Valvular Heart Disease. Kul

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    Valvular Heart Disease

    Dr.Suhaemi,SpPD, Finasim

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     Types

      Mitral Stenosis  Mitral Regurgitation  Mitral Valve Prolapse

      Aortic Stenosis  Aortic regurgitation   Tricuspid valve

    •  Tricuspid stenosis

    •  Tricuspid regurgitation

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     Tricuspid Valve

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    Mitral Valvehoc!ey stic!

    appearanceindicatingRheumatic Valve

    DiseaseValve area varied"et#een $.% to

    $.&'(ercise 'cho #asdone

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    Rheumatic Heart Disease

      )n*ammatory process that may a+ectthe myocardium, pericardium and orendocardium

      sually results in distortion andscarring o- the valves

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    Rheumatic Heart Disease

      Su"ectivesymptoms• Prior history o-

    rheumatic -ever• /eneral malaise

    • Pain 0 may or maynot "e present

      1"ectivesymptoms•  Temperature

    • Murmurs• Dyspnea

    • Polyarthritis

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    Rheumatic Heart Disease

      Diagnosis• H2P

    • 345 and 'SR

    • 56reactive protein• 5ardiac en7ymes

    • '8/

    • 5hest (6ray

    • 'cho• 5ardiac cath

    • 5ardiac output

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    Rheumatic Heart Disease

      9ursing 5are• Vital signs

    • Rest and :uiet environment

    • /ive anti"iotics, digitalis, and diuretics• Provide ade:uate nutrition

    • Monitor )21

    '(plain treatment and home care

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    Mitral Stenosis  sually results -rom rheumatic carditis  )s a thic!ening "y ;"rosis or calci;cation  5an "e caused "y tumors, calcium and throm"us  Valve lea*ets -use and "ecome sti+ and the

    cordae tendineae contract   These narro#s the opening and prevents normal"lood *o# -rom the

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    Mitral Stenosis, cont.

      Mild 0 asymptomatic  3ith progression 0 dyspnea, orthopneas,

    dry cough, hemoptysis, and pulmonary

    edema may appear as hypertension andcongestion progresses  Right sided heart -ailure symptoms occur

    later  S2S

    • Pulse may "e normal to A6Fi"• Apical diastolic murmur is heard

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    =6D 'cho sho#ing heavily calci;ed

    Mitral valve lea*ets and Mitral stenosis

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    3-D Echo of Mitral Stenosis

    LA view LV view

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    LALA

    A B   C

    D   E F   G

    Real Time TT' o- MS

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    MitralStenosis

    MitralStenosisManagement PrinciplesManagement Principles

    evere MS

     is usually symptomatic

     Percutaneous mitral commissurotomy (PMC) is the treatment

      modality of choice in the vast majority PMC in optimal anatomy has acturial survival rate of 95%

      after 7 years

     PMC in silled centers has a mortality of ! "%

     Success of PMC depends on the pre#PMC valve anatomy

     Commissural calci$cation is a predictor of suoptimal outcom

     Complications& severe M' emoliation and cardiac perforati

    evere MS

     is usually symptomatic

     Percutaneous mitral commissurotomy (PMC) is the treatment

      modality of choice in the vast majority PMC in optimal anatomy has acturial survival rate of 95%

      after 7 years

     PMC in silled centers has a mortality of ! "%

     Success of PMC depends on the pre#PMC valve anatomy

     Commissural calci$cation is a predictor of suoptimal outcom

     Complications& severe M' emoliation and cardiac perforati

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    •  Surgical treatment

    -  commissurotomy (only occasionally indicated

    usually PMC)

    -  valve replacement

    MitralStenosis

    MitralStenosisManagement PrinciplesManagement Principles

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    Mitral Regurgitation  Primarily caused "y rheumatic heart disease, "ut

    may "e caused "y papillary muscle rupture -ormcongenital, in-ective endocarditis or ischemicheart disease

      A"normality prevents the valve -rom closing  4lood *o#s "ac! into the right atrium during

    systole  During diastole the regurg output *o#s into the

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    Mitral Valve Anatomy

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    Pathophysiology

    Hemodynamic changes much morepronounced than in chronic MR dueto lac! o- time -or adaptation

     The a"rupt increase in le-t atrialpressure is transmitted to thepulmonary circulation

    5ardiac output -alls and systemicvascular resistance increases

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     'cho per-ormed>

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    Mitral Valve Prolapse

      5ause is varia"le and may "e associated#ith congenital de-ects

      More common in #omen  Valvular lea*ets enlarge and prolapse into

    the

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    Mitral Valve ProlapseMitral Valve Prolapse

