Valvular Heart Disease

Bernardo D. Morantte Jr. M.D.

Dept. of Medicine
College of Medicine
Pamantasan Ng Lungsod Ng Maynila
 Cardiac valves
Anatomy
 There are 4 cardiac valves
 2 semilunar valves_ aortic and pulmonic
 2 AV valves _ mitral and tricuspid

Valve structure:
AV _ papillary muscle, chordae, leaflets
 Left Heart

EKG
LA
Aorta VA = 2cm2
Mitral valve
2

1
VA =4 cm2

Aortic valve LV

Mitral Stenosis 1

Aortic Stenosis 2
 Intracardiac pressures
 Diagramatic mm HG
 LA= 10

 RA= 5 LVEDP = 10
 RVEDP= 5

RVEDP = RV endiastolic pressure

LVEDP = LV endiastolic pressure
 Mitral Stenosis
 Narrowed mitral valve orifice < 4 cm2 with
obstruction to the blood flow from LA to LV

 Presence of a pressure gradient across the

mitral valve
< 4 cm2 pressure gradient occurs with
exercise
 < 2 cm2 pressure gradient occurs at rest
 Mitral Stenosis

EKG
LA
Aorta Mitral valve
2

Aortic valve LV

Mitral Stenosis VA = < 4 cm2

 Normal Pressures
100

LV

50
LA
A V
C

0
EKG
mm HG

P QRS T
 Mitral stenosis
100

LV
Presurre
gradient
50
A V
LA

0
EKG
mm Hg

p QRS T
 Valve area calculaton
 Gorlin’s formula:

 Mitral valve = valve flow in ml / sec
V* x 44.3 (mean gradient) 1/2

 * V is a variable
 V = 0.85 for mitral valve
 V = 1 for aortic valve
 Etiology
 Congenital
 Valvular
 Subvalvular ring
 Supravalvular ( cor tri-atriatum)

 Rheumatic heart disease

 Rheumatic fever
Jones Criteria
 Major Minor
 Migrating polyarthritis Clinical
 Carditis fever
 Sydenham chorea arthralgia
 Subcutaenous nodules Laboratory
 Erythema marginatum acute phase reactants
 prolonged PR interval

 Criteria: 2 major or 1 major + 2 minor

 Plus
 A recent group A strep infection, + rapid antigen detection
test, or + ASO titer
 Pathophysiology in Mitral
Stenosis
 Increase pulmonary wedge pressure
> 12 mm Hg

 Reduced cardiac output (CO)

 Moderately Severe MS _slow rise in
CO with exercise
 Severe MS _no increase CO or CO drops
 Severity of Mitral Stenosis
based on valve area (VA)
 Mild Mitral stenosis_ VA < 4 cm2 but > 2cm2

 Moderate _ VA 1.5 cm2 _ 2 cm2

 Moderately severe _ VA 1.1 cm2_ 1.5 cm2

 Severe_ VA 1 cm2 or less

 Symptoms
 Easifatigability
 Dyspnea at rest / exertion
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Palpitations
 Edema
 Cough
 Hemoptysis
 Exertional syncope ( uncommon)
 Key physical examination findings
 Opening snap (OS) and diastolic rumbling murmur
at the apex

 P2

 A2 - OS interval is inversely proportional to the

severity of MS
 Other PE findings
 Thrill at the apex
 Sternal pulsation (RV enlargement)
 Cardiac arrhythmia _ A-fib
 S1 increased
 Mild apical systolic murmur (gr I-II)

 Signs of congestive heart failure

 Jugular venous distention
 Dullness on chest percussion pleural effusion
 Fine rales
 Hepatomegaly and ascites
 Pedal or sacral edema
 Associated Valve lesions
 Mitral regurgitation

 Tricuspid stenosis / regurgitation

 Aortic regurgitation
 Differential Diagnosis
 Severe Mitral regurgitaton (MR)
 * Loud systolic murmur ( Gr III/VI or >)
 Presence of S3
 Atrial septal defect
 Fixed wide splitting of S2
 Absence of LA enlargement on EKG and
 CXR
 Aortic regurgitation ( Austin Flint murmur)
 Maneuvers with amyl nitrate, exercise
 Atrial myxoma
 Changing murmur with change in position
 Echocadiogram
 Calcified mitral valve
 Coving of the anterior mitral leaflet
 Reduced EF slope in the M- mode echo
 Anterior motion of the posterior mitral leaftlet in
diastole
 Left atrial enlargement
 Presence of mural thrombus
 On doppler
 presence of a diastolic gradient across the MV.
narrowed mitral valve area
 Other Diagnostic Studies
 EKG
 atrial fib
 left atrial hypertrophy

 RV hypertrophy
 RA hypertrophy

 Chest x-ray
 left atrial enlargement
 prominent PA

 Kerley B lines
 pleural effusion and alveolar infiltrates
 pulmonary edema
 Complications
 Congestive Heart Failure

