Heart valve disease

Heart valve disease is

a structural abnormality due
to different causes and it is a
deformation of heart valves
and sub-valve apparatus,
that disturb intra -heart and
system hemodynamic, and
leads to an acute or chronic
heart falure.
 Etiology

Heart valve disease appears

because of different etiological processes.
Rheumatismus is a main etiological factor of a mitral
stenosis (85%), rarer of a aortic valve disease(26%), and
may lead to a combination of a stenosis and insufficiency
of a mitral or aortic valve.
Isolated mitral insufficiency, aortal stenosis and aortal
insufficiency can often be of non-rheumatic origin and be
caused by degenerative changes.
Infectious endocarditis, atherosclerosis, sepsis, syphilis,
trauma, systemic lupus erythematosus, systemic
scleroderma, rheumatic arthritis with visceral lesion may
also lead to the development of heart valve disease.
 Classification

This classification of Heart Valve Disease

was accepted at the 6 Ukrainian Congress
of Cardiologists ( Kiev, 2000). The
nosological units are followed by the MKB-
10 Classification( an International
Classification of Diseases).
 Classification
Mitral stenosis :

Mitral valve stenosis

rheumatic 105.0
non- rheumatic 134.2 (with specification of etiology)

Mitral insufficiency :
rheumatic 105.1
non- rheumatic 134.0 (with specification of etiology)
Combined rheumatic mitral valve disease
(rheumatic mitral stenosis with an
insufficiency 105.2):
With a prevalence of a stenosis
With a prevalence of an insufficiency
Without any strong prevalence

Mitral valve prolapse 134.1

Aortic valve stenosis:

rheumatic 106.0
non-rheumatic 135.0 (with specification of etiology)
Aortic insufficiency:
rheumatic 106.1
non-rheumatic 135.1 (with specification of etiology)

Combined aortic valve disease:

rheumatic aortic stenosis with insufficiency 106.2
Non-rheumatic aortic (valve) stenosis with
insufficiency 135.2 (with specification of etiology)
With a prevalence of a stenosis
With a prevalence of insufficiency
Without any strong prevalence

Tricuspid valve stenosis :

rheumatic 107.0
non-rheumatic 136.0 (with specification of etiology)
Tricuspid insufficiency:
rheumatic 107.1
non-rheumatic 136.1 (with specification of etiology)

Combined tricuspid valve disease:

rheumatic tricuspid stenosis insufficiency 107.2
non-rheumatic tricuspid stenosis insufficiency 136.2 (with
specification of etiology)

Associated heart valve disease:

Mitral-aortic 108.0
Mitral - tricuspid 108.1
Aortic- tricuspid 108.2
Multi affection of mitral, aortic AND tricuspid valves 108.3
 Heart valve diseased is considered to be
COMBINED if there is a stenosis and an
insufficiency of one valve. Heart valve
disease is considered to be associated
if there is lesion of several valves. If there
are several heart valve diseases, they
should be enumerated, you put the heart
valve disease that has more manifestations
the first.
 Stages of valve calcinosis
І + Separate blocks of Calcium in width of
commissures or valvulars 

ІІ ++ Significant calcification

ІІІ +++ Massiv calsinosis of a valve, also

affecting a  fibrous ring, and sometimes affecting
aorta wall and miocardium of ventricles.  
 In diagnosis you should also point out the
etiology of the valve disease( rheumatism,
infectious endocarditis, degenerative
changes) and the heart insufficiency grade.

For patients who underwent the heart

valve operation, you should indicate the
previous heart valve disease, the date of the
operation, the complications.
 Echocardiography is a standard
diagnostic method for the evaluation of the
structure and function of the valve.

According to Ministry of Ukraine Order

№ 436  there is a compulsory list of
treatment, in which operative treatment of a
heart valve disease, year-long penicillin
prophylaxis when rheumatic etiology and the
treatment of a heart failure according to the
type( systolic or diastolic) are state.
 Mitral valve stenosis

Mitral valve stenosis  – the most widespread

rheumatic valve disease.

Appears due to rheumatic endocarditis. This valve

disease is usually formed at young age and more
frequently in women (80%).  
 Hemodynamics
The area, which leads to a noticeable hemodynamic
disorder is called a “Critical area” and it is 1-1.5 sm2.

