Valvular Heart Disease

Mitral regurgitation (MR)

Aorta regurgitation (AR)

Mitral stenotic ( MS)

Aorta stenotis (AS)

Mitral Regurgitation - Aetiology
Primary
Annulus annular calcification
Leaflet myxomatous degeneration
rheumatic deformity
infectious perforation
Chordae myxomatous degeneration
spontaneous rupture
rheumatic shortening
infectious destruction
Papillary infarction
ischemic lengthening
Functional
 Mitral Regurgitation - Clinical findings
Acute dyspnoea, orthopnoea
no cardiomegaly, short murmur, S3
Chronic variable symptoms
cardiomegaly, murmur, P2 loud, S3
Quantification
echocardiography, angiography
serial studies, LV function
Mitral Regurgitation - Pathophysiology
CXR
 Mitral Regurgitation - Treatment

Acute
Diuretics LV filling P, p oedema
Vasodilators forward SV
IABP

Chronic
No known effective therapy
Vasodilators - theoretical risks
Treat complications
 Mitral Regurgitation - Surgery

Options
Valve repair
MVR with chordal preservation
MVR with destruction MV apparatus
Outcome
Mortality 80-94% v 40-60% at 5-10years
Valve function
Ventricular function
 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
 Mitral Regurgitation - Indications for surgery

3. Asymptomatic with abnormal LV function

? Asymptomatic
Detection of LV dysfunction is the key
EF<60%, LVESD > 45mm, LVESV>55ml/m 2

4. Asymptomatic with normal LV function

?guaranteed repair
PHT, recent AF
Mitral Regurgitation - Indications for surgery
 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
 Aortic Regurgitation - Aetiology

Root
Annuloaoroectasia
Marfans
Dissection
Syphillis
Ankylosing spondylitis
Leaflet
Endocarditis
Bicuspid valve
Aortic Regurgitation - Pathophysiology

Normal
 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
 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
Chronic Aortic Regurgitation - Clinical features
LV decompensation

Maybe asymptomatic, LVF, angina

 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
LVEF<55%, LVESD>55mm, LVESV 60ml/m2

2. Symptomatic
NYHA class II
Mitral Stenosis
 Mitral Stenosis

Causes
rheumatic fever
congenital abnormality, calcification, myxoma

Natural history
RF age 12
murmur 1st heard 20 yrs later
symptoms in 4-5th decade
 Mitral Stenosis - Clinical features
Severity MVA (cm) LAP (mm Hg) CO
Mild >2.0 <10-12 NL
Moderate 1.1-2.0 ~10-17 NL
Severe <1.0 >18
Very Severe <0.8 >20-25

Severity Symptoms
Mild Asymptomatic or mild DOE
Moderate Mild-mod DOE; orthopnea, PND, hemoptysis

Severe Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest;

severe fatigue; cyanosis
 Mitral Stenosis - Examination
Inspection
Malar flush
Peripheral 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 rumble

Auscultation
Increased intensity of the first heart sound
Opening snap
Low-pitched diastolic rumbling murmur
 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
 Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
 Mitral Stenosis - Treatment
Balloon Mitral Valvuloplasty
100% MVA, final area ~2cm 2

Failure rate 1-15%

Mortality 0-3%
Severe MR 2-10%
Restenosis ~40% at 7years
Contraindications - thrombus, MR, Ca++, other
disease
 Mitral Stenosis - Treatment
Mitral Valve Replacement
Open mitral valvotomy
Mitral valve replacement
 Aortic Stenosis - Aetiology

Congenital 1st-3rd decade

Valve degeneration and calcification
Rheumatic - 4th decade
Bicuspid valve; 1%, males>females, 5-6th decades
Tricuspid valve - 7-8th decades, 1-2% incidence
 Aortic Stenosis - Pathophysiology

LV pressure overload LV hypertrophy diastolic LV

dysfunction
Systolic function usually preserved except late in disease
Systolic function improves with AVR
Outcome is dependent on symptoms
 Aortic Stenosis - Clinical features
Symptoms
None
DOE, dizziness
HF, syncope, angina
Examination
Pulse - amplitude, delay
Sustained apex
S2- soft and single paradoxical splitting
 Aortic Stenosis - Severity
Echocardiography
 Aortic Stenosis - Outcome
Symptoms
2-year survival < 50%
Asymptomatic
Generally good prognosis
Peak velocity >4.0m/s 2yr event-free survival 21%
Progression of> 0.3m/s per year - worse
 Aortic Stenosis - Treatment
Medical
None!!!
Diuretics v LVF
ACEI contraindicated
Balloon aortic valvuloplasty
Average MVA improvement 0.8cm 2 1.0cm 2

Restenosis <6/12 in 50%

No improvement in mortality
Procedural mortality 5%
 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
Dimensionless index to be reported in all prosthetic AVR and if moderate + LV
Aortic
dysfunction is present. Index Stenosis - AVR
<0.25 correlates to an AVA < 1.0cm2.

Approach to symptomatic patients

Ao V max

4.0m/s 3.0-4.0 m/s 3.0m/s

Doppler AVA

1.0cm2 1.1 1.6 cm2 1.7cm2

AI severity

2-3+ 0-1+

AVR recommended AVR for AS not recommended