Valvular heart disease for post graduates

MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj.
For post-graduates
drtoufiq19711@yahoo.com16/8/2019
Post graduate version 2019

Normal valve function
•Maintain forward flow and prevent
reversal of flow.
•Valves open and close in response to
pressure differences (gradients) between
cardiac chambers.

Abnormal valve function
•Valve Stenosis
•Obstruction to valve flow during that phase of the
cardiac cycle when the valve is normally open.
•Hemodynamic hallmark -“pressure gradient”
•Valve Regurgitation, insufficiency, incompetence
•Inadequate valve closure → reverse flow of the blood,
back leakage
•Combined – a single valve can be both stenotic and
regurgitant; combinations of valve lesions can coexist
•Single disease process
•Different disease processes
•One valve lesion may cause another
•Certain combinations are particularly common(AS & MR,
MS & TR)

Essential questions in the evaluation of
patients for valvular intervention

Diagnosis
• History
• Physical examination
• ECG
• Chest x-ray
• Echocardiography
• Invasive evaluation, CT,
MRI

History
•Other known heart diseses
• Congenital heart disease,
bicuspid aortic valve
• Ischemic heart disease
• Rheumatic fever
• Hypertrophic/dilated
cardiomyopathy
• Aortic diseases –
Marfans,Ehlers-Danlos

History
• Generally: symptoms of heart failure
and low cardiac output
• Breathlessness
• Chest pain or dyscomfort
• Syncope
• Fatigue
• Peripheral or pulmonary oedema
• Palpitations

Physical examination
• MURMURS!!!
• Periferal oedema
• Lung crackles
• Elevated JVP
• Displaced apex beat,
irregular heart beat…
Hundreds of eponymous signs from past
millenium (↓importance in daily
routine, ↑importance for passing exam)

Heart murmurs
•Sounds produces by turbulent
blood flow (in valve diseseses,
artery stenosis, abnormal
chamber or AVcommunication)
•Localization,grade,
propagation, timing, quality

Heart murmurs
Intensity Description
Grade I/VI Barely audible
Grade II/VI Audible, but soft
Grade III/VI Easily audible
Grade IV/VI Easily audible, associated with a thrill
Grade V/VI Easily audible, associated with a thrill, and still audible with the
stethoscope onlylightly on the chest
Grade VI/VI Easily audible, associated with a thrill, and still audible with the
stethoscope off of the chest

ECG
• Not specific
• Findings might be caused or altered by other
concomitant heart disease (hypertensive heart
disease, ischemic heart disease)
• Left ventricular hypertrophy (aortic valve
disease)
• Left atrial enlargement (mainy MS, but any left
heart valve disease)
• Atrial fibrilation
• Bundle branch block
• Arrytmias (atrial fibrilation, ectopic beats)

Chest x-ray in valvular disease
• Different heart shapes in different valvular
heart diseses, ↓specificity, ↓significance
• Cardiomegaly, pulmonary congestion
• Widened mediastinum
• Valve calcifications, prosthetic valves

Echocardiography
• Mainstay of valve disease
diagnosis and follow-up
• Allows real-time measurement of
chamber and wall diameters,
ejection fraction assessment and
functional valve evaluation
• Easily avaiable and repeated
• Essential in acute valve disease
diagnosis
• No radiation harm
• Trans-esophageal echocardiography
avaiable for patients with poor
transthoracic sonographic window

Invasive evaluation, CT, MRI
• Methods usualy used for uncertain cases or repeat
cardiac surgery / percutaneous inteventions planning
• Angiography to assess regurgitation severity – direct
transcatheter contrast medium administration into
heart chambers – aortography, ventriculography
• Hemodynamic measurment – measuring of
intracardial pressures and gradients
• CT aortography – method of choice in aortic
dissection diagnosis
• CMRI – very precise evaluation of cardiac tissues and
function, but expensive, low avaiability, long
examination time

Echocardiographic criteria for the definition of
severe valve regurgitation: an integrative approach

