Medicine

Dr. Jawad Lec: -2-

2-Oct-06

MITRAL REGURGITATION
 Causes
 Rheumatic heart disease
 Mitral valve prolaps
 Dilatation of MV ring
 Damage to valve cusps and ring
 Damage to papllary muscle
 Myocardial infarction

CLINICAL FEATUERS

 Symptoms

 Acute MVR -symptoms of acute pulmonary oedema

 Chronic MVR
 Exersional dyspnoea,nocturnal dyspnoea,palpitation
 Symptoms of pulmonary oedema (pregnancy or AF)
 Symptoms of diminished cardiac output (fatigue)
 Ankle/leg oedema,abdominal swelling (right heart failure)

 Signs

 Atrial fibrillation
 Cardiomegaly
 Apical pansystolic murmur ±thrill
 Soft s1,apical s3
 Cripitation,pulmonary oedema ,effusion
 Signs of pulmonary hypertension

INVESTIGATIONS

 ECG Left atrial hypertrophy, Left ventricular hypertrophy

 CXR enlarged LA ,enlarged LV,pulmonary venous hypertension ,pulmonary
oedema.
 Echo dilated LA,LV ,dynamic LV.
 Doppler to detect and quantitate regurgitation
 Cardiac catheterization

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MANAGEMENT
90
80
 Medical 70
 Diuretic 60
 Vasodilator 50 East
 Digoxin 40 West
 Anticoagulant 30 North
 Antibiotic prophylaxis20
10
 Mitral valve replacement
0
 Worsening of symptoms 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
 Progressive LV dilatation
 Progressive LV dysfunction

AORTIC STENOSIS
 Aetiology and pathophysiology
 Causes
 Congenital
 Bicusped aortic valve
 Rheumatic heart disease
 Senile degenerative aortic stenosis

CLINICAL FEATURES

 Symptoms
 Mild to moderate aortic stenosis usually asymptomatic
 Exersional dyspnea
 Angina
 Pulmonary oedema
 Exersional syncope
 Sudden death

 Signs
 Ejection systolic murmur
 Slow-rising carotid pulse,reduced pulse pressure
 Left ventricular hypertrophy-thrusting apex beat
 Left ventricular failure (cripitation,pulmonary oedema)

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INVESTIGATIONS

 ECG---LVH (usually),LBBB
 CXR---normal ,enlarged LV,dilated ascending aorta,calcified AV on lat.view
 Echo---calcified AV,LVH
 Doppler ---to measure the gradient
 Cardiac cath.---to measure the gradient,post stenotic dilatation of the
aorta,regurgiatation ,associated coronary artery disease

MANAGEMENT
 Symptoms---(angina ,syncope ,heart failure)
 Baloon aortic valvuloplasty---usually indicated in adulscent ,elederly as
apalliative measure in high surgical risk patients.
 Aortic valve replacement

AORTIC REGURGITATION

 Causes

 Acquired
 Rheumatic disease
 Infective endocarditis
 Trauma
 Aortic dilatation: Marfan syndrom ,Atheroma ,Syphilis ,Ankylosing
spondylitis

CLINICAL FEATURES

 Symptoms

 Mild-moderate AR
 Often asymptomatic
 Awareness of heart beat (palpitation)
 Sever AR
 Symptoms of heart failure
 angina

 Signs

3
  Large-volume pulse (collapsing)
 Bounding peripheral pulses (corrigan)
 Capillary pulsation in nail beds (quinckes)
 Femoral bruit (duroziez)
 Head nodding with pulse (de Musset)

 Murmurs
 Early diastolic murmur
 Systolic murmur of increased stroke volume
 Austin flint murmur (soft mid diastolic)
 Other signs
 Thrusting apex,S4 ,ENLARGED LV
 Signs of heart failure

INVESTIGATIONS

 ECG-- Intially normal ,later LVH

 CXR—cardiac dilatation,may be aortic dilatation ,Features of left heart failure
 Echo—dilated LV ,hyperdynamic ventricle ,flttering anterior mitral
leflet,doppler detect reflux
 Cardiac cath.—dilated LV,aortic regurgitation ,dilated aortic root

MANAGEMENT

 Treatment of the underlying cause

 Vasodilator may prevent progressive LV dilatation
 AVR:
 Symptomatic
 Progressive LV dilatation
 Progressive LV dysfunction

PULMONARY VALVE DISEASE

PULMONARY STENOSIS

 SYMPTOMS
 Right sided heart failure
 That of carcinoid syndrome

 SIGNS
 Giant a wave in JVP

4
  RVH and dilatation
 Ejection systolic murmur ±thrill
 P2 soft and delayed

INVESTIGATIONS
 CXR---prominent PA with post stenotic dilatation
 ECG---RA and RV hypertrophy
 Echo---abnormal PV,outflow gradient on doppler

MANAGEMENT
 Mild –moderate PS is very common and usually asymptomatic ,low risk for
endocarditis need no treatment
 Sever PS defined as gradient >50 mm hg treated by balloon valvuloplasty ,or
rarely by surgery.

PULMONARY REGURGITATION

 Rarely an isolated lesion

 Associated with pulmonary hypertension
 Early diastolic murmur to left parasternal area(graham steell murmur
 Trivial PR is afrequent echo finding and its of not clinical significant

TRICUSPED STENOSIS
 Usually rheumatic in origin
 Nearly always occur with rheumatic mitral and aortic valve disease
 Significant TS occur in 5%
 Isolated TS is very rare
 TS and TR may be associated with carcinoid syndrom

CLINICAL FEATURES

 SYMPTOMS
 SYMPTOMS OF associated MV and AV disease
 Symptoms of right sided heart failure (abdominal swelling ,hepatic discomfort
,peripheral oedema ,fatigue)

 Signs

5
  Raised JVP ,prominent a wave
 Mid-diastolic murmur—increased by inspiration
 Signs of right sided heart failure

INVESTIGATIONS
 CXR—enlarged right atrium
 Echo---fused thickened TV leaflets ,dilated RA ,doppler features of TS

MANAGEMENT
 Balloon valvuloplasty for symptomatic isolated TS
 Surgical valvotomy or TVR ,when the patient need surgery for other
associated valve disease

TRICUSPED REGURGITATION
CAUSES

 PRIMARY
 Rheumatic
 Endocarditis (i.v. drug abuser)
 Ebstien’s anomaly
 SECONDARY
 Right sided dilatation secondary to chronic left sided failure
 Right ventricular infarction
 Pulmonary hypertension

CLINICAL FEATURES

 SYMPTOMS---usually non specific ,tiredness, edema

 SIGNS:
 Raised JVP,large systolic wave c-v
 Systolic hepatic pulsation
 Pansystolic murmur louder on inspiration

INVESTIGATIONS

 CXR---dilated RA,RV
 Echo---RV dilatation,TV may be structurally abnormal,estimate PA pressure
by Doppler

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MANAGEMENT
 Treatment of the underlying causes
 Few patients with TR and abnormally elevated PA pressure need surgical
correction or replacement

Written By:
Rand Aras Najeeb