    •  *omen +, to 5, years

    •  -o. /P orthostatic hypotension palpitations chest pain

    •  Mid systolic clic maye mid systolic murmur

    •  0cho&

    -  thicened redundant lea1ets

    -  lea1et e2cursion (prolapse) into -3 in systole

    -  redundant chordae tendinae trivial or mild M'

    •  -ittle progression of M' 32 prophyla2is

    •  *omen +, to 5, years

    •  -o. /P orthostatic hypotension palpitations chest pain

    •  Mid systolic clic maye mid systolic murmur

    •  0cho&

    -  thicened redundant lea1ets

    -  lea1et e2cursion (prolapse) into -3 in systole

    -  redundant chordae tendinae trivial or mild M'

    •  -ittle progression of M' 32 prophyla2is

     Types Types

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    Mitral Valve ProlapseMitral Valve Prolapse

    •  Men 4, to 7, years

    •  My2omatous and thicened M

    •  Signi$cant lea1elt prolapse

    •  Signi$cant M' progressive M'

    •  Complications& Chordal rupture 3$

    •  0ndocarditis prophyla2is

    •  Surgery for M' often re6uired

    •  Men 4, to 7, years

    •  My2omatous and thicened M

    •  Signi$cant lea1elt prolapse

    •  Signi$cant M' progressive M'

    •  Complications& Chordal rupture 3$

    •  0ndocarditis prophyla2is

    •  Surgery for M' often re6uired

     Types Types

    Classic or non#classic comined MP e6ual in male andfemales More complications in M08

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    ransthoracic echocardiographic image in parasternallong#a2is vie. sho.ing posterior mitral lea1et o.ingac.ard and prolapsing into left atrium during systole-:left ventricle -3:left atrium PM-:posterior mitralvalve lea1et 

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    Aortic Stenosis  Valve "ecomes sti+ and ;"rotic, impeding "lood *o# #ith

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    AorticStenosis

    AorticStenosis;iagnosis;iagnosis

    Clinical

    # pulsus parvus et tardus (asent in hypertensives and elderl

    -  systolic thrill and typical heaving apical impulse

    -  S4 and late peaing ejection systolic murmur

    -  parado2ical split of +nd '

    -  dilated ascending aorta (post#stenotic dilatation)

    -  alve calci$cation

    Clinical

    # pulsus parvus et tardus (asent in hypertensives and elderl

    -  systolic thrill and typical heaving apical impulse

    -  S4 and late peaing ejection systolic murmur

    -  parado2ical split of +nd '

    -  dilated ascending aorta (post#stenotic dilatation)

    -  alve calci$cation

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    AorticStenosis

    AorticStenosisManagement PrinciplesManagement Principles

    •  3symptomatic

    -  no speci$c therapy

    -  endocarditis prophyla2is

    -  if appropriate rheumatic fever prophyla2is

    •  Mild and Mod 3S ( 33 ? "5 s6 cm and ", to "4 s6 cm)

    -  8ormal physical activity

    - 8o speci$c therapy restoration of 8S' in case of 3@i

    -  appro2 progression is a decrease y ," s6 cm per year

    -  annual echo follo.#up

    •  3symptomatic

    -  no speci$c therapy

    -  endocarditis prophyla2is

    -  if appropriate rheumatic fever prophyla2is

    •  Mild and Mod 3S ( 33 ? "5 s6 cm and ", to "4 s6 cm)

    -  8ormal physical activity

    -

     8o speci$c therapy restoration of 8S' in case of 3@i-  appro2 progression is a decrease y ," s6 cm per year

    -  annual echo follo.#up

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    •  8onsurgical (/alloon vavuloplasty)

    -  only a palliative treatment

    -  high ris elderly patients or as an emergent

    procedure

    AorticStenosis

    AorticStenosisManagement PrinciplesManagement Principles

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    5ardiac MR) and 5T

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    )ndications -or Surgery

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    )ndications -or Surgery

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    Aortic Regurgitation  Aortic valve lea*ets do not close properly during diastole   The valve ring that attaches to the lea*ets may "e dilated,

    loose, or de-ormed   The ventricle dilates to accommodate the ? "lood volume

    and hypertrophies  5auses in-ective endocarditis, congenital, hypertension,

    Mar-an@s  May remain asymptomatic -or years  Develop dyspnea, orthopnea, palpitations, ,and angina  May have ? systolic pressure #ith "ounding pulse  Have a high pitch, "lo#ing, decrescendo diastolic murmur

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    Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154

    E!a"#le o$ a Jet o$ %orti& 'egurgitation, a( S)o*n + olor-lo* /"aging

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    Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154

    E!a"#le o$ uantitation o$ %orti& 'egurgitation + t)e onergen&e o$ t)e ro!i"al lo*

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    Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154

    la((i$i&ation o$ t)e Seerit o$ %orti& 'egurgitation

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    Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154

    uideline( $or /ndi&ation( $or Surger in atient( *it) Seere %orti& 'egurgitation

    Assessment -or Valve

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    Assessment -or ValveDys-unction

      Su"ective symptoms• Fatigue• 3ea!ness•

    /eneral malaise• Dyspnea on e(ertion• Di77iness• 5hest pain or discom-ort

    • 3eight gain• Prior history o- rheumatic heart disease

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    Assessment, cont.

