Valvular Heart Disease

Dr.Suhaemi,SpPD, Finasim
 Types
• Mitral Stenosis
• Mitral Regurgitation
• Mitral Valve Prolapse
• Aortic Stenosis
• Aortic regurgitation
• Tricuspid valve
– Tricuspid stenosis
– Tricuspid regurgitation
Tricuspid Valve
 Mitral Valve:
hockey stick
appearance
indicating
Rheumatic Valve
Disease
Valve area varied
between 1.4 to 1.6
Exercise Echo was
done
 Rheumatic Heart Disease
• Inflammatory process that may affect the
myocardium, pericardium and or endocardium
• Usually results in distortion and scarring of the
valves
 Rheumatic Heart Disease
• Subjective symptoms • Objective symptoms
– Prior history of – Temperature
rheumatic fever – Murmurs
– General malaise – Dyspnea
– Pain – may or may not – Polyarthritis
be present
 Rheumatic Heart Disease
• Diagnosis
– H/P
– WBC and ESR
– C-reactive protein
– Cardiac enzymes
– EKG
– Chest x-ray
– Echo
– Cardiac cath
– Cardiac output
 Rheumatic Heart Disease
• Nursing Care
– Vital signs
– Rest and quiet environment
– Give antibiotics, digitalis, and diuretics
– Provide adequate nutrition
– Monitor I/O
– Explain treatment and home care
 Mitral Stenosis
• Usually results from rheumatic carditis
• Is a thickening by fibrosis or calcification
• Can be caused by tumors, calcium and thrombus
• Valve leaflets fuse and become stiff and the cordae tendineae
contract
• These narrows the opening and prevents normal blood flow
from the LA to the LV
• LA pressure increases, left atrium dilates, PAP increases, and
the RV hypertrophies
• Pulmonary congestion and right sided heart failure occurs
• Followed by decreased preload and CO decreases
 Mitral Stenosis, cont.
• Mild – asymptomatic
• With progression – dyspnea, orthopneas, dry cough,
hemoptysis, and pulmonary edema may appear as
hypertension and congestion progresses
• Right sided heart failure symptoms occur later
• S/S
– Pulse may be normal to A-Fib
– Apical diastolic murmur is heard
2-D Echo showing heavily calcified
Mitral valve leaflets and Mitral
stenosis
3-D Echo of Mitral Stenosis

LA view LV view
 Real Time TTE of MS

A B C

LA

D E F G
 Mitral Stenosis
Management Principles

• Severe MS
- is usually symptomatic
- Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority
- PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
- PMC in skilled centers has a mortality of < 1%
- Success of PMC depends on the pre-PMC valve anatomy
- Commissural calcification is a predictor of suboptimal outcome
- Complications: severe MR, embolization and cardiac perforation
Mitral Stenosis
Management Principles

• Surgical treatment

- commissurotomy (only occasionally indicated, usually

PMC)

- valve replacement
 Mitral Regurgitation
• Primarily caused by rheumatic heart disease, but may be
caused by papillary muscle rupture form congenital, infective
endocarditis or ischemic heart disease
• Abnormality prevents the valve from closing
• Blood flows back into the right atrium during systole
• During diastole the regurg output flows into the LV with the
normal blood flow and increases the volume into the LV
• Progression is slowly – fatigue, chronic weakness, dyspnea,
anxiety, palpitations
• May have A-fib and changes of LV failure
• May develop right sided failure as well
Mitral Valve Anatomy
 Pathophysiology
• Hemodynamic changes much more
pronounced than in chronic MR due to lack of
time for adaptation
• The abrupt increase in left atrial pressure is
transmitted to the pulmonary circulation
• Cardiac output falls and systemic vascular
resistance increases
Echo performed…
 Mitral Valve Prolapse
• Cause is variable and may be associated with
congenital defects
• More common in women
• Valvular leaflets enlarge and prolapse into the LA
during systole
• Most are asymptomatic
• Some may report chest pain, palpitations or exercise
intolerance
• May have dizziness, syncope and palpitations
associated with dysrhythmias
• May have audible click and murmur
Mitral Valve Prolapse
Types
• Women 20 to 50 years

• Low BP, orthostatic hypotension, palpitations, chest pain

• Mid systolic click, maybe mid systolic murmur

• Echo:
- thickened, redundant leaflets
- leaflet excursion (prolapse) into LA in systole
- redundant chordae tendinae, trivial or mild MR

• Little progression of MR, Abx prophylaxis

 Mitral Valve Prolapse
Types

• Men 40 to 70 years

• Myxomatous and thickened MV

• Significant leaflelt prolapse

• Significant MR, progressive MR

• Complications: Chordal rupture, Afib

• Endocarditis prophylaxis

• Surgery for MR often required

Classic or non-classic combined MVP equal in male and females.
More complications in MEN
Transthoracic echocardiographic image in parasternal long-axis
view, showing posterior mitral leaflet bowing backward and
prolapsing into left atrium during systole. LV=left ventricle. LA=left
atrium. PML=posterior mitral valve leaflet.
 Aortic Stenosis
• Valve becomes stiff and fibrotic, impeding blood flow with LV contraction
• Results in LV hypertrophy, increased O2 demands, and pulmonary
congestion
• Causes – rheumatic fever, congenital, arthrosclerosis
• Atherosclerosis and calcification is primary cause in the elderly
• Complications – right sided heart failure, pulmonary edema, and A-fib
• S/S – Early: dyspnea, angina, syncope
Late: marked fatigue, debilitation, and
peripheral cyanosis, crescendo- decrescendo murmur is
heard
 Aortic Stenosis
Diagnosis