When the mitral valve area goes less than 1 cm2,

there will be an increase in the left atrial pressures
(required to push blood through the stenotic valve).
Since the normal left ventricular diastolic pressures is
about 5 mmHg, a pressure gradient across the mitral
valve of 20 mmHg due to severe mitral stenosis will
cause a left atrial pressure of about 25 mmHg. This left
atrial pressure is transmitted to the pulmonary
vasculature and causes pulmonary hypertension.
 Pulmonary capillary pressures in this level
cause an imbalance between the hydrostatic
pressure and the oncotic pressure, leading to
extravasation of fluid from the vascular tree and
pooling of fluid in the lungs ( congestive heart
failure causing pulmonary edema ).

The constant pressure overload of the left

atrium will cause the left atrium to increase in size.
As the left atrium increases in size, it becomes
more prone to develop atrial fibrillation.
 Clinical picture (Physical
examination)
A Peripheral signs include:
 Ankle/sacral edema (oedema) when there is
right heart failure
 Atrial fibrillation - irregular pulse and loss of
'a' wave in jugular venous pressure
 Left parasternal heave - presence of right
ventricular hypertrophy due to pulmonary
hypertension
 Tapping apex beat which is not displaced
 Changes when atrial fibrillation
develops:

Нeart rate is about 100-150/min.

irrerugarly irregular pulse with a pulse
deficit>10. varying first heart sound
intensity. opening snap is not heard
sometimes. absent a waves in the neck
veins. presystolic accentuation of diastolic
murmer disappears. embolic manifestations
may appear.
 When the blood pressure is risen in
a small circle the complaints of
dyspnoe and palpitation on the physical
upload.
If patients experience severe
pulmonary hypertension, fatigue
develops.
 We can see typical facies mitralis: Malar flush on
cheeks, pale skin of a face, cyanosis of lips, a tip
of a nose, ears.

Upon examination of the chest cavity a inferior

part of a sternum can pulsate. On the heart apex
you can find a murmur.  Upon auscultation of an
individual with mitral stenosis, the first heart sound
is unusually loud and may be palpable (tapping
apex beat) because of increased force in closing
the mitral valve. The first heart sound is comprised
of the mitral and tricuspid heart valves closing.
These are normally synchronous. Mid-diastolic
rumbling murmur is usual in patients with mitral
stenosis.
 Diagnostics
  ECG: signs of upload of a left ventricle (P-mitrale), hypertrophy of a right ventricle. The
rhythm disorders can be frequently found ( fibrillation, atrial flutter) .

       
 X-rays examination: the enhancement of
a left atrium and a right ventricle, increase of
 pulmonary vessels in the upper parts of
lungs, widening of a truncus pulmonaris.
 In most cases, the diagnosis
of mitral stenosis is most
easily made by
echocardiography, which
shows decreased opening of
the mitral valve leaflets, and
increased blood flow velocity
during diastole. The trans-
mitral gradient as measured
by Doppler echocardiography
is the gold standard in the
evaluation of the severity of
mitral stenosis.
 Outcome
     Mitral stenosis of majority of patiens is severely
developing, the speed of the reduction of a mitral
ring area is 0,09-0,32 sm2/per year. After the
onset of heart failure symptoms, 50% of patients
die in 5 years.

     There are 5 satges of mitral stenosis:

I  – total compensation .
  ІІ  – cor pulmonare.
  ІІІ  – right ventricular insufficiency
ІV  – distrofic.
  V – terminal.
 Treatment
Medication Treatment is headed for the
treatment and prevention of complications. It is
necessary to prescribe antibiotics before dental
and other interventions for decrease of the risk of
an infectious endocarditis.

         Diuretics use or nitrates allows to make

dyspnoe less expressed. B-blockers and blockers
of Ca-channels decrease the heart rate, can
increase the tolerance to the physical upload.

The indication for anticoagulant use is atrial

fibrillation. In patients with sinus rhythm they are
indicated if the left ventricle is big ( more than 50
мм), thromboembolism in anamnesis and a
thrombus in the left atrium.
 When undergoing the electrical cardio version
it is necessary to use anticoagulants during 3-4
weeks before and 4 weeks after the cardioversion.

         Mitral stenosis is successfully treated by

surgical methods (valvuloplasty and endoprothesis
of a valve)

The commissurotomy is used in patients with

severe Mitral stenosis with symptoms that limits
physical activity.

     The improvement of a status comes in 70-89%

cases. Unsuccessful intervention is usually due to
the late operation.   
 Mitral insufficiency 

Etiology

Degenerative mitral insufficiency (61%)

dominate on the rheumatic one (14%).