Case report
• A 23 years old lady presented with shortness of
breath on exertion, increasing in intensity for last 3
months. On examination she is dysnoeic, pulse-
110/min, regular, BP-Normal, RR-30/min, diastolic
thrill in apex, S1 loud P2-loud, mid-diastolic murmur
in apical area best heard in left lateral position, breath
held in expiration. ECG-sinus tachycardia, CXR-P/A
view-straightening of left border, double right border,
Echocardiogram-severe mitral stenosis with
moderate pulmonary hypertension with Wilkins echo
score-6. Patient underwent PTMC and she is doing
well.
8/16/2019
Col. Malek Medical College, Manikganj
drtoufiq19711@yahoo.com
28
Mitral Stenosis
Mitral stenosis

Mitral stenosis
• Causes
• Rheumatic heart disease in up to 99% of all
cases
• Other causes are rare - mitral annular
calcification, obstruction with massive
endocarditis vegetations, left atrial
myxoma, post radiation
• Nowadays rare in developed countries, still
prevalent in developing countries due to
rheumatic fever
Mitral stenosis

• Pathophysiology:
• Normal mitral valve area 4-6 cm2 – stenosis
becomes severe with MVA < 1cm2
• Increased transmitral pressure gradient: leads to
left atrial pressure increase, enlargement and atrial
fibrillation →
• Development of postcapillary pulmonary
hypertension (there is no valve to isolate the
increased left atrial pressure from pulmonary veins)
→
• Right heart failure symptoms - due to pulmonary
HT, secondary right ventricle dilation and tricuspid
regurgitation
Mitral stenosisMitral stenosis

Mitral stenosis
Physical finding
• Diastolic murmur
• Low-pitched diastolic rumble most prominent at the
apex.
• Heard best with the patient lying on the left side in held
expiration
• Intensity of the diastolic murmur does not correlate with
the severity of the stenosis
• Lung crackles
• Pleural effusion
• Facies mitralis: When MS is severe and the cardiac
output is diminished, there is vasoconstriction, resulting in
pinkish-purple patches on the cheeks (might be seen in
terminal heart failure of any cause)

Mitral stenosis

Case report
• A 53 years old gentleman presented with shortness of
breath on exertion for last 2 years , increasing in
intensity for last 3 months. On examination she is
dysnoeic, pulse-128/min, irregular, BP-100/30 mm Hg,
RR-32/min, diastolic thrill in apex, mid-diastolic
murmur in apical area, early diastolic murmur in left
lower sternal area and systolic murmur in aortic area.
ECG- Atrial Fibrillation, CXR-P/A view-Cardiomegaly,
Echocardiogram-severe mitral stenosis with Moderate
AS with severe AR with moderate pulmonary
hypertension. Patient underwent DVR and she is doing
well.
8/16/2019
36
Mitral Stenosis
Aortic stenosis

Aortic stenosis
• Common indication for valve intervention
• Causes
• Degenerative aortic stenosis
• Bicuspid aortic valve
• Congenital aortic stenosis, unicuspid aortic valve
• Rheumatic disease (always with mitral valve
involvement)
• Infective endocarditis (but severe stenosis due to
massive vegetations is extremely rare)
• Other rare causes – post radiation, associated
with systemic disease
Aortic stenosis

Aortic stenosis
•Pathophysiology
• Normal aortic valve area (AVA) – 3-4 cm2
• With a decrease of AVA ,a pressure
gradient develops between the left
ventricle and the aorta (increased
afterload)
• LV function initially maintained by
compensatory concentric hypertrophy
(but without an adequete increase in
vascularization)
• When compensatory mechanisms are
exhausted, LV function declines.
Aortic stenosis

Aortic stenosis

Aortic stenosis
Presentation
• Angina pectoris (increased myocardial oxygen
demand; demand/supply mismatch)
• Dyspnea on exertion due to heart failure (systolic
and diastolic)
• Syncope (exertional)
• Sudden death, mortality – when asymptomatic
with preserved left ventricle ejction fraction, the
sudden death risk is about 1%/y, when
symptomatic, however, the mortality increases to
up to 50%/y
Aortic stenosis

Aortic stenosis
Physical finding
• Systolic crescendo-decrescendo murmur with
maximum at right sternal border, 2nd-3rd intercostal
space , propagated to the carotic arteries – the
loundness of the murmur is not directly correlated to
severity of stenosis
• Slow rising carotid pulse (pulsus tardus) & decreased
pulse amplitude (pulsus parvus)
• Heart sounds - soft and split second heart sound, S4
gallop due to LVH…
Aortic stenosis

Stepwise integrated approach
for the assessment of aortic
stenosis severity. Pseudosevere
AS is defined by an increase to
an AVA >1.0cm2 with flow
normalization.

