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Valvular Heart Disease
Songsak Kiatchoosakun, MD.Division of CardiologyDepartment of MedicineKhon Kaen University
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Normal Heart
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Mitral Valve Stenosis
Etiology• Rheumatic heart disease
– Most common cause • Calcified mitral annulus
– Elderly– Chronic renal failure
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Pathology of Mitral Stenosis
• Fibrosis and adhesion of mitral valve apparatus– Fish mouth appearance– Subvalvular stenosis
• Calcification of MV
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Mitral Stenosis
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Pathophysiology
• Normal MV area is 4-6 cm2
• Severity of mitral stenosis– MV area 1.5-2 cm2 : Mild MS– MV area 1.0-1.5 cm2 : Moderate MS– MV area < 1 cm2 : Critical or severe MS
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Pathophysiology of MS
LA pressure depends on heart rate and mitral valve area
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Pathophysiology of MS
• Elevated LA pressure • Pulmonary congestion • LA enlargement• Atrial fibrillation • LA clot• Reduced cardiac output• Normal LV contraction
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Pathophysiology of MS
• RA/ RV hypertrophy • Right heart failure• Tricuspid regurgitation• Hepatomegaly• Edema
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Natural History of MS
2 years 10-20 years
Acute Rheumatic Fever
Mitral Stenosis
SymptomaticMitral Stenosis
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Natural History and Prognosis of MS
Symptoms 10- year survival
None (class I) 84Mild-moderate (class II-III) 40Severe (class IV) 0
At 1 year 42At 5 year 10
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Clinical Manifestations• Exertional dyspnea• Pulmonary edema• Hemoptysis• Chest pain• Edema• Hoarseness of voice or “Ortner syndrome”• Systemic embolism
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Physical Examination
• Mitral facies • Normal or small volume of arterial pulse• Atrial fibrillation• RV heaving
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Physical Examination
Auscultation• Augmentation of S1
• Diastolic rumbling murmur– Duration of murmur relates with the
severity of MS• Augmentation of P2
• Opening snap (OS)
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Mitral stenosis
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Mitral Stenosis
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Mitral Stenosis
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Mitral Stenosis
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ECG
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Chest X- ray
Left atrium
RA Double contour
Straightening ofLeft heart border
Widening ofCarinal angle
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Left Atrial Enlargement in Mitral Stenosis
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Echocardiography in MS
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LA Thrombus
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Management of Mitral Stenosis
Mitral Stenosis
MVA 1.5- 2.0 cm2 MVA 1.0-1.5 cm2 MVA < 1 cm2
Medical treatment
Follow up q 3 years
Medical treatment
Follow up q 1-3 years
Symptomatic
PTMCMVR
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Medical Management• Antibiotic prophylaxis
– Rheumatic prophylaxis• Bezathine Penicillin 1.2 mu q 3 weeks• Penicillin V 250 mg oral bid
– Infective endocarditis prophylaxis• Restrict activities in moderate to severe MS
– Severe exercise• Prevent and control AF (Digitalis or Beta-
blocker)• Diuretics in pulmonary congestion
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Systemic Embolism in MS
• Risk was increased by 17 times compared to normal population• Not related to mitral valve area• May be the first manifestation of MS
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Anticoagulant Therapy in MS
• Warfarin • Indications
– Atrial fibrillation– Systemic embolism– LA thrombus
• Keep INR 2-3
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Management
Percutaneous balloon mitral valvuloplasty– Indications
1. Symptomatic severe MS2. No LA clot3. Favorable MV morphology
Mitral valve replacement– Indications
1. Symptomatic severe MS2. LA thrombus3. Unfavorable or calcified mitral valve
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Mitral Regurgitation
Mitral apparatus
• Mitral leaflet
• Papillary muscle
• Chordae
• Mitral annulus
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Mitral Regurgitation
Etiology• Mitral valve leaflet
– Mitral valve prolapse, rheumatic, endocarditis• Mitral annulus
– LV dilatation, calcified annulus• Chordae tendinea
– Rupture, myocardial infarction• Papillary muscles
– Myocardial infarction, bacterial abscess
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Rheumatic Mitral Regurgitation
Thickening of leaflet and chordae and the retraction of mitral tissue
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Mitral Regurgitation due to Endocarditis
Vegetations of the anterior leaflet and the ruptured cord
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Ruptured Posterior Papillary Muscle
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Pathophysiology of MR
