Objectives
Normal aortic valve: # of cusps
3 cusps
right, left and non-coronary
Normal aortic valve: Thickness
0.5 - 2mm
Normal aortic valve: Length
1.5 - 2 cm
Normal aortic valve: Area
3 - 5 cm2
Normal aortic valve: Annulus
1.8 - 2.7 cm
Normal aortic valve: Aortic root
~ 3.5 cm
Normal aortic valve: Trivial regurgitation
0 - 2 %
Normal aortic valve
Aortic Stenosis: Valve area
when the aortic valve area is 1 cm2 or less
this is severe aortic stenosis
Normal aortic valve: Echocardiograph
Normal Mitral Valve: leaflets
2 leaflets
Anterior and posterior leaflets
Normal Mitral Valve: leaflet structure
Each leaflet is divided into 3 scallops: AL, Mid and PM
Normal Mitral Valve: Leaflets thickness
0.7 - 3 mm
Normal Mitral Valve: D shape
AntPost < MedLat diameter
Normal Mitral Valve: valve area
4 - 6 cm2
Normal Mitral Valve: annulus
fibromuscular annulus
Normal Mitral Valve: what structures are involved in the action of the valve?
3 listed
- Chordae Tendinae
- AL and PM Papillary muscles
- LV walls
Normal Mitral Valve: etiology from dysfunction in what structures?
3 listed
Pathology in
- chordae tendinae
- AL and PM papillary muscles
- LV walls
can lead to mitral valve dysfunction
Normal Mitral Valve: Trivial to mild Regurgitation
30 - 45 %
Normal Mitral Valve
Normal Mitral Valve: Echo
Identify
Identify phases
Identify
Types of valvular heart disease
4 listed
- Aortic stenosis
- Aortic regurgitation
- Mitral regurgitation
- Mitral stenosis
Aortic stenosis brief description
narrowing of the aortic valve area causing obstruction to LV ejection
Mitral stenosis brief description
narrowing of Mitral valve area causing obstruction to LV filling
Aortic regurgitation brief description
Backflow from the aorta to the LV
Mitral regurgitation brief description
Backflow from the LV to the LA
Aortic stenosis common etiology
- younger than 70 50% congenital bicuspid valve
- Older than 70 48% degenerative
- post inflammatory or rheumatic
- radiation therapy to the chest
Bicuspid aortic valve description
A bicuspid aortic valve (BAV) is an aortic valve that only has two leaflets, instead of three. The aortic valve regulates blood flow from the heart into the aorta. The aorta is the major blood vessel that brings oxygen-rich blood to the body.
Pathology of aortic stenosis
Aortic Stenosis: Echo
Aortic Stenosis: Hemodynamic consequences
6 listed
Identify hemodynamic changes in aortic stenosis
Pathophysiology of aortic stenosis
- the LV systolic pressure increases to open the aortic valve
- LV hypertrophy occurs from chronic increased LV pressure
- LV compliance decreases and so LA pressure and end diastolic pressure increases
- aortic pressure is decreased from a reduced stroke volume
- reduced coronary perfusion during diastole
- so increased oxygen demand and reduced perfusion/supply
also
*
Coronary blood flow in Aortic stenosis
- reduced end-diastolic volume
- ventricular is less compliant
- ventricle end-diastolic pressure is increased
- aortic diastolic pressure is decreased so the epicardial pressure gradient is decreased and therefore the coronary blood flow is decreased and eventually leads to myocardial ischemia
the thicker the heart muscle is…
, the less compliant it becomes
Pressure-volume loop of compensated aortic stenosis
6 listed
End-systolic pressure curve in compensated aortic stenosis
shifted to left
Pressure-volume loop of decompensated aortic stenosis
6 listed
now the ventricle doesnt eject normally and so the LVES volume is increased because LV contractility has decreased as a result of myocardial ischemia from chronic pressure overload and LV systolic dysfunction
difference between compensated and decompensated aortic stenosis
Symptoms of aortic stenosis
Characteristic symptoms of aortic stenosis
- Angina
- Syncope (exercise related too!) (exercise related syncope)
- Heart failure
Aortic stenosis murmur
the later the intensity murmur peaks the worse it is
auscultation of aortic stenosis
Aortic stenosis best heard
right sternal border 2nd intercostal with the diaphragm
Aortic stenosis severity sound
the later the murmur peaks the more severe the stenosis
Treatment of aortic stenosis
TAVR is evolving
Aortic regurgitation mechanisms
4 listed
- Primary disease of the leaflets
- Aortic root diseases
- Acute processes
- Chronic processes
Aortic regurgitation mechanisms: Primary disease of leaflets causes
3 listed
- Aging
- Infection
- Inflammation
Aortic regurgitation mechanisms: Aortic root diseases
3 listed
- Dilation
- Aneurysm
- Dissection
Aortic regurgitation mechanisms: Acute processes causes
3 listed
- Infective endocarditis
- Dissection of the aorta
- Traumatic injury
Aortic regurgitation mechanisms: Chronic processes causes
5 listed
- Bicuspid aortic valve
- aortic root dilation
- Previous endocarditis
- Rheumatic disease
- Connective tissue diseases
Aortic regurgitation echo: holes in the leaflets on this echo
quadricuspid valve on this
Endocarditis
Endocarditis is an infection of the endocardium, which is the inner lining of your heart chambers and heart valves.Endocarditis generally occurs when bacteria, fungi or other germs from another part of your body, such as your mouth, spread through your bloodstream and attach to damaged areas in your heart.
