute AR: infective, trauma, aortic dissection


Aortic RegurgitationAortic Regurgitation

Clinical Manifestations:Clinical Manifestations: - Symptom: palpitation, angina- Symptom: palpitation, angina - Sign: - Sign: apical impulse→ left, inferiorapical impulse→ left, inferior cardiac dullness →left, inferiorcardiac dullness →left, inferior Boot-shaped shadow—cardiac waist↓Boot-shaped shadow—cardiac waist↓ DM in AV2 area →apexDM in AV2 area →apex S1↓,A2↓S1↓,A2↓ relative MI—SM at apexrelative MI—SM at apex relative MS—Austin Flintrelative MS—Austin FlintSign: Peripheral vascular sign:Sign: Peripheral vascular sign: - pulse pressure↑, carotid pulsation↑- pulse pressure↑, carotid pulsation↑ - Musset sign, water hammer pulse, - Musset sign, water hammer pulse, Traube sign, Duroziez murmur,Traube sign, Duroziez murmur, Muller sign, Quincke sign, Muller sign, Quincke sign, Laboratory Examination:Laboratory Examination: ECG, X-Film, Echo, etcECG, X-Film, Echo, etc

Documents

Acquired valve diseases Prof. S. Smiyan. EPIDEMOLOGY ARF is mainly a disease of children aged 5–14 years. ARF is mainly a disease of children aged 5–14