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Heart valve disease

Heart valve
disease

Liu Chao,MD
Anatomy of heart
Anatomy of heart valve
 The heart has two
halves, a left and a
right, each with two
chambers - the atrium
and the ventricle.
Between the chambers
are the heart valves
which ensure the
blood runs only in one
direction.
Anatomy of heart
 There are also
heart valves
situated between
the ventricles and
the major arteries -
the aorta and
pulmonary artery -
where they have
the same function.
Classification of heart valve
disease?

 Narrowed valves

 Leaking valves
Narrowed valves
 These may be due to:
 congenital abnormality

 degeneration through atherosclerosis (aortic


stenosis only)

 damage from rheumatic fever

 excessive calcification in old age (aortic stenosis


only).
Leaking valves
 These may be due to:

 bacterial infection or inflammation of a valve

 excessive floppiness of the leaflets (mitral


valve prolapse)

 enlargement of the heart or aorta - the main


blood vessel into which the left ventricle
pumps.
Valve heart disease

 Mitral stenosis and insufficiency


 Aortic stenosis and insufficiency
 Tricuspid stenosis and insufficiency
 Pulmonary stenosis and insufficiency
Anatomy of mitral valve
Mitral stenosis
Mitral stenosis
 Etiology and pathology
 Pathophysiology
 Diagnostic considerations
 Natural history
 Complication
 Operative treatment
Etiology
 Rheumatic fever is the known cause
of mitral stenosis, although a difinite
clinical history can be obtained in only
about 50% of patients.
 Mitral stenosis may also be associated
with aging and a buildup of calcium
on the ring around the valve where
the leaflet and heart muscle meet.
Etiology

 Rarely congenital

 Two-thirds of all patients with MS are


female.
Pathology
 Rheumatic valvulitis produces at least three
distinct pathologic changes, the degree
varying widely among different patients:
fusion and shortening of the chordae
tendineae; and fibrosis of the leaflets with
subsequent stiffening, contraction, and
calcificaion. The most extensive changes
usully are seen in patients with recurrent
attacks of rheumatic fever.
Pathophysiology
 The cross-sectional area of
the mitral valve is 4-6 square
centimeter, varying with
body size. Significant
hemodynamic changes from
mitral stenosis do not
appear, however, until the
cross-sectional area is
reduced to less than 2 to
2.5cm
Mitral Stenosis:
Pathophysiology
 Normal valve area: 4-
6 cm2
 Mild mitral stenosis:
 MVA 1.5-2.5 cm2
 Minimal symptoms
 Mod mitral stenosis
 MVA 1.0-1.5 cm2 usually
does not produce
symptoms at rest
 Severe mitral stenosis
 MVA < 1.0 cm2
Mitral Stenosis:
Pathophysiology
Right Heart Failure: ↑ Pulmonary HTN
Hepatic Congestion Pulmonary
JVD Congestion
Tricuspid LA Enlargement
Regurgitation Atrial Fib
RA Enlargement LA Thrombi
↑ LA Pressure

RV Pressure
Overload
RVH LV Filling
RV Failure
What are the symptoms?
 Most people with mitral stenosis
have no symptoms. When symptoms
do happen, they may get worse with
exercise or any activity that
increases your heart rate. These may
include
What are the symptoms?
 Dyspnea on exertion, orthopnea, paroxysmal
nocturnal dyspnea
 Coughing, hemoptsis, pinkish, blood-tinged
sputum.
 Fatigue.
 Chest pain that gets worse with activity and goes
away with rest.
 Frequent respiratory infections such as
bronchitis.
 Heart palpitations (the feeling that the heart has
skipped a beat).
 Swelling (edema) of the feet and ankles.
 A hoarse or husky-sounding voice.
What is the sign?
 Thin and frail
 Atrial fibrillation
 Apical diastolic rumble murmur, an
increased first sound, an opening
snap
Diagnostic consideration

 Clinical manifestation
 Chest radiography
 EKG
 Echocardiography
Chest X-ray
 Enlargement of the left atrium (double contour )
 Kerley’s line (enlarged pulmonary lymphatics)
 Distention of the pulmonary arteries and viens
 “Straight” left border of the heart (the enlargement of
atrium and pulmonary artery obliterates the normal
concavity between the aorta and ventricle)
Mitral Stenosis: EKG
 LAE
 RVH
 Premature contractions
 Atrial flutter and/or fibrillation
 ↑ freq. in pts with mod-severe MS for several
years
 A fib develops in ≈ 30% to 40% of pts
w/symptoms
Mitral Stenosis: Role of
Echocardiography
 Diagnosis of Mitral Stenosis
 Assessment of hemodynamic severity
 mean gradient, mitral valve area, pulmonary artery
pressure
 Assessment of right ventricular size and function.
 Assessment of valve morphology to determine

