Valvular Heart Valvular Heart DiseaseDisease

•Read Robbins 588-594Read Robbins 588-594

•Web atlas: Valvular Heart Web atlas: Valvular Heart DiseaseDisease

•Heart Sound Program (on all Heart Sound Program (on all student computers-- same student computers-- same authors on web site: authors on web site: www.blaufuss.org/tutorial/indextut.html

Valvular Heart Valvular Heart DiseaseDisease

•Stenosis - failure of a valve Stenosis - failure of a valve to open completely - impeding to open completely - impeding forward flowforward flow

•Insufficiency - failure of a Insufficiency - failure of a valve to close completely - valve to close completely - allowing reversed flow(also allowing reversed flow(also called regurgitation)called regurgitation)

•Congenital or acquiredCongenital or acquired

Aortic StenosisAortic Stenosis

•Calcific aortic Stenosis Calcific aortic Stenosis (degeneration)(degeneration)

•Congenital abnormality - Congenital abnormality - bicuspid valvebicuspid valve

•Rheumatic HD ( rare <10%)Rheumatic HD ( rare <10%)

•Never syphilisNever syphilis

•Moderate LVHModerate LVH

Normal aortic valve – opened

Normal aortic valve – shut

Chronic rheumatic aorticstenosis (&probablyinsufficiency)

Note fusion of leaflets

Chronic rheumatic AS - very fibrotic and fusion of leafletsChronic rheumatic AS - very fibrotic and fusion of leaflets

Calcific Aortic Calcific Aortic StenosisStenosis

•Most due to age related Most due to age related degeneration degeneration

•Congenital bicuspid valve 1-Congenital bicuspid valve 1-2% of population2% of population

•LVHLVH

•Angina and syncopeAngina and syncope

Valvular Valvular Degeneration caused Degeneration caused by Calcificationby Calcification

•Valves stressed by highly repetitive Valves stressed by highly repetitive mechanismsmechanisms

•40 million cycles /year40 million cycles /year

•Substantial tissue deformations at Substantial tissue deformations at each cycleeach cycle

•High pressure gradientsHigh pressure gradients

•All lead to thickening and in some All lead to thickening and in some individuals massive calcificationindividuals massive calcification

•Tend to be advanced age (except Tend to be advanced age (except for bicuspid valves) for bicuspid valves)

Chronic calcific aorticStenosis- a degenerativeProcess

Note: the cusps are not fused

Globes of calcium make it impossible forthe leaflets to close.

Bicuspid aortic Valve- becomes calcified

Bicuspid aorticvalve -now virtually Non-moving due to themassive dystrophiccalcification

Aortic InsufficiencyAortic Insufficiency•ASVD & hypertension- degenerative ASVD & hypertension- degenerative aortic dilationaortic dilation

•Collegen disorders (Marfan’s, E-D Collegen disorders (Marfan’s, E-D etc)etc)

•Infectious Endocarditis (acute)Infectious Endocarditis (acute)

•Rheumatic HD (rare) - usually Rheumatic HD (rare) - usually stenosis alsostenosis also

•Syphilis (rare today)Syphilis (rare today)

•Leads to: Massive LVH, CHF Leads to: Massive LVH, CHF

AI- bacterial endocarditis with destruction of leafletAI- bacterial endocarditis with destruction of leaflet

AI- destruction of valve leaflets due to bacterial AI- destruction of valve leaflets due to bacterial endocarditisendocarditis

Mitral StenosisMitral Stenosis

•Chronic rheumatic Chronic rheumatic endocarditis - almost alwaysendocarditis - almost always

•Congenital abnormalitiesCongenital abnormalities

•Lead to:Lead to:

•CPC of lungCPC of lung

•Atrial fibrillationAtrial fibrillation

•mural thrombosismural thrombosis

Normal mitral valve Chronic rheumatic endocarditis

Chronic rheumatic endocarditis – mitral stenosis

Chronic rheumatic stenosis

Mitral InsufficiencyMitral Insufficiency

•Mitral valve prolapseMitral valve prolapse

•Papillary muscle dysfunction Papillary muscle dysfunction (MI)(MI)

•Rheumatic HD - post inflammatory Rheumatic HD - post inflammatory scaring (usually MS also)scaring (usually MS also)