Criteria that increase the likelihood of severe aortic stenosis
in patients with AVA <1.0cm2 and mean gradient <40mmHg
in the presence of preserved ejection fraction
Aortic stenosis

Aortic stenosis
Therapy – medical therapy has no prognostic
effect
• Aortic valve replacement
• Standard therapy for patients with low
surgical risk or with indication for other
procedure
• Mechanical/biological prosthesis
• TAVI (transcatheter aortic valve implantation) –
patiens at unaccaptable surgical risk (elderly,
comorbid)
• Percutaneous aortic balloon valvuloplasty (for
congenital stenosis, or as a bridging therapy for
unstable patients)
Aortic stenosis

Indication for replacement
• Severe aortic stenosis (AVA <1 cm2, mean
PG > 40mmHg)
• Symptomatic
• LV function decreases
• Other indication for surgery
• Moderate stenosis (AVA 1,5-1 cm2 )
• With other indication for surgery
Aortic stenosis

Management of severe aortic stenosis

Aortic regurgitation
• Causes
• Chronic aortic regurgitation
• Bicuspid aortic valve
• Rheumatic and degenerative – always with some
degree of stenosis
• Aortic root dilation (hypertension, Marfan’s,
Ehlers-Danlos, syphylitic aortopathy)
• Other rare causes (SLE, RA)
• Acute aortic regurgiation
• Infective endocarditis
• Aortic regurgitation

• Pathophysiology of chronic aortic regrgitation
• Leakage of blood into LV during diastole due
to ineffective coaptation of the aortic cusps
• Combined pressure and volume overload
• Compensatory Mechanisms: LV dilation, LVH.
Progressive dilation leads to heart failure
• Greatest mass of myocardium in any valve
disease – „cor bovinum“ – over 500g

• Presentation
• Dyspnea: exertional, orthopnea,
and paroxsymal nocturnal
dyspnea
• Chest pain
• Fatigue
• Palpitations: due to increased
force of contraction or arrythmias

•Physical findings (the ones you might find)
• Diastolic blowing murmur at the left sternal border –
might be very discrete. Systolic ejection murmur might
be present due to increased blood flow across the
aortic valve of concomitant valve stenosis
• Wide pulse pressure – caused by diastolic
regurgitation of blood to LV and fast decrease of
diastolic BP – „Corrigan’s pulse“ (160/30 mmHg…)
• Heaving and laterally displaced apex beat – due to
dilated heart with giant stroke volume

•Physical findings (the ones you might not find…)
• Quincke’s sign - pulsations of nail bed
• Muller’s sign - pulsation of uvula
• De Musset sign - (head nodding in time with
the heart beat)
• Duroziez sign (systolic and diastolic murmurs
heard over the femoral artery when it is
gradually compressed with the stethoscope)
• Austin Flint murmur (apex): Regurgitant jet
impinges on anterior MVL causing it to vibrate

• Acute aortic regurgitation
• Caused by a leaflet perforation in infective
endocarditis
• In aortic dissection due to a change in aortic root
geometry – dilation, extensive intimal tear with
prolapse into LVOT and coaptation impairment
• Presentation of acute aortic regurgitation itself is
usually a pulmonary oedema accompanied by
symptoms of the causing pathology
• True emergency – mostly requires immediate cardiac
surgery

Therapy –surgical
• Isolated leaflet pathology - aortic valve
replacement
• Aortic root pathology - combined aortic
root, ascendent aorta and aortic valve
replacement – Bentall’s procedure

Indication for replacement
• Severe aortic regurgitation (EROA – effective
regurgitant orifice area >0,3 cm2)
• Symptomatic
• LV dilates (over 50 mm EDD) or function
decreases (EF < 55%)
• Other indication for surgery
• Acute
• Moderate regurgitation (AVA 1,5-1 cm2 )
• With other indication for surgery