 Atrial fibrillation

 Systemic embolism

 Bacterial endocarditis
 Medical Management of Mitral
Stenosis
 Treatment of Congestive Heart Failure
 Control of Cardiac arrhythmias
 Anti-coagulant therapy
 SBE prophylaxis with antibiotics

Invasive cardiac Intervention:

 Percutaneous balloon mitral valvulotomy
for non-calcified or pliable leaflets
 Natural History of MS
based on functional class
 NYHA Class 5 year survival rate

 I 97 %
 II 60 %
 III 47 %
 IV 0
 Surgical Therapy
 Closed mitral commisurotomy

 Open mitral commisurotomy

 Mitral valve replacement (MVR)

 bioprosthesis
 Artificial valve

 5 year survival after MVR_ 89-90 %

 Indications for intervention
 Class III-IV functional capacity

 Severe mitral stenosis _ valve area 1 cm2

 or less with symptoms
 Mitral Regurgitation
 It is the leakage of blood back to the left atrium during systole. The
amount of blood that leaks back is the regurgitant volume (RV)

RV = LVSV – FSV

 LVSV= Left ventricular stroke volume calculated by echo or

angiography
 FSV = Forward Stroke volume

 FSV= CO / HR

* CO = Cardiac output (Fick method)

* HR = Heart rate
 Types of Mitral Regurgitation

 1. Transient _ PVC’s, myocardial

ischemia

 2. Acute_ sudden as in Acute MI,

bacterial endocarditis

 3. Chronic
 Left Heart _Mitral regurgitation

EKG
LA
Aorta VA = 2cm2
Mitral valve
2

1
VA =4 cm2

Aortic valve LV
 Hemodynamics in MR
 LV dilatation

 LA dilatation

 Pulmonary venous congestion

 Pulmonary hypertension pulmonic regurgitation

 RV dilatation

 Tricuspid regurgitation
 Etiology of Chronic MR
 Congenital
 Coronary artery disease with papillary
muscle dysfunction
 Mitral annular calcification
 Prolapse of the mitral valve
 Rheumatic heart disease
 Cardiomyopathy
 Collagen vascular disease
 Symptoms of MR
Acute MR Chronic MR
sudden dyspnea recurrent exertional
dyspnea

orthopnea orthopnea, PND

palpitations palpitations
chest pain easifatigability
RUQ abdominal tenderness
pedal edema
fever?
 Differential Diagnosis of MR**
 Aortic stenosis

 Ventricular septal defect

 Hypertrophic cardiomyopathy

 Tricuspid regurgitation

**Location, quality, radiation and maneuvers

* Echocardiography
 Diagnostics
Acute MR Chronic MR
EKG
 Acute MI or ischemia  LA and LV enlargement

Chest x-ray
 pulmonary edema  CHF
 normal heart size  LA and LV enlargement
  mitral annular calcification

 Echocardiogram
Acute Chronic
2-D echo
 LA and LV size usually normal  LA and LV enlargement
 hyperkinetic LV  RV enlargement
 wall motion abnormality suggest
MI or trauma
 Reduced EF
 EF usually normal  Mitral valve thickening and
 ruptured chordae calcification suggesting a
 ruptured papillary muscle concomitant MS
 bacterial vegetations  Prolapse of MV
 Associated Congenital anomalies

Cardiac doppler
 Presence of regurgitant jet  Presence of regurgitant jet
 Medical Therapy
Acute MR Chronic MR
Vasodilators
IV Nitroprusside or Nitroglycerin Ace inhibitors
Ace Inhibitors Diuretics + K supplement
Hydralazine Loop
Nifidipine Thiazide
IV Loop diuretics + K supplement K sparing

Digoxin Digoxin
Anti-coagulants for A-fib Anti-coagulants for A-fib _ Warferrin
Heparin / Warferrin
IV antibiotics for acute endocarditis
Fluid and salt restriction Fluid and salt restriction
O2 therapy O2 therapy
Ventillator support for PO2 <55 Exercise program
and RR > 40 / min SBE and RF prophylaxis
 Natural History of Chronic MR
 3 year survival _ 50 %

 5 year survival _ 35 %
 Indications for surgical therapy
 Severe MR with class III-IV functional capacity

 Echocardiogram
 Reduced EF < 55%
 Progressive LV dilatation
 ESD > 45mm
 ESV index 55 ml/ m2
 Moderate pulmonary hypertension
 PA > 50 mm HG

 Contraindication: EF < 30 %

 Diagnostic studies prior to surgical
intervention
 Cardiac catherization
large V waves in the LA or PCP
pressure
pulmonary hypertension
 Left ventriculography
regurgitation of contrast material to LA
 Coronary angiography
 Surgical therapy
 Mitral annuloplasty with Carpentier ring
 Mitral valve replacement
 bioprosthesis
 artificial valve

 The surgical procedure of choice depends

on the underlying cause and the pathology