Other reasons: infectious endocarditis,

system connective disorders.
 Hemodinamic disorders

The left ventricle develops eccentric

hypertrophy in order to better manage the
larger than normal stroke volume. The
eccentric hypertrophy and the increased
diastolic volume combine to increase the
stroke volume (to levels well above normal)
so that the forward stroke volume (forward
cardiac output) approaches the normal
levels.
 Later, the ventricular myocardium is no longer
able to contract adequately to compensate for the
volume overload of mitral regurgitation, and the
stroke volume of the left ventricle will decrease.
The decreased stroke volume causes a decreased
forward cardiac output and an increase in the
end-systolic volume. The increased end-systolic
volume translates to increased filling pressures of
the ventricular and increased pulmonary venous
congestion. The left ventricle begins to dilate
during this phase. This causes a dilatation of the
mitral valve annulus, which may worsen the
degree of mitral regurgitation.
 Clinical picture
The symptoms associated with mitral
regurgitation are dependent on which phase of
the disease process the individual is in.
Individuals with acute mitral regurgitation will
have the signs and symptoms of
decompensated congestive heart failure (ie:
shortness of breath, pulmonary edema,
orthopnea, paroxysmal nocturnal dyspnoea), as
well as symptoms suggestive of a low cardiac
output state (ie: decreased exercise tolerance).
Cardiovascular collapse with shock
(cardiogenic shock) may be seen in individuals
with acute mitral regurgitation due to papillary
muscle rupture or rupture of a chordae
tendineae
 Individuals with chronic compensated mitral
regurgitation may be asymptomatic, with a normal
exercise tolerance and no evidence of heart failure.
These individuals may be sensitive to small shifts in
their intravascular volume status, and are prone to
develop volume overload (congestive heart failure).
Findings on clinical examination depends of the
severity and duration of mitral regurgitation. The
mitral component of the first heart sound is usually
soft and is followed by a pansystolic murmur which
is high pitched and extends, as the name suggests,
the whole of systole. The murmur usually radiates to
the axilla.
Patients with mitral valve prolapse often have a
mid-to-late systolic click and a late systolic murmur.
 Diagnostics
ECG may show
evidence of left atrial
enlargement and
left ventricular hypertrop
hy
. Atrial fibrillation may
also be noted on the
ECG in individuals with
chronic mitral
regurgitation.
 The chest x-ray in individuals with chronic
mitral regurgitation is characterized by
enlargement of the left atrium and the left
ventricle. The pulmonary vascular markings
are typically normal, since pulmonary venous
pressures are usually not significantly
elevated.

Echo is also very important method.

 Stages of mitral insufficiency
 There are 5 stages of mitral insufficiency:
I  – compensation .
  ІІ – subcompensation.
  ІІІ – right ventricular decompensation
ІV – distrofical.
  V – terminal.
 Treatment

Patients can be treated with standard

methods. There are two surgical options for
the treatment of mitral regurgitation: mitral
valve replacement and mitral valve repair.
 Aortic stenosis

      Nowadays aortic stenosis is

considered to be the most widespread heart
valve disease in Europe and North America.
 Classification

    According to severity of a disease:

- small Aortic stenosis (area of a ring is more
than 1,8 см2, maximal pressure gradient 10-
35 мм рт.ст.);
- moderate (area 1,2-0,75 см2, maximal
pressure gradient 36- 65 мм рт.ст.);
-  severe (area is less than 0,75 см2, maximal
pressure gradient 65 мм рт.ст.).
   Hemodynamics at the  aortic
stenosis
When the aortic foramen becomes 0,8-1 см2, it causes a
pressure gradient between the left ventricle (LV) and the
aorta.

  Due to the increased pressures generated by the left

ventricle, the myocardium of the LV undergoes isometric
hypertrophy.

The process that comes later  is

called tonogenic, and then
miogenic dilatation.

The next step is the mitralization

of a disease and development
of pulmonary hypertension.
         Symptoms and signs
   The Triad of Aortic Stenosis is Dyspnea on
exertion, Angina and Syncope. Aortic
stenosis can cause dizziness, syncope and
congestive heart failure. More symptoms
indicate a worse prognosis.
In particular, there may be a slow and/or
sustained upstroke of the arterial pulse, and
the pulse may be of low volume. This is
sometimes referred to as
pulsus parvus et tardus.
 There may also be a noticeable delay between
the first heart sound (on auscultation) and the
corresponding pulse in the carotid artery (so-called
'apical-carotid delay').

An easily heard systolic, crescendo-

decrescendo murmur is heard loudest at the upper
right sternal border, and radiates to the
carotid arteries bilaterally.