Marfans aortic regurgitation
Hemodynamics of chronic aortic regurgitation
6 listed
Describe hemodynamic changes of chronic aortic regurgitation
6 listed
Aortic regurgitation murmur
decrescendo diastolic murmur & an associated flow related systolic murmur
Acute Aortic regurgitation
- large regurgitant volume coming to a non-adapting, non-dilating, non-accommodating ventricle so it can only dilate minimally, get a rapid increase in end-diastolic pressure translating into high atrial pressure, high pulmonary capillary pressure and pulmonary edema which is the mean pathophysiology of acute aortic regurgitation from such a sudden onset of end-diastolic volume.
- As the ventricle responds by increasing HR and contractility but diastolic filling period is decreased but there is a further decrease of CO and eventually leads to relative ischemia and myocardial dysfunction
- Both combined lead to heart failure
Hemodynamics of Acute Aortic regurgitation
Describe the hemodynamic changes of Acute Aortic regurgitation
Effect of Aortic regurgitation on oxygen consumption
so have increased demand and reduction in supply
Describe changes of PV loop in Hemodynamics of chronic compensated Aortic regurgitation
Describe changes of PV loop in Hemodynamics of chronic decompensated Aortic regurgitation
Murmurs of Aortic regurgitation
Treatment of aortic regurgitation
4 listed
- medical therapy
- Valve replacement
- Aortic root repair with spare of native valve
- Aortic root repair with valve replacement
Treatment of aortic regurgitation: Medical therapy
Afterload reduction with CCBs (Nifedipine), ACEI (lisinopril) or ARBs (losartan)
Treatment of aortic regurgitation: Valve replacement
2 listed
- Bioprosthetic valve
- Mechanical valve
Treatment of aortic regurgitation: Aortic root repair
2 listed
Aortic root repair with spare of the native valve or with a valve replacement
Mitral Regurgitation etiology
- 60% degenerative
- 20% Ischemic
- 20% other including Rheumatic fever and endocarditis
Pathology of mitral valve prolapse
Acute mitral regurgitation by Echo
Chronic mitral regurgitation by Echo
Hemodynamics of mitral regurgitation
6 listed
Describe the hemodynamic changes of mitral regurgitation
Pathophysiology of mitral regurgitation
7 listed
PV Loop of Acute Mitral Regurgitation
Describe PV Loop changes of Acute Mitral Regurgitation
PV Loop of chronic compensated Mitral Regurgitation
9 listed
Describe PV Loop changes of chronic compensated Mitral Regurgitation
Pathophysiology of chronic decompensated Mitral Regurgitation
8 listed
The murmur of Mitral regurgitation
Auscultation of Mitral Regurgitation
Treatment of Mitral Regurgitation
3 listed
- Surgical repair
- Percutaneous Repair
- Valve replacement
Treatment of Mitral Regurgitation: Surgical Repair
2 listed
- Quadrangular resection
- Mitral annuloplasty
Treatment of Mitral Regurgitation: Percutaneous repair
Mitral valve clip
Treatment of Mitral Regurgitation: Valve Replacement
2 listed
- Bioprosthetic valve
- Mechanical valve
Mitral Stenosis: Etiology
2 listed
>95% Rheumatic Fever
Congenital, infection, tumor, throbus or drugs <5%
Mitral Stenosis Pathophysiology
4 listed
Mitral Stenosis by Echo
Hemodynamics of mitral stenosis
7 listed
Describe Hemodynamics changes of mitral stenosis
7 listed
Pathophysiology of Mitral stenosis
PV Loop of mitral stenosis
4 listed
Describe PV Loop changes of mitral stenosis
Auscultation of Mitral stenosis
Treatment of mitral stenosis
3 listed
- Temporary Medical Rx
- Percutaneous repair
- Valve replacement
Treatment of mitral stenosis: Temporary Medical Rx
2 listed
Atrial fibrillation/flutter
- Warfarin
- A-V nodal blockers
Treatment of mitral stenosis: Percutaneous repair
MV balloon valvuloplasty
Treatment of mitral stenosis: Valve replacement
2 listed
- bioprosthetic valve
- Mechanical valve
Summary of valvular heart disease
4 listed
Aortic stenosis summary
2 listed
Obstruction to LV ejection (systole)
↑ afterload = LV pressure overload
Aortic regurgitation summary
- Backflow from aorta to LV (diastole)
- ↑ LV preload and afterload = LV volume + pressure overload
Mitral regurgitation summary
2 listed
- Backflow from LV to LA (systole)
- ↓ LV afterload & ↑ LV + LA preload = LV + LA volume overload
Mitral stenosis summary
2 listed
- Obstruction to LV filling (diastole)
- ↓ LV preload & ↑ LA preload & afterload = LA volume + pressure overload