Valvular Heart Disease2

7/30/2019 Valvular Heart Disease2

1/46

Valvular Heart Disease

Cardiology Division, Medical Faculty Diponegoro University


2/46

Rheumatic Fever

Etiologi

Acute rheumatic fever is a systemic disease of

childhood,often recurrent that follows group A

beta hemolytic streptococcal infection

It is a delayed non-suppurative sequelae to

URTI with GABH streptococci.

It is a diffuse inflammatory disease ofconnective tissue,primarily involving heart,blood

vessels,joints, subcut.tissue and CNS


3/46

Epidemiology

Ages 5-15 yrs are most susceptible Rare boys

Common in 3rd world countries Environmental factors-- over crowding,

poor sanitation, poverty,

Incidence more during fall ,winter &early spring


4/46

Pathogenesis

Delayed immune response to infection withgroup.A beta hemolytic streptococci.

After a latent period of 1-3 weeks, antibody

induced immunological damage occur toheart valves,joints, subcutaneous tissue &

basal ganglia of brain


5/46

Pathologic Lesions

Fibrinoid degeneration of connective

tissue,inflammatory edema, inflammatory cell

infiltration & proliferation of specific cells

resulting in formation of Ashcoff nodules,

resulting in-- Pancarditis in the heart

- Arthritis in the joints

- Ashcoff nodules in the subcutaneoustissue

- Basal gangliar lesions resulting in

chorea


6/46

Clinical Features

(Mayor feature)

1. Arthritis

2. Carditis

3. Sydenham Chorea4. Erythema Marginatum

5. Subcutaneous nodules


7/46

Other features (Minor features)

Fever

Arthralgia

Pallor

Anorexia Loss of weight


8/46

Laboratory Findings

High ESR

Anemia, leucocytosis

Elevated C-reactive protien

ASO titre >200 Todd units.

(Peak value attained at 3 weeks,then comes down to

normal by 6 weeks)

Anti-DNAse B test

Throat culture-GABH streptococci

ECG- prolonged PR interval, 2nd or 3rd degree blocks,ST depression, T inversion

2D Echocardiography- valve edema, mitral

regurgitation, LA & LV dilatation, pericardial effusion,

decreased contractility


9/46

Diagnosis

Rheumatic fever is mainly a clinical

diagnosis

No single diagnostic sign or specific

laboratory test available for diagnosis

Diagnosis based on MODIFIED J ONES

CRITERIA


10/46

Jones Criteria (Revised) for GuidanDiagnosis of Rheumatic Fev

Major Manifestation MinorManifestations

Supporting Evidenceof Streptococal Infectio

CarditisPolyarthritis

ChoreaErythema Marginatum

Subcutaneous Nodules

Clinical Laboratory

Increased Titer of Anti-Streptococcal Antibodies AS

(anti-streptolysin O),

othersPositive Throat Culturefor Group A Streptococcus

Recent Scarlet Fever

Previous

rheumaticfever orrheumaticheart diseaseArthralgiaFever

Acute phase

reactants:Erythrocytesedimentationrate,C-reactive

protein,

leukocytosisProlonged P-

R interval

*The presence of two major criteria, or of one major and two min


11/46

Treatment

Step I - primary prevention

(eradication of streptococci)

Step II- anti inflammatory treatment

(aspirin,steroids)

Step III- supportive management &

management of complications

Step IV- secondary prevention

(prevention of recurrent attacks)


12/46

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


13/46

Step II:Anti inflammatory treatmentClinical condition DrugsArthritis only Aspirin 75-100

mg/kg/day, give as 4

divided doses for 6 weeks

(Attain a blood level 20-30 mg/dl)Carditis Prednisolone 2-2.5 mg/kg/day,

give as two divided doses for 2 weeks

Taper over 2 weeks & while tapering add

Aspirin 75 mg/kg/day for 2 weeks

Continue aspirin alone

100 mg/kg/day for another 4 weeks.