suitability for percutaneous mitral balloon valvuloplasty


 Diagnosis and assessment of concomitant valvular lesions
 Reevaluation of patients with known MS with changing
symptoms or signs.
Mitral Stenosis: Natural
History
 Progressive, lifelong disease,
 Usually slow & stable in the early years.
 Progressive acceleration in the later
years
 20-40 year latency from rheumatic fever
to symptom onset.
 Additional 10 years before disabling
symptoms
Mitral Stenosis:
Complications
 Atrial dysrrhythmias
 Systemic embolization (10-25%)
 Risk of embolization is related to, age, presence of
atrial fibrillation, previous embolic events
 Congestive heart failure
 Pulmonary infarcts (result of severe CHF)
 Hemoptysis
 Massive: ruptured bronchial veins (pulm HTN)
 Streaking/pink froth: pulmonary edema, or infection
 Endocarditis
 Pulmonary infections
Mitral Stenosis:Therapy
 Medical
 Diuretics for LHF/RHF
 Digitalis/Beta blockers/CCB: Rate control
in A Fib
 Anticoagulation: In A Fib
 Endocarditis prophylaxis

 Balloon valvuloplasty
 Effective long term improvement
Mitral Stenosis:Therapy
 Surgical
 Mitral commissurotomy
 Mitral Valve Replacement
 Mechanical
 Bioprosthetic
Cardiopulmonary bypass
Mitral commissurotomy
Mitral valve replacement
 FDA-approved
mechanical mitral
valves. (A) Starr-
Edwards ball-and-
cage. (B)
Medtronic-Hall
tilting-disk. (C)
Omnicarbon
tilting-disk. (D) St.
Jude Medical
bifleaflet.
Mitral valve replacement
 FDA-approved
mechanical
mitral valves. (E)
Carbomedics
bileaflet. (F) ATS
bileaflet. (G) ON-
X bileaflet.
Mitral valve replacement
 FIGURE 38-3 FDA-
approved bioprosthetic
mitral valves. (A)
Hancock II porcine
heterograft. (B)
Carpentier-Edwards
standard porcine
heterograft. (C) Mosaic
porcine heterograft. (D)
Carpentier-Edwards
pericardial bovine
heterograft.
Operative procedure
 (A) An ellipse is removed from
the posterior leaflet, and a flap
is cut form the central portion of
the anterior leaflet. The anterior
flap is flipped to the posterior
annulus and tacked to the
caudad edge of the posterior
leaflet and the posterior
annulus. Sutures anchoring the
prosthesis include the annulus
and anterior and posterior
leaflet remnants to which
chordae are attached. (B) The
anterior leaflet is partially
excised, and remnants are
"furled" to the annulus by
sutures used to insert the
prosthesis.
 Suturing techniques for
prosthetic mitral valve
implantation.
Subannular sutures
placed from ventricle to
atrium for bioprosthetic
or Starr-Edwards
valves. Everting (supra-
annular) sutures placed
from atrium to ventricle
for bileaflet or tilting-
disk valves.
Recommendations for Mitral
Valve Repair for Mitral
Stenosis
 ACC/AHA Class I
 Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),*and valve
morphology favorable for replacement if percutaneous mitral
balloon valvotomy is not available
 Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),*and valve
morphology favorable for replacement if a left atrial thrombus
is present despite anticoagulation
 Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable
or calcified valve with the decision to proceed with either
repair or replacement made at the time of the operation.
Recommendations for Mitral
Valve Repair for Mitral
Stenosis
ACC/AHA Class IIB
 Patients in NYHA functional Class I, moderate or
severe MS (mitral valve area <1.5 cm 2 ),* and
valve morphology favorable for repair who have
had recurrent episodes of embolic events on
adequate anticoagulation.
ACC/AHA Class III
 Patients with NYHA functional Class I-IV
symptoms and mild MS.
*The committee recognizes that there may be a variability in the
measurement of mitral valve area and that the mean trans-mitral
gradient, pulmonary artery wedge pressure, and pulmonary artery
pressure at rest or during exercise should also be considered.
 Fig. 1.1:
 Dr. C. Walton Lillehei (opposite page), working
at the University of Minnesota, developed a
novel technique of cardiopulmonary bypass
called cross circulation, in which the circulation
of one person is used to support that of another
during an open-heart operation. It was used
successfully in sick children.