The murmur  tends to become softer as the

aortic stenosis becomes more severe.
     Diagnostics
ECG
ECG manifestations of
left ventricular hypertrophy (LVH)
are common in aortic stenosis
and arise as a result of the
stenosis having placed a
chronically high pressure load on
the left ventricle . Left ventricular
hypertrophy is detected by the
increase of QRS amplitude in
consequential leads, often with
the changed end of QRS.
 Echocardiogram
Echocardiogram (heart ultrasound) is the best
non-invasive test to evaluate the aortic valve
anatomy and function.
 
The aortic valve area can be calculated non-
invasively using echocardiographic flow velocities.
 
Using 2-dimentional Echo you can measure the
pressure gradient and the square of aortic   ring.
You can define signs of diastolic disfunction 
 X-rays examination reveals enhancement of the
heart to the left and prolonging the arc. If the
disease stays for a long time, the heart will have a
typical aortal configuration.
 

The heart may be catheterized to directly

measure the pressure on both sides of the aortic
valve. The pressure gradient may be used as a
decision point for treatment. Catheterization is
accurate for moderate velocity stenosis, while
Doppler echo is more accurate at faster velocities
   The stages of aortic stenosis
There are 5 stages of    aortic stenosis 
1 – total compensation .
2 – latent heart falure.
3 – relative coronary insufficiency .
4 – expressed left ventricular insufficiency.
5 – terminal
 Treatment
     Aortic stenosis may be medically treated to control
symptoms, although survival is poor with medical treatment
alone. All patients are indicated to receive endocarditis
prophylaxis.

Surgical
In adults, aortic stenosis usually requires
aortic valve replacement if medical management does not
successfully control symptoms.

Prognosis
     The average duration of life after the symptoms of a heart
falure develop, is 1 year.
 Aortic insufficiency
 
The persentage of this disease is 10%,
and it increases with the age, furthermore,
the clinical findings are more serious in men,
than women.
 Etiology
The most frequent reason is aneurism of ascendent aorta and the diseases of 2-
valvular aortic valve, in 50% of cases the degenerative changes of the aortic valve exist.

Less frequent reasons are : rheumatism(15%),  atherosclerosis, infectious

endocarditis (8%).
 Classification
- initial aortic insufficiency ( regurgitation fraction is
less than  30 ml for a systol, egection fraction is less 
30%, effective square of an  apertura of
regurgitation  is less than  10см2);

- moderate aortic insufficiency   (regurgitation

volume is less than  30-39 мл for a systol,
regurgitation fraction is  30-49%, effective square of
an apertura of regurgiation  is less than 0,1-
0,29см2);

- severe aortic insufficiency (regurgiation volume is

more than 60 мл зfor a systol, regurgitation fraction
is more than 50%, эeffective area of an apertura of
regurgitation is more  than 0,3 см2).
    Hemodynamics
There are severe disorders of central and peripheral
hemodynamic, that are due to blood regurgitation in the left
ventricle in the time of diastole.

The left ventricle adapts by eccentric hypertrophy and

dilatation of the left ventricle, and the volume overload is
compensated for. The left ventricular filling pressures will
revert to normal and the individual will no longer have overt
heart failure.

Eventually (typically after a latency period) the left ventricle

will become decompensated, and filling pressures will
increase. And related insufficiency of mitral valve will appear
with the following  pulmonary hypertension.
 Physical examination
Peripheral physical signs of aortic insufficiency
are related to the high pulse pressure and the rapid
decrease in blood pressure during diastole large-
volume, 'collapsing' pulse rapid upstroke and
collapse of the carotid artery pulse.

Musset's sign (head nodding in time with the heart

beat)

Quincke's sign (pulsation of the capillary bed in the

nail)

Paleness of skin
 Landolfi's sign (alternating constriction & dilatation of
pupil)

Müller's sign (pulsations of uvula)

Corrigan's pulse (rapid upstroke and collapse of the

carotid artery pulse)

Traube's sign (systolic and diastolic murmurs described

as 'pistol shots' heard over the femoral artery when it is
gradually compressed)

Duroziez's sign (a double sound heard over the femoral

artery when it is compressed distally)

High systolic blood pressure (160-180  ), low diastolic

blood pressure(50-30).
     The physical examination of an individual
with aortic insufficiency involves auscultation
of the heart to listen for the diastolic
murmur, that goes directly after 2 tone,
doing to the end of diastole( descendo)
 Diagnostics
     ECG: hypertrophy of the left ventricle
 X-rays examination: enlarged heart , aortic
configuration of the heart.
  