14/46

Bed rest

Treatment of congestive cardiac failure:

- digitalis,diuretics

Treatment of chorea:- diazepam or haloperidol

Rest to joints & supportive splinting

3. Step III: Supportive management &

management of complications


15/46

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

orSulfadiazine 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



16/46

Duration of Secondary Rheumatic Fever

Prophylaxis

Category DurationRheumatic 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.



17/46

Prognosis

Rheumatic fever can recur whenever theindividual experience new GABH

streptococcal infection,if not on prophylactic

medicines

Good prognosis for older age group & if nocarditis during the initial attack

Bad prognosis for younger children & those

with carditis with valvar lesions


18/46

Mitral Regurgitation - Aetiology

Primary

Annulus annular calcification

Leaflet myxomatous degeneration

rheumatic deformity

infectious perforation

Chordae myxomatous degenerationspontaneous rupture

rheumatic shortening

infectious destruction

Papillary infarction

ischemic lengthening

Functional

LV dilatation and PM displacement


19/46

Mitral Regurgitation - Clinical findings

Acute dyspnoea, orthopnoea

no cardiomegaly, short murmur, S3

Chronic variable symptoms

cardiomegaly, murmur, P2 loud, S3Quantification

echocardiography, angiography

serial studies, LV function


20/46

Mitral Regurgitation - Outcome in

Chronic MR

Variable course - diagnosis to symptoms 16 years

Symptomatic severe - survival 33% at 5 years

mortality ~5% per year

LV dysfunction most important factor


21/46

Mitral Regurgitation - Treatment

Diuretics LV filling P, p oedema

Vasodilators forward SV

IABP

Acute

Chronic

No known effective therapyVasodilators - theoretical risks

Treat complications


22/46

Mitral Regurgitation - Surgery

OptionsValve repair

MVR with chordal preservation

MVR with destruction MV apparatus

Outcome

Mortality 80-94% v 40-60% at 5-10years

Valve function

Ventricular function


23/46

Mitral Regurgitation - Indications for surgery

No randomised trials!!

1. Symptomatic with normal LV function

prognosis worse once NYHA class II

symptoms

2. Symptomatic with abnormal LV function

If severe LV impairment - poor outlook

EF < 30% ? medical Rx better


24/46


3. Asymptomatic with abnormal LV function

? Asymptomatic

Detection of LV dysfunction is the key

EF 45mm, LVESV>55ml/m2

4.Asymptomatic with normal LV function

? guaranteed repair

PHT, recent AF


25/46


Chronic severe

mitral regurgitation

No symptoms Symptoms

EchocardiographyEchocardiography

Left ventricle ejectionfraction >0.60

and end-systolicdimension


26/46

Mitral Regurgitation - Prolapse

2-4% population

females:males 2:1

diagnosis from echocardiography

subcategory according to leaflet abnormality

SBE prophylaxis; normal + MR or abnormal leaflets


27/46

Mitral Stenosis

Causesrheumatic fever

congenital abnormality, calcification, myxoma

Natural historyRF age 12

murmur 1st heard 20 yrs later

symptoms in 4-5th decade


28/46

Mitral Stenosis - Clinical features

Severity MVA (cm) LAP (mmHg) CO

Mild >2.0


29/46

Mitral Stenosis - Examination

Inspection

Malar flushPeripheral cyanosis (severe MS)

Jugular venous distension (right ventricular failure)