      1"ective symptoms• 1rthopnea

    • Dyspnea, rales

    Pin!6tinged sputum• Murmurs

    • Palpitations

    • 5yanosis, capillary re;ll

    • 'dema• Dysrhythmias

    • Restlessness

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    Diagnosis

      History and physical ;ndings  '8/  5hest (6ray  5ardiac cath  'chocardiogram

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    Medical Treatment

      9onsurgical management -ocuses ondrug therapy and rest

      Diuretic, "eta "loc!ers, digo(in, 1=,

    vasodilators, prophylactic anti"iotictherapy

      Manage A6;", i- develops, #ith

    conversion i- possi"le, and use o-anticoagulation

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    )nterventions  Assess vitals, heart sounds, adventitious "reath

    sounds  ? H14  1= as prescri"ed 

    'motional support  /ive medications  )21  3eight  5hec! -or edema 

    '(plain disease process, provide -or home care#ith 1=, medications

    S i l M - V l

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    Surgical Management o- ValveDisease

      Mitral Valve• 5ommissurotomy

    • Mitral Valve Replacement

    • 4alloon Valvuloplasty  Aortic Valve Replacement

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    Mechanical Valve

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    Mechanical Valve

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    Porcine Valve

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     Tissue Valve

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     Tissue Valve

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    )nitial studies

      First report o- left sided  percutaneous valve implants "y4onhoe+er

    • se o- "ovine ugular vein containing a valve #hich #asdissected and sutured into a stent in lam"s

    • Valve initially implanted in descending aorta -or acuteaortic insuciency model.

      1rientation and orthotopic position optimi7ed in -urtheranimal models

      )n vitro testing sho#ed a satis-actory dura"ility -or up to =

    yrs.

    'ur Heart B =CC= =E $C%G6$C%

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    Schematic views of device  

    Left - 3 parts of device arerepresented separately (from

    top: platinum stent, nitinol

    stent, and valve).  Middle - Fully epanded device

    is shown lon!itudinally and

    aially.  "i!h - dia!rams demonstrate

    where nitinol and platinum

    stents are attached, which

    allowed stepwise approach.

    From:  #oud$emline: %irculation, &olume '(*).Fe+ruary ', .-

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    /ewly desi!ned stent crimped on outer +alloon of delivery system +efore

    +ein! covered. /otice spontaneous epansion of nitinol stent. 

    #oud emline: %irculation, &olume ' * .Fe+ruar ', .-

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    (') 0hole system advanced in left ventricle.

    () 1evice then uncovered, deployin! nonsutured part of nitinol stent.

    Free wires of nitinol stent positioned in +ottom of native leaflet.

    (3) #alloons are inflated to epand platinum stent

    (2) Finally deflated, and retrieved, leavin! device in position.

    #oud$emline: %irculation, &olume '(*).Fe+ruary ', .-

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    From:  %ri+ier: %irculation, &olume '*(2).1ecem+er ', .3*-3

    he percutaneous valve crimped

    over the 3-mm-lon! +alloon +efore

    implantation

    Percutaneous

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     BA55 =CC% %E$CI=6J  BA55 =CC= E$&&%6$&&

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    Summary  Percutaneous alvuloplasty

    • M valvuloplasty eAcacious in carefully selected patients• 3 valvuloplasty

    Bnly transient improvement and high restnosis rate in adultpopulation

    -ast resort or ridge to surgery in patients .ith severe calci$ed 3S• P valvuloplasty

    mainly in pediatric population *ell#accdepted treatment for PS and good fu results

      Percutaneous alve repair

    • Currently investigational devices for M' only• Still early stage .ith no pulished results (that D no. of) in human

      Percutaneous valve replacementimplantation• 0arly stages .ith very limited data on human• Promising results for P in pediatric population• -imited ut promising data in human for 3 implant in non#surgical

    candidates

    • -arger scale clinical trials and long term data needed• Enans.ered 6uestions regarding ideal material paravalvular leas

    duraility complications and more

      Bverall percutaneous valve intervention is an e2citing $eld ininterventional cardiology ut still at an infantile stage .ith potentiallyimmense clinical applicationF