Echo and Dopplerography are important

methods in evaluating the diagnosis and grade of
the aortic insufficiency
      Clinical course  
There are 5 stages of the aortic
insufficiency
 1  stage – compensation;
 2  – latent heart falure;
 3 – subcompensation;
 4  – decompensation ;
 5  – terminal.
 Treatment
     Speciefic concervative methods of treatment do
not exist. The heart failure is treated acording to
commonly used methods. The antibiotics
prophylaxis must be conducted before all invasive
procedures.
Indications for surgery is symptomatic aortic
insufficiency exept terminal stage of the disease.

Prognosis     
The average duration from the symptom onset to
the lethal outcome is 6,5 years .
 Tricuspid valve stenosis
Tricuspid valve stenosis is a valvular heart
disease which results in the narrowing of the
orifice of the tricuspid valve of the heart.
Etiology
It is almost always caused by
rheumatic fever and is generally
accompanied by mitral stenosis.
Rare other causes include
carcinoid syndrome, endocarditis,
endomyocardial fibrosis, lupus
erythematosus, right atrial myxoma.
     Hemodynamics
The blood flow from the right atrium to the
right ventricle happens due to the gradient of
pressure. This gradient increases on breath, or
upon physical activity, and it decreases on
exhalation. Compensation appears due to
hypertrophy of the right atrium. Later the right
atrium is being quickly dilateted. The blood
hemostasia is found in the big circle of
circulation. Orthopnoe and pulmonary blood
storage are absent ( at the early stages). 
 Clinical picture and diagnostics 
There are no specefic complaints. Dyspnoe
and big ugular veins are usually found. Venous
blood pressure is highly increased, but arterial
blood pressure is decreased.

       There often is presystolic pulsation of the

veins of the neck.
     A mid diastolic murmur can be heard on
auskulatation.
 ECG- hypertrophy of the right atrium( high
P in 2 and 1, aVF leads, slightly expressed
hypertrophy of the right ventricle.

     X-rays examination reveal enhancement

of the right atrium.

On Echocardiography the typical picture

of stenosis with the pressure gradient
between right ventricle and right atrium is
found.
 Treatment
Since a person with known tricuspid valve stenosis is at
risk for infections of the heart, antibiotics should be taken
before and after oral or dental surgery, or urologic
procedures. The treatment is usually by surgery (tricuspid
valve replacement) or percutaneous balloon valvuloplasty.
The resultant tricuspid regurgitation from percutaneous
treatment is better tolerated than insufficiency occurring
during mitral valvuloplasty .

Prognosis 
     Compensation period does not last long.
Atrium fibrillation occures earlz, that distorbs the
hemodynamics more. Tricuspid stenosis refers to the most
severe going heart valve disease.
  Tricuspic insufficiency 
Etiology
Although congenital causes of tricuspid
insufficiency exist, most cases are due to dilation of
the right ventricle. Such dilation leads to
derangement of the normal anatomy and mechanics
of the tricuspid valve and the muscles governing its
proper function. The result is incompetence of the
tricuspid valve. Common causes of right ventricular
dilation include left heart failure, pulmonary
hypertension, and right ventricular infarction. Other
diseases can directly affect the tricuspid valve. The
most common of these is rheumatic fever, Carcinoid
tumors, Injury.
 Hemodynamics

     Blood regurgitation from the right ventricle

to the right atrium quickly leads to the
dilatation  of the right atrium without its
hypertrophy. Venous hypertension is formed
early and venous blood storage in liver and
other organs of abdomenal cavity.
 Clinical picture
Complaints at dyspnoe, fatigue, palpitation,
pain in the right  subcostal area. 

     On physical examination you can find pulsation

of the veins of the neck, expressed pulsation in the
epigastrium, in liver.

On auscultation there is systolic murmur of

middle intensivity. It increases to the 2 tone.
You can listen to this murmur on the tip of the
sternum, it increases on breath.
    Diagnostics
ECG- hypertrophy of the right ventricle, P
increase in 2,1,aVL leads. Atrial fibrillation can
be found.
 X-rays examination revelas enhancement
vena cava superior, enlargenment of the
right part of the heart.

Echorevelas the structural disorders of

the valve, vegetations. Doplerography gives
the possibility to evaluate the severity of the
regurgitation, the systolic pressure in the
right ventricle.
   Clinical course
The clinical course usually quickly develops into
severity.

   Complications
     Atrial fibrillation, thrombus formation in the right
atrium, thromboemolism of the pulmonary artery,
gastro-interstenal bleedings.
 Treatment
    
There is no specefic treatment. Heart
failure is treated according to the
guidelines. Peripheral vasodilatators, B-
blockers, anticoagulants are used on
indications.
Thanks for attention!