•Infective endocarditisInfective endocarditis

•Leads to LVHLeads to LVH

•Mitral annular calcificationMitral annular calcification

Abnormalities of the Abnormalities of the Mitral ValveMitral Valve

•Valve LeafletsValve Leaflets

•Chordae TendineaeChordae Tendineae

•Papillary MusclesPapillary Muscles

•Mitral AnnulusMitral Annulus

Abnormalities of the Abnormalities of the Valve LeafletsValve Leaflets

•Rheumatic Heart DiseaseRheumatic Heart Disease

•shortening, rigidity, shortening, rigidity, deformity and retraction of deformity and retraction of the leafletsthe leaflets

•Infective EndocarditisInfective Endocarditis

•Perforation and Perforation and retraction(healing)retraction(healing)

Abnormalities of the Abnormalities of the Mitral AnnulusMitral Annulus

•DilationDilation

•normally the normally the mitral annulus mitral annulus constricts during constricts during systole. A systole. A dilated left dilated left ventricle will ventricle will result in dilation result in dilation of the mitral of the mitral annulus and result annulus and result in mitral in mitral regurgitation.regurgitation.

Abnormalities of the Abnormalities of the Mitral AnnulusMitral Annulus

•Calcification of annulusCalcification of annulus

•one of the most common cardiac one of the most common cardiac abnormalities found at autopsy. abnormalities found at autopsy.

•Usually of little consequence Usually of little consequence but may immobilize the basal but may immobilize the basal portions of the MV leaflets portions of the MV leaflets preventing their normal preventing their normal excursion.excursion.

Abnormalities of the Abnormalities of the Chordae TendineaeChordae Tendineae

•RuptureRupture

•primaryprimary

•infective endocarditisinfective endocarditis

•traumatrauma

•rheumatic feverrheumatic fever

•Lenghtening of the chordal Lenghtening of the chordal structures may occur with MV structures may occur with MV prolapse allowing excessive prolapse allowing excessive billowing of the MV leafletsbillowing of the MV leaflets

Mitral Valve Mitral Valve ProlapseProlapse

•Enlarged leaflet balloons into Enlarged leaflet balloons into left atriumleft atrium

•Midsystolic clicks heardMidsystolic clicks heard

•Valve may become incompetentValve may become incompetent

•Late systolic murmurLate systolic murmur

•3% of population3% of population

•6:4 female:male ratio6:4 female:male ratio

•Most no untoward effectsMost no untoward effects

Mitral valve prolapse

Myxomatous degeneration in a patientMyxomatous degeneration in a patientWith mitral valve prolapseWith mitral valve prolapse

Mitral Valve Mitral Valve Prolapse Prolapse

ComplicationsComplications•Most have no untoward Most have no untoward effects - 3% have effects - 3% have complicationscomplications

•Infectious endocarditisInfectious endocarditis

•Mitral insufficiencyMitral insufficiency

•ArrhythmiasArrhythmias

•Stroke or other systemic Stroke or other systemic infarctinfarct

•Sudden death (very rare)Sudden death (very rare)

Mitral valve prolapse with rupture of chordae tendinae

Damaged papillaryDamaged papillarymuscle causingmuscle causingmitral regurgitationmitral regurgitationComplete rupture fromComplete rupture fromMIMI

Muscle dysfuctionMuscle dysfuctiondue to MIdue to MI

Complications of Complications of Artificial ValvesArtificial Valves•Paravalvular leakParavalvular leak

•ThromboembolismThromboembolism

•Infective endocarditisInfective endocarditis

•Structural deteriorationStructural deterioration

•Occlusion by tissue Occlusion by tissue overgrowthovergrowth

SummarySummary•Mitral Stenosis : Rheumatic Heart Mitral Stenosis : Rheumatic Heart DiseaseDisease

•Mitral insufficiency: myxomatous Mitral insufficiency: myxomatous degeneration (mitral valve degeneration (mitral valve prolapse), damaged papillary muscle prolapse), damaged papillary muscle due to infarctdue to infarct

•Aortic stenosis: calcification of Aortic stenosis: calcification of normal and congenitally bicuspid normal and congenitally bicuspid aortic valvesaortic valves

•Aortic insufficiency: dilation of Aortic insufficiency: dilation of the ascending aorta, related to the ascending aorta, related to hypertension and aginghypertension and aging