A S Y N O P S I S

VALVULAR HEART LESIONS

MITRAL STENOSIS (MS)

• Normal 4-6 cm2

• Stenosis <4 cm2

• Symptoms <2 cm2

• Severe stenosis <1 cm2

• Causes:-• Rheumatic heart disease• Calcification• Congenital• Lutembacher’s syndrome (acquired MS+ASD)• Carcinoid tumour metastases

MS

• Pathophysiology:-• LA outlet obstruction• LA pressure ↑, LA dilatation• LV filling ↓, dependent on LA contraction

• Symptoms:-• ↑ing DoE, haemoptysis, cough, chest pain(Pulm cong,

PAH)• Fatigue, pedal edema, ascites (Rt sided HF)• Palpitation (AF)• Systemic embolism:- CVA, Renal, Mesenteric, Peripheral

ischaemia

MS EXAMINATION

• Signs:-• Malar flush (AV anastamoses, venous stasis)• JVP ↑ (RVH, TR, PAH)• Pulse – SR, low volume, AF• Apex – localized tapping• RV – heaving, sustained (PAH, RVH)• Loud palpable S1, opening snap, loud P2 (PAH)• Mid-diastolic, rough, rumbling apical murmur +

presystolic accentuation• Graham Steele – EDM (func PR)

MS INVESTIGATIONS

• CXR:-• Enlarged LA• PVH, PAH, pulm edema• Calcified mitral valve

• ECG:-• Bifid P (P mitrale)• RVH – RAD, tall R V1

• ECHO:-• Mitral valve – area, severity, calcific, mobility• PR, TR• Atria – size, LA thrombus• Ventricles – size, function

• CAG – prior to MVR

MS TREATMENT

• Diuretics (HF)• Digoxin, β-blocker, CCB, anticoag (AF)• Rheumatic fever prophylaxis• IE prophylaxis• Surgery – medical fails/not feasible• Trans-septal balloon valvotomy• Closed valvotomy• Open valvotomy• MVR

MITRAL REGURGITATION (MR)

• Abnormality of:-• Valve leaflets• Valve annulus• Chordae tendinae• Papillary muscles• Left ventricle

• Pathophysiology:-• Part of stroke vol back to LA• LA overload• CO ↓

MR

• Acute:-• Large vol back to LA, acute LA press ↑• PVH, pulm edema• Next LV enlarges, maintain stroke vol & CO

• Chronic:-• LA dilates, LA press N/slight ↑• Less PVH & pulm edema

MR CAUSES

• Myxomatous valvular degeneration• Ischaemic HD• Rheumatic HD• Infective endocarditis• DCM, HCM• Autoimmune – SLE• Collagen vascular – Marfan’s, Ehler Danlos• Congenital – 1o ASD• Drugs – Fenfluramine, cabergoline

MR SYMPTOMATOLOGY

• Slow progress – No symp for years• Sense forceful heartbeat - ↑ stroke volume• Fatigue, lethargy, cardiac cachexia - ↓ CO• Dyspnoea, orthopnoea –PVH, a/c pulm edema• Later – dyspnoea, ascites, pedal edema, ↑ JVP,

palpitation (RVH, PAH, AF)• Sub a/c IE – PUO

MR EXAMINATION

• Pulse:-• AF• SR, N/low volume

• Apex:-• Forceful• Systolic thrill

• Auscultation:-• S1 soft, S3+• Apical PSM. Radiating to axilla

• JVP ↑ if RV failure

MR INVESTIGATION

• CXR:-• Cardiomegaly, LA & LV enlarged, valve calcific

• ECG:-• AF, SR, bifid P mitrale, LVH

• ECHO:-• LA & LV dilated• Valve leaflet motion• Papillary muscle anatomy & function• Regurg jet direction, severity

MR TREATMENT

• Mild MR – asymp – conservative• Vasodilators - ↓ pre & afterload• Diuretics – HF• Anticoag, antiarrhythmics – AF• β blockers – atrial arrhythmia• ICD – vent arrhythmia• Endocarditis prophylaxis• Symptomatic = Sx (prevent LVD)• MV repair – Sx, clip• MV replacement