Palpation

Parasternal right ventricular impulse

Palpable pulmonary arterial impulse

Palpable S1, P2, and occasionally, the diastolic

rumbleAuscultation

Increased intensity of the first heart sound

Opening snap

Low-pitched diastolic rumbling murmur


30/46

Mitral Stenosis - Treatment

Medical

Diuretic - pulmonary congestion

Prevent embolism - cause of 19% deaths,

with LA size and age

anticoagulate all with PAF/AF, SR in older age

Control atrial fibrillation


31/46


Balloon Mitral Valvuloplasty


32/46


Balloon Mitral Valvuloplasty

100% MVA, final area ~2cm2

Failure rate 1-15%

Mortality 0-3%Severe MR 2-10%

Restenosis ~40% at 7years

Contraindications - thrombus, MR, Ca++, other

disease


33/46


Mitral Valve Replacement

Open mitral valvotomy

Mitral valve replacement


34/46

Aortic Regurgitation - Aetiology

Root

Annuloaoroectasia

Marfans

Dissection

Syphillis

Ankylosing spondylitis

Leaflet

Endocarditis

Bicuspid valve

Rheumatic heart disease


35/46

Acute Aortic Regurgitation - Clinical features

No time for LV to enlarge

total SV, fwd SV, LVEDP

Quiet S1 (presystolic MV closure),

short murmur

Treatment

Medical therapy ineffective

AVR if symptoms/signs LVF


36/46

Chronic Aortic Regurgitation - Clinical features

total SV, maintained fwd SV, RV runoff in diastole

systolic BP, diastolic BP Volume and pressure overload

Examination - hyperdynamic circulation, wide pulse pressure,

dilated LV, EDM duration important


37/46

Chronic Aortic Regurgitation - Clinical features

Maybe asymptomatic, LVF, angina

LV decompensation


38/46

Chronic Aortic Regurgitation - Treatment

Medical - afterload

Nifedipine 20mg bd delayed surgery by 2-3 yrs

Duplicated with small ACEI trials

Surgery - AVR prior to irreversible LV dysfunction

1. Asymptomatic

LVEF55mm, LVESV 60ml/m2

2. Symptomatic

NYHA class II

A ti St i A ti l


39/46

Aortic Stenosis - Aetiology

Congenital 1st-3rd decade

Valve degeneration and calcificationRheumatic - 4th decade

Bicuspid valve; 1%, males>females, 5-6th decades

Tricuspid valve - 7-8th decades, 1-2% incidence


40/46

Aortic Stenosis - Pathophysiology

LV pressure overload LV hypertrophy diastolicLV dysfunction

Systolic function usually preserved except late in

diseaseSystolic function improves with AVR

Outcome is dependent on symptoms

A ti St i Cli i l f t


41/46

Aortic Stenosis - Clinical features

Symptoms

None

SOBOE, dizziness

HF, syncope, anginaExamination

Pulse - amplitude, delay

Sustained apex

S2- soft and single paradoxical splitting

ESM - loud

late peak

soft


42/46

Aortic Stenosis - Severity

Echocardiography

Meangradient(mmHg)

Peak Aovelocity

AVA(cm2)

Normal 1.0-2.0 >2.5

Mild 1.7

Moderate 20-40 3.0-4.0 1.0-1.7

Severe >40 >4.0


43/46

Aortic Stenosis - Outcome

Symptomtic

2-year survival < 50%

Asymptomatic

Generally good prognosisPeak velocity >4.0m/s 2yr event-free survival

21%

Progression of> 0.3m/s per year - worse


44/46

Aortic Stenosis - TreatmentMedical

None!!!

Diuretics v LVF

ACEI contraindicated

Balloon aortic valvuloplasty

Average MVA improvement 0.8cm2 1.0cm2

Restenosis


45/46

Aortic Stenosis - AVR

Indicated only if symptomatic

Mortality 0.6-5%

Survival 67-85% at 5 yrs, 70% at 10yrs

2yr survival 4x greater than medical treatment

LV dysfunction

?impairment from pressure overload or other cause

DSE may be helpful

A ti St i AVR


46/46

Aortic Stenosis - AVR

Approach to symptomatic patient

Ao V max

4.0m/s 3.0m/s3.0-4.0m/s

Doppler AVA

1.1-1.6cm2 1.7cm21.0cm2

2-3+ 0-1+

AVR recommended AVR for AS not recommended

AI severity

Documents

Valvular Heart Disease2