• Half of cardiac output is ejected into left atrium
• Effective or forward is depressed
• Eccentric hypertrophy of LV and dilatation of left atrium
• Left ventricular systolic function is normal until late stage of disease
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Syndrome of Mitral Regurgitation
1. Acute MR (normal LA compliance)• Acute pulmonary edema• Hypotension• Edema is usually not present
2. Chronic MR (increased LA compliance)• Low cardiac output• Atrial fibrillation• Edema
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Clinical Presentations
• Acute pulmonary edema• Fatigue• Atrial fibrillation• Chest pain• Infective endocarditis
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Physical Examination
• Carotid pulse is normal • PMI shifts to the left• Pansystolic murmur at apex with
radiation to axilla
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ECG
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Chest- X ray
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Medical Management
• Treat underlying disease• Digitalis in AF• Diuretics in pulmonary congestion• Vasodilators in acute MR and MR with LV
dysfunction• The effectiveness of vasodilator in chronic
valvular MR is not well demonstrated• Rheumatic prophylaxis• Bacterial endocarditis prophylaxis
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Indications for Surgery
• Symptomatic MR (acute or chronic)• Asymptomatic MR with LV dysfunction
• LVEF 30- 60 %• Cardiac enlargement (LVESD 45-55 mm)
ACC/AHA guideline 1998
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Aortic Stenosis
Etiology• Rheumatic • Degenerative• Bicuspid aortic valve
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Aortic Stenosis
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Pathophysiology of AS
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Clinical Presentation of AS• Common symptoms
– Angina pectoris – Syncope – Heart failure
• Less common symptoms– Systemic emboli
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Natural History of AS
Ross J. Circulation 1968
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Physical Examination• Carotid pulse
– Pulsus parvus et tardus– Carotid shudder
• LV heaving• Auscultation
– Normal S1, decrease S2
– Systolic ejection murmur at right upper sternal border and radiate to carotid artery
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Aortic Stenosis
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ECG
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Chest X-ray
Post-stenotic dilatation
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Severity of AS
AS AVA (cm2)
Mild > 1.5
Moderate 1.1 - 1.5
Severe < 1.0
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Management of AS• Antibiotic prophylaxis• Restriction of activities
– Severe exercise/ competitive sports• Arrhythmias: AF; restore sinus rhythm• Avoid negative inotropic drug, diuretic and
vasodilators• Follow up
– Asymptomatic; 2-5 years– Moderate; 6-12 months
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Indication for Surgery
• All symptomatic severe AS patients• LV dysfunction
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Aortic Regurgitation
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Aortic Regurgitation
Etiology2. Aortic valve abnormality
– Infective endocarditis– Rheumatic disease
3. Aortic root abnormality– Dissection of aorta– Marfan syndrome– Aortitis
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Aortic Regurgitation
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Pathophysiolgy
Diastolic Regurgitation Heart murmur
Large Stroke Volume Peripheral signs
LV enlargement CardiomegalyFatigue
LV failure, Increased LVEDP: Dyspnea, chest pain
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Clinical Presentations
• Asymptomatic• Nocturnal anginal pain
– Low diastolic blood pressure• Palpitation: heart contraction• Heart failure
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Physical Examination
• Wide pulse pressure • Corrigan’s pulse, Water hammer’s pulse• Pulsus bisferiens• LV heaving• Diastolic blowing murmur at left lower sternal
border• Peripheral signs
– Muller’s sign– Quincke’s sign- Hill’s sign
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Aortic Regurgitation
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Aortic Regurgitation
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Natural History of AR
Bonow, et al. JACC Nov 1988 2Aronow , et a. Am J Cardiol 1994; 74: 286.
• Normal LV function– Heart failure < 6 %/yr– Mortality < 1 %/yr
• LV dysfunction– Mortality rate > 10%/yr
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ECG
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Chest X-ray
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Medical Management of Patient with AR
• Restriction of activities– Severe exercise/ competitive sports
• Vasodilator– Severe AR– LV dysfunction
• Diuretics• Digitalis in AF/ heart failure• Endocarditis prophylaxis
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Surgical Therapy
• Indications for AVR (Severe AR)– Symptomatic (NYHA III-IV) regardless of LV
function– Symptomatic (NYHA II) with evidence of
progressive LV dysfunction
1 Bonow, et al. Circulation 1998;98:1949-84
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