BARLOW’S SYNDROME (MVP)

• Pathophysiology:-• Large leaflet/ annulus• Long chordae• Papillary muscle dysfunction

• Seen max in young females• Associations:-• Marfan’s• Thyrotoxicosis• RHD, IHD, ASD, HCM

• Findings – early systolic click, PSM +/-

AORTIC STENOSIS (AS)

• LV outflow obstruction

• Causes:-• Calcific degeneration – elderly, male, DM, HTN, DLP• Congenital bicuspid vlave• Rheumatic HD• Misc –• CKD• Paget’s of bone• Radiation• Familial hypercholesterolemia

AS PATHOPHYSIOLOGY

• LV emptying obstructed• LV pressures ↑• LV hypertrophy (press overload)• LV ischaemia – angina, arrhythmia, HF• Exertion –• CO rises very little• Worsens angina and fatigue• Syncope/presyncope

• Later LA press ↑, PVH = dyspnoea

AS SYMPTOMS

• When AV area <⅓ normal• Exertional symptoms• Angina = 4 years• Syncope = 3 years• Dyspnoea = 2 years• Heart failure = 1.5 years• Cachexia, fatigue = end-stage

AS EXAMINATION

• Pulse – SR, low vol, slow rising (parvus et tardus)• Apex – undisplaced, heaving• Aortic area – systolic thrill• Auscultation:-• Ejection click• Soft A2, reversed split +/-• S4• Systolic, low pitched, ejection (crescendo-decrescendo)

murmur – aortic area, radiating to carotids

AS INVESTIGATION

• CXR:-• Cardiac size N, HF = cardiomegaly• AV calcification• Dilated ascending aorta

• ECG:-• SR, Vent arrhythmia• LVH + strain = ST ↓, T ↓, Left leads

• ECHO:-• AV area, calcific, jet velocity, severity• LVH, dysfunction• Aorta dilatation

• MRI/CT:-• Aortic aneurysm, dilatation, coarcation

AS TREATMENT

• Asymptomatic:-• Regular follow-up ECHO

• IE prophylaxis• Valvotomy:-• Buys time, improves LV temporarily• Childhood, adolescents mainly

• Surgery:-• Symptomatic• Aorta gross/rapidly progressing dilatation• AV replacement – open, percutaneous

AORTIC REGURGITATION (AR)

• Pathophysology:-• Blood ejected into aorta in systole• Leaks back into LV in diastole• DBP ↓• LV volume overload• ↑ Stroke vol to maintain effective CO• LV dilatation, later dysfunction

AR CAUSES

• Acute:-• Rheumatic fever• Infective endocarditis• Aortic dissection• Rupture sinus of valslva• Prosthetic valve failure

• Chronic:-• Rheumatic heart disease, syphilis, HTN• Bicuspid valve, valve calcification, subvalvular VSD• Arthritides – reactive, ankylosing spondylitis, rheumatoid• Marfan’s, osteogenesis imperfecta

AR SYMPTOMS

• Late in disease, when LV fails• Pounding of heart• ↑ Stroke volume & force of contraction

• Angina• DoE• Arrhythmias +/-

AR EXAMINATION

• Pulse:-• SR, large vol, collapsing• Water hammer/Corrigan’s pulse

• BP:-• SBP ↑, DBP ↓• Wide pulse pressure

• Apex:- Displaced down & out (LV dilatation)

• Sounds:-• High pitched EDM at Lt sternal border• ESM at aortic area, radiating to carotids• MDM at apex (Austin-Flint)