Case report
• A 53 years old lady presented with shortness of breath on
exertion for last 8 months, increasing in intensity for last 1.5
months. She had h/o CMC 20 years back, H/O PTMC 10 years
back . On examination she is dysnoeic, pulse-118/min, irregular,
BP-90/70 mm Hg, RR-32/min, diastolic thrill in apex, S1 soft P2-
loud, mid-diastolic murmur in apical area best heard in left
lateral position, breath held in expiration and pansystolic
murmur in apical area with radiation to left axilla. ECG- Atrial
Fibrillation, CXR-P/A view-Cardiomegaly, straightening of left
border, double right border, Echocardiogram-severe mitral
stenosis with severe MR with severe pulmonary hypertension
with Wilkins echo score-13. Patient underwent MVR and she is
doing well.8/16/2019
61
Mitral Stenosis
Mitral regurgitation

Causes
• Primary mitral regurgitation („valve is the pathology“) -
impairment of the valve itself, the cords or the papilary muscles
• Myxomatous degeneration (Barlow valve disease)
• Leaflet prolapse (in Barlow disease or in normal valve with
cord rupture)
• Infective endocarditis
• Rheumatic valve disease
• Secondary mitral regurgitation („left ventricle it the
pathology“) – impairment of left ventricle function and
geometry
• Ischemic heart disease
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Aortic valve disease drtoufiq19711@yahoo.com

Pathophysiology
• Backflow of blood from the LV to the LA during systole
• Pure volume overload – LV end-diastolic volume is
increased by the regurgitant volume
• Compensatory Mechanisms - left atrial enlargement, LV
increased contractility and dilation
• Progressive left atrial dilation and right ventricular
dysfunction due to pulmonary
hypertension – in advanced cases

Presentation
• Very long period of asymptomatic progresion
• Exertional dyspnea, fatigue
Physical finding
• Holosystolic murmur best heard at heart apex with
propagation to axilla
• In case of mitral leaflet prolaps, a systolic click might be
heard

Therapy
• Difers greatly according to the cause
• Primary
• Mitral valve repair – preserving the valve with surgically
correcting the cause of regurgitation – ruptured cords
replaced with artificial (Gore Tex) cords, resection of
redundant leaflet tissue
• Mitral valve replacement
• Secondary
• Treating the cause of ventricular dysfunction
• Medical, device therapy - in dilated CMP,
revascularization with annuloplasty in ischemic
heart disease

Acute mitral regurgitation
• Causes
• Cord rupture
• Infective endocarditis – leaflet perforation, cord rupture,
perivalvular fistula, absces
• Papillary muscle rupture (mechanical complication of
myocardial infarction, high force chest trauma)
• Presentation
• Acute heart failure – cardiogenic shock, pulmonary
oedema
Management
• Diuretics, nitrates, IABC → emergency surgery

Tricuspid valve disesease
•Tricuspid regurgitation
• Is usually secondary – due to right ventricle dilation and failure as a result
of pumonary hypertension (the most common cause of right heart failure
is left heart failure) or volume overload (left-right shunt abnormalities)
• Cor pulmonale – right ventricle failure in pulmonary disease
•Primary:
•Infective endocarditis – in i.v. abusers
•Other are rare - Carcinoid, rheumatic, Ebstein anomaly – apical
displacement of septal and posterior leaflet of tricuspid valve →
„atrialization“ of a portion of the morphologic right ventricle
•Symptoms of right heart failure – periferal oedema, elevated JVP,
hepatomegaly, ascites…
•Symptoms treated by diuretics, surgical treatment is only indicated in
case of left sided valve intervention

Pulmonic valve disesease
•Isolated severe pulmonic valve diseases are
extremely rare
•Pulmonic stenosis – congenital
•Systolic murmur at left sternal border, with
possible interscapulary propagation
•Pulmonic regurgitation – might be a result of
pulmonary hypertension, usually no treatment

Target INR for mechanical prostheses

Management of CAD in patients with VHD

Recommended requirements of a heart valve Centre

Management of atrial fibrillation in
patients with VHD

Valvular heart disease for post graduates

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