• Clinical
- pulsus parvus et tardus (absent in hypertensives and elderly)
- systolic thrill and typical heaving apical impulse
- S4 and late peaking ejection systolic murmur
- paradoxical split of 2nd HS in severe AS
- other auscultatory signs modified by co-existing disease

• ECG
- LVH with strain

• CXR
- dilated ascending aorta (post-stenotic dilatation)
- Valve calcification
Aortic Stenosis
Management Principles

• Asymptomatic
- no specific therapy
- endocarditis prophylaxis
- if appropriate, rheumatic fever prophylaxis

• Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm)
- Normal physical activity
- No specific therapy, restoration of NSR in case of AFib
- approx. progression is a decrease by 0.1 sq cm per year
- annual echo follow-up
Aortic Stenosis
Management Principles

• Nonsurgical (Balloon vavuloplasty)

- only a palliative treatment

- high risk elderly patients or as an emergent procedure

Cardiac MRI and CT
Indications for Surgery
Indications for Surgery
 Aortic Regurgitation
• Aortic valve leaflets do not close properly during
diastole
• The valve ring that attaches to the leaflets may be
dilated, loose, or deformed
• The ventricle dilates to accommodate the ^ blood
volume and hypertrophies
• Causes: infective endocarditis, congenital,
hypertension, Marfan’s
• May remain asymptomatic for years
• Develop dyspnea, orthopnea, palpitations, ,and
angina
• May have ^ systolic pressure with bounding pulse
• Have a high pitch, blowing, decrescendo diastolic
murmur
Example of a Jet of Aortic Regurgitation, as Shown by Color-Flow Imaging

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Example of Quantitation of Aortic Regurgitation by the Convergence of the Proximal Flow

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

 Classification of the Severity of Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Guidelines for Indications for Surgery in Patients with Severe Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

 Assessment for
Valve Dysfunction
• Objective symptoms
• Subjective symptoms
– Fatigue
– Weakness
– General malaise
– Dyspnea on exertion
– Dizziness
– Chest pain or
discomfort
– Weight gain
– Prior history of
rheumatic heart disease
Assessment, cont.
– Orthopnea
– Dyspnea, rales
– Pink-tinged sputum
– Murmurs
– Palpitations
– Cyanosis, capillary refill
– Edema
– Dysrhythmias
– Restlessness
 Medical
Diagnosis Treatment
• History and • Nonsurgical management
physical findings focuses on drug therapy
and rest
• EKG • Diuretic, beta blockers,
digoxin, O2, vasodilators,
• Chest x-ray prophylactic antibiotic
therapy
• Cardiac cath • Manage A-fib, if develops,
with conversion if
• Echocardiogram possible, and use of
anticoagulation
 Surgical Management
Interventions of Valve Disease
• Assess vitals, heart sounds,
adventitious breath
sounds
• Mitral Valve
• ^ HOB – Commissurotomy
• O2 as prescribed – Mitral Valve
• Emotional support
Replacement
• Give medications
• I/O – Balloon Valvuloplasty
• Weight
• Aortic Valve
• Check for edema
• Explain disease process, Replacement
provide for home care
with O2, medications
Mechanical Mechanical Valve
Valve
Porcine
Tissue Valve
Valve
Tissue Valve
 Initial studies

Eur Heart J 2002 (23) 1045-1049

• First report of left sided percutaneous valve implants by Bonhoeffer

– Use of bovine jugular vein containing a valve which was dissected
and sutured into a stent in lambs
– Valve initially implanted in descending aorta for acute aortic
insufficiency model.
• Orientation and orthotopic position optimized in further animal models
• In vitro testing showed a satisfactory durability for up to 2 yrs.
 Schematic views of device

• Left - 3 parts of device are

represented separately (from
top: platinum stent, nitinol
stent, and valve).
• Middle - Fully expanded device
is shown longitudinally and
axially.
• Righ - diagrams demonstrate
where nitinol and platinum
stents are attached, which
allowed stepwise approach.

From: Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-

778
Newly designed stent crimped on outer balloon of delivery system before
being covered. Notice spontaneous expansion of nitinol stent.

Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

(1) Whole system advanced in left ventricle.
(2) Device then uncovered, deploying nonsutured part of nitinol stent.
Free wires of nitinol stent positioned in bottom of native leaflet.
(3) Balloons are inflated to expand platinum stent
(4) Finally deflated, and retrieved, leaving device in position.

Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

 Percutaneous Heart Valve (PHV)
14 mm in length
Trileaflet
Tissue valve made of three equal size
sections of bovine pericardium

The percutaneous valve crimped

over the 30-mm-long balloon before
implantation

From: Cribier: Circulation, Volume 106(24).December 10, 2002.3006-3008

JACC (2004) 43:1082-7 JACC (2002) 39:1664-1669
• Percutaneous Valvuloplasty
Summary
– MV valvuloplasty efficacious in carefully selected patients
– AV valvuloplasty
• Only transient improvement and high restnosis rate in adult population
• Last resort or bridge to surgery in patients with severe calcified AS
– PV valvuloplasty
• mainly in pediatric population
• Well-accdepted treatment for PS and good f/u results

• Percutaneous Valve repair

– Currently investigational devices for MR only
– Still early stage with no published results (that I know of) in human

• Percutaneous valve replacement/implantation

– Early stages with very limited data on human
– Promising results for PV in pediatric population
– Limited but promising data in human for AV implant in non-surgical candidates
– Larger scale clinical trials and long term data needed
– Unanswered questions regarding ideal material, paravalvular leaks, durability,
complications and more.

• Overall, percutaneous valve intervention is an exciting field in interventional cardiology

but still at an infantile stage with potentially immense clinical application!