AR PERIPHERAL SIGNS

• Light-house – Flushing & blanching forehead• Landolfi’s – Pupillary size alternation• Becker’s – Retinal artery pulsation• De Musset’s – Head nodding• Muller’s – Uvula pulsation• Corrigan’s – Dancing carotids• Quincke’s – Capillary pulsation in nails• Locomotor brachii• Rosenbach’s – Liver pulsations• Gerhardt’s – Spleen pulsations• Traube’s – Pistol shot sounds over femorals• Duroziez’s – Systolic & diastolic murmurs over femorals• Hill’s – SBP popliteal>brachial

AR INVESTIGATIONS

• CXR:-• LVH• Ascending aorta dilatation & calcification• AV calcific

• ECG:- LVH• Tall R & deep T ↓ in left side leads• Deep S right side leads

• ECHO:-• Dilated aortic arch• LV – dilatation, dysfunction• Severity of AR• TEE – Aortic valve & aortic root

• MRI & CT – Assess thoracic aorta & root

AR TREATMENT

• Rx for specific cause• A/c AR – vasodilators, inotropes• LV dysfunction – ACEi• Surgery:-• Before LVD sets in – not completely reversible• Before significant symptoms develop• A/c severe AR• Symptomatic c/c severe AR• LVD present• LV dilatation present• Along with other cardiac Sx

TRICUSPID STENOSIS (TS)

• Uncommon• Women > men• Associated mitral & aortic valve disease• Causes:-• RHD• Carcinoid

• Pathophysiology:-• RA emptying impaired, CO ↓• RA press ↑• Venous congestion (↑JVP, hepatomeg, ascites, pedal

edema)

TS

• Symptoms:-• Abd pain + swelling• Pedal edema• Left sided failure symptoms

• Signs:-• ↑ JVP, pedal edema• Pulsatile liver, hepatomegaly• Rumbling MDM @ lower LSE, louder on inspiration• Tricuspid OS

TS INVESTIGATIONS

• CXR:-• Prominent right atrial bulge

• ECG:-• Peaked, tall P waves (>3 mm) in lead II (RAE)

• ECHO:-• Thickened & immobile tricuspid valve

TS TREATMENT

• Medical:-• Diuretic therapy• Salt restriction

• Surgical:-• Tricuspid valvotomy• Tricuspid valve replacement is often necessary• Other valves usually also need replacement

TRICUSPID REGURGITATION (TR)

• RA pressure overload

• Causes:-• Functional-• RV dilatation• Cor pulmonale, MI, pulmonary HTN

• Organic-• RHD• IE• Carcinoid syndrome • Congenital - Ebstein’s anomaly

TR

• Symptoms:-• Right heart failure

• Signs:-• Large jugular venous c & v waves• Hepatomegaly + pulsates in systole• Lt parasternal heave (RVH)• Blowing PSM @ LSE, best heard on inspiration • AF common

• ECHO:-• Dilated RV• Thickened tricuspid valve

TR TREATMENT

• Functional – Medical Rx

• Severe organic:-• TV repair – plasty, plication• TV replacement

PULMONARY STENOSIS (PS)

• Causes:-• Congenital – most common (isolated, ToF)• RHD• Carcinoid

• Pathophysiology:-• RV press overload• RVH, then RAH• Rt heart failure

PS

• Symptoms:-• Mild – asymptomatic• Moderate – fatigue, syncope, dyspnoea +/-• Severe – incompatible

• Signs:-• JVP – prominent a wave• Lt parasternal heave• Delayed, soft P2 + pulmonary ejection click• Harsh midsystolic ejection murmur @ 2nd Lt ICS, best

heard on inspiration, thrill +• RV S4

PS

• Investigations:-• CXR:-• Prominent pulmonary artery

• ECG:-• RAH – Tall P right leads• RVH – Tall R right leads

• ECHO:-• Doppler – stenotic flow• RVH• RA hypertrophy/enlargement

• Treatment:-• Pulmonary valvotomy (balloon,direct surgery)

PULMONARY REGURGITATION (PR)

• Most common acquired pulm valve defect• Pulm HTN most common cause (annular

dilatation)• Decrescendo diastolic murmur• No symptoms• Treatment rarely needed