Departemen Kardiologi FK USU

RSUP. H. Adam Malik

Medan

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Valve lesions and their abbreviations
Valve involved Lesion Abbreviation

Mitral valve Mitral stenosis MS

Mitral regurgitation MR
Floppy(prolapsing) mitral valve MVP

Aortic valve Aortic stenosis AS

Aortic regurgitation AR

Tricuspid valve Tricuspid regurgitation TR

Tricuspid stenosis TS

Pulmonary Pulmonary stenosis PS

valve Pulmonary regurgitation PR

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MITRAL STENOSIS
• Definition
 an obstruction to LV inflow at the level of mitral valve
as a result of a structural abnormality of the mitral valve
apparatus, preventing proper opening during diastolic
filling of the left ventricle

• Etiology
Rheumatic carditis ( 60 % )
Congenital malformation ( rare, children )

• Prevalance
- Female : male = 2 : 1
- 40% of RHD ACC/AHA Guidelines for Management
of Patients with valvular heart disease,1998 5
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• Pathophysiology

Shahbudin H, Rahimtoola MB,et al; 2002 8

• Symptoms
- Some are asymptomatic
- Chief complaint : dyspnoe
- DOE, OP, PND, and even acute pulmonary oedema
- Pulmonary hypertension with secondary right-sided heart failure
( hepatomegali, ascites, elevated jugular pressure, lower limb
oedema )
- Atrial arrhythmia : AF
- Hemoptysis (rare, end stage)
Alpert, JS, The AHA Clinical cardiac Consult,2001
• Signs
- Loud S1
- Opening snap
- Diastolic rumble, near apex
- Variably present ( loud P2, murmur of MR, murmur of TR )

Crawford, MH; Current Diagnosis and treatment in Cardiology, 2003

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• Medical treatment
- Antibiotics prophylaxis ( reccurent RF, IE )
- Restrict activities (mod – severe MS)
- AF :
- control ventricular rate (Digoxin)
- Anticoagulant : Heparin and Warfarin IV, when INR
is 2 to 3 discontinue heparin
- Diuretics ( elevated pulmonary venous pressure,
pulmonary congestion )
- ACE-I ( LV systolic dysfunction )
- Beta blockers after the patients are stablized

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BMV/PMC Surgical

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MITRAL REGURGITATION

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 On examination
 Atrial fibrillation – an irregularly irregular pulse is
common, especially in patients who have chronic MR and
a dilated left atrium.
 Jugular venous pressure may be elevated – if the patients
has developed pulmonary hypertension and right heart
failure, or fluid retention
 The apex is displaced downward and laterally as the left
ventricle dilates
 The murmur of MR is pansystolic and best heard at the
apex
 Signs of congestive cardiac failure
 P2 may be loud and there may be a right ventricular
heave

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 Investigations
 Electrocardiography
 Chest radiography
 Echocardiography
 Cardiac catheterization

Management
Medical management
This may consist of diuretics and ACE inhibitors to
treat the congestive cardiac failure.

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AORTIC STENOSIS

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 Clinical features

 Dyspnoea – may lead to orthopnoea and paroxysmal

nocturnal dyspnoea as the left ventricle fails.
 Angina – due to the increased myocardial work and
reduced blood supply (the coronary arteries may be
normal).
 Dizziness and syncope – especially on exertion.
 Sudden death.
 Systemic emboli.

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 On examination
 A slow rising, small volume pulse – best felt at the
carotid pulse.
 A low blood pressure.
 Heaving apex beat – rarely displaced
 Ejection systolic murmur at the aortic area radiating
to the carotids accompanied by a palpable thrill
 Signs of left ventricular failure

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AORTIC REGURGITATION

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ETIOLOGY

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Clinical features

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Mechanical Valve Bioprothese Valve

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 TRICUSPID REGURGITATION
Causes
Most cases of tricuspid regurgitation (TR) are due
to dilatation of the tricuspid annulus resulting from
dilatation of the right ventricle. This may be due to
any cause of right ventricular failure or pulmonary
hypertension.
Occasionally, the tricuspid valve is affected by
infective endocarditis (usually in intravenous drug
abusers). Rarer causes include congenital
malformations and the carcinoid syndrome.

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 Clinical features
The symptoms and signs are due to the backpressure effects of
the regurgitant jet into the right atrium, which are transmitted
to the venous system causing a prominent v wave in the
jugular venous waveform.
Fatigue and discomfort due to ascites or hepatic congestion are
the commonest feature. Patients usually present with
symptoms of the disease causing the underlying right
ventricular failure;the TR is often an incidental finding.

Management
The mainstay of management is medical with diuretics and
angiotensin-converting enzyme inhibitors to treat the right
ventricular failure and fluid overload. Tricuspid valve
replacement is considered in very severe cases.

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 Overview of other valve lesions
Valve lesion Cause Clinical features Management

Tricuspid Rheumatic fever; rare Venous congestion – JVP Treat pulmonary

raised, large a waves, ascites, hypertension, valve
stenosis hepatomegaly, peripheral replacement
oedema, soft deastolic
murmur at left lower sternal
edge
Pulmonary Congenital If mild asymptomatic, if Pulmonary valvuloplasty or
malformation- severe- RVF and cyanosis, Pulmonary valve
stenosis Noonan’s syndrome, ejection systolic murmur in the replacement
maternal rubella pulmonary area (second left
syndrome, carcinoid ICS), wide splittting of second
syndrome heart sound

Pulmonary Dilatation of the valve RVF in severe cases, low- Treat underlying disease
ring secondary to pitched diastolic murmur in
regurgitation pulmonary pulmonary area, Graham
(PR) hypertension, infective Steel murmur- in severe PR
endocarditis the murmur is high pitched
due to the forceful parasternal
edge(i.e. similar to that in
aortic regurgitation but whith
signs of severe pulmonary
hypertension and RVF)
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