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Valvular heart disease

Richard Schilling

St Mary’s Hospital

London

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Valve disease

• Aetiology

• Clinical findings

• Investigations

• Management

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Heart Valve lesions

• Mitral stenosis• Aortic stenosis• Pulmonary stenosis• Tricuspid stenosis• Prosthetic stenosis

• Mitral regurgitation• Aortic regurgitation• Pulmonary regurgitation • Tricuspid regurgitation• Prosthetic regurgitation

• Mitral valve prolapse

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Mitral regurgitation - Aetiology

• Valve– Rheumatic fever– Endocarditis

• Mitral valve annulus– Dilation– Calcification

• Chordae tendinae– Rupture– Lengthening

• Papillary muscle– ischaemia– dilation

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Mitral regurgitation – pathophysiology

LV emptying LA pressure (if acute, pulmonary odema)

LV filling LVedd

• LV stretch failure

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Mitral regurgitation – Clinical

• Symptoms appear late– SOB– Fatigue– Right heart failure

• Signs– Full volume pulse– Pan systolic murmur

radiating to apex– Right heart failure – Pulmonary hypertension

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Mitral Regurgitation

• Investigations– ECG p mitrale– Xray large heart, calcified

mv annulus, pulmonary odema

– Echocardiogram large LA, abnormal valve, MR

– LV angio MR, large LA

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Mitral Regurgitation

• Heart Failure

• Decrease afterload

• Replacement

• Anticoagulation

• Antibiotic prophylaxis

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Mitral Stenosis - Aetiology

• Rheumatic fever

• Congenital

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Mitral Stenosis - pathophysiology

LA pressure Pulmonary pressure

• R Heart failure LV function

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Mitral Stenosis – Symptoms/Signs

• SOB

• Haemoptysis

• Embolisation

• Mitral Facies

• AF, thready pulse JVP

• RV heave

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Mitral Stenosis – Symptoms/Signs

• Opening snap

• Rumbling diastolic murmur

• Presystolic murmur

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Mitral stenosis - Investigations

• ECG – AF

• Xray – Pulmonary congestion, large LA and R heart

• Echo – tight valve, high inflow large LA

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MS ECG

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MS x-ray

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MS echo

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MS Treatment

• Antibiotic prophylaxis

• Anticoagulation (AF)

• Digoxin (AF)

• Mitral Valvuloplasty

• Surgical Replacement

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Mitral Valvuloplasty

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Aortic Stenosis - aetiology

• Congenital – bicuspid valve

• Acquired – Rheumatic– Senile/degenerative

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Aortic Stenosis – pathophysiology

• LVH Cardiac output on exercise

• LV dilatation and failure

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Aortic stenosis – symptoms/ signs

• Asymptomatic

• Angina

• Heart Failure

• Syncope

• Sudden Death

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Aortic stenosis – symptoms/ signs

• Slow rising pulse

• LV heave

• Ejection systolic murmur radiating to carotids

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Aortic Stenosis - investigations

• ECG – LVH

• Echo – LVH, calcified valve, high doppler velocity

• Angio – Ao valve gradient

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AS ECG

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Congenital AS

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Echo AS

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Doppler/Pressure Aortic stenosis

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Aortic stenosis - treatment

• Antibiotic prophylaxis

• Surgical replacement before heart failure

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Aortic valve replacement

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Aortic Regurgitaiton- aetiology

• Aortic valve– Rheumatic fever– Infective endocarditis– Bicuspid vlave

• Aortic dilation– Age related– Marfans– Dissection

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Aortic regurg - pathophysiology

• Increased Lved volume

• Increased stroke volume

• LV dilatation

• LV failure

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AR – symptoms/signs

• Often asymptomatic

• Chest pounding

• Prominent pulse

• Heart failure

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AR – symptoms/signs

• deMusset’s sign

• Collapsing pulse

• Displaced apex beat

• Early diastolic murmur

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Auscultation AR

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AR investigations

• ECG – LVH

• X-ray – abnormal aorta, large heart

• Echo – AR, LV dilation, dissection

• Angiogram – AR, LV dilation

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AR - xray

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AR - Echo

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AR - treatment

• Antibiotics

• Vasodilators

• Replacement – when LV begins to dilate or fail

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When to replace the aortic valve?

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When to replace the mitral valve

• When symptoms significant

• Before LV failure

• Before significant pulmonary hypertension

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Right heart valves

• Low pressure

• Tricuspid regurg (drug addicts)

• Pulmonary stenosis (congenital)