VALVULAR HEART DISEASE

Question 1

Valvular heart disease

Answer 1

■ MITRAL STENOSIS
■ AORTIC STENOSIS
■ MITRAL REGURGITATION
■ AORTIC REGURGITATION
■ TRICUSPID REGURGITATION
■ TRICUSPID STENOSIS
■ PULMONARY STENOSIS
■ PULMONARY REGURGITATION
■ MIXED LESION

Question 2

MITRAL STENOSIS

Definition:

Answer 2

The mitral valve’s incapacity to open completely in diastole, due to

• comisural fusion
• cusps thickenning
• remodeling of the subvalvular structures

Question 3

MITRAL STENOSIS

Etiology

Answer 3

Rheumatic fever - most of the patients,
 Other etiologies are very rare: 
–Congenital, MS+atrial septal defect= Lutembacher syndrome. 
–Mitral valve annular calcification - elderly. 
–Other causes of LV inflow obstruction:
■atrial myxoma
■LA ball thrombus
■cor triatriatum.

Question 4

MITRAL STENOSIS-Pathology

Answer 4

Fusion of the comissures, cusps or chords.

Contracture and thickening of the cusps.

Shortening and fusion of the chordae tendinae.

Funnel –shaped orifice.
SLIDE 5

Question 5

Mitral Stenosis

Pathophysiology

Answer 5

■ Obstruction between LA and LV. 
■ Pressure gradient. 
■ Elevated LA pressure. 
■ LA pressure increases at elevated HR.
■ Pulmonary vascular resistance elevated.
■ Pulmonary hypertension
■ Right ventricular hypertrophy, enlargement.
■ Systemic venous congestion

Question 6

Mitral stenosis-Classification

Answer 6

■ Large: more than 2 sqcm.
■ Medium: 1,5-2sqcm.
■ Severe:<1sqcm.

Question 7

Mitral stenosis-Symptoms.

Answer 7

■ Exertional dyspnea.
■ Fatigue.
■ Presyncope, syncope.
■ Cough, wheezing.
■ Paroxysmal nocturnal dyspnea.
■ Orthopnea.
■ Hemoptysis.
■ Hoarsenes(Ortner syndrome

Question 8

Mitral stenosis

Physical findings

Answer 8

■ Mitral facies.
■ Tachypnea.
■ Turgid jugulars.
■ Jugular pulse.
■ Pulmonary rales, 
pleural fluid. 
■ Diastolic thrill.
■ Sustained RV lift

Question 9

Mitral stenosis

-Auscultaion

Answer 9

slide 10 ,11 ,12

Question 10

Mitral stenosis- Complications

Answer 10

■ Atrial fibrillation/flutter.
■ Embolism: Systemic:cerebral, coronary, preipheral; pulmonary.
■ Acute pulmonary edema.
■ RV heart failure.
■ Infective endocarditis. 
■ Chest pain/angin

Question 11

Mitral regurgitation

Answer 11

Definition: Clinical syndrome determined by the

incomplete closure of the mitral valve during systole.

Question 12

MR - Causes

Answer 12

SLIDE 15 , 16

Question 13

MR-pathophysiology

Answer 13

■ A volume of blood is regurgitated from the LV to the LA
LV overload.
■ End diastolic pressure increases
LA preassure is increased,
LA is dilated,
Pulm HTN can develop.
■ LV is dilated
Syst LV dysfunction appears (may be irreversible)
■ Pulmonary arterial hypertension can appear
+
RV failure during evolution.

Question 14

MR-pathophysiology

Answer 14

SLIDE 18

Question 15

MR-physical examination

Answer 15

■ Carotid upstroke is brisk.
■ Laterally displaced apical impulse with enlarged LV.
■ Apical thrill-severe MR.
■ Left sternal border lift –RV dilation.
■ S1 is included in the murmur, usually normal, may be increased in rheumatic heart disease.
■ S3 gallop-large volume of regu

Question 16

MR-physical examination (II)

Answer 16

■ The hallmark of MR is the systolic murmur-most often holosystolic, is of blowing type, but may be harsh in mitral valve prolapse

Question 17

MR in mitral valve prolapse.

Answer 17

■ MR limited to telesystole.
■ Frequent -5%pop. especially in young women.
■ Habitus is sometimes characteristic: longiline- asthenic woman with mild chest
deformities:pectus excavatum, pectus carinatum.
■ Palpation- bifid apical impulse.
■ Meso or telesystolic click, followed by –in a minority of cases – by telesystolic murmur

Question 18

Mitral Valve Repair

Answer 18

SLIDE 22

Question 19

Aortic stenosis

Answer 19

Definition: obstruction to blood outflow from the LV to the aorta.
Causes:
1. Congenital.
2. Acquired:
- Degenerative
- Rheumatic

Rare causes:

1. Infective endocarditis
2. Paget bone disease
3. SLE
4. Rheumatoid involvement
5. Irradiation

Question 20

Aortic stenosis - PATHOLOGY

Answer 20

SLIDE 24

Question 21

Aortic stenosis - Pathophysiology

Answer 21

■ Obstruction in LV outflow.
■ Gradient LV-Ao.
■ LV pressure rises,.
■ LV wall stress increases.
■ LV dysfunction develops
■ LV hypertophy develops.
■ LV filling pressure increaqses.
■ LV systolic failure develop

Question 22

Aortic stenosis-classification

Answer 22

SLIDE 26

Question 23

Aortic stenosis-symptoms

Answer 23

■ Angina pectoris.
■ Exertional presyncope
■ Syncope.
■ Heart Failure
■ Pulmonary edema

Question 24

AS- CLINICAL FINDINGS

Answer 24

■ Peripheral pulse: parvus et tardus- taking longer time to reach the peak pressure, peak is reduced.
■ Heart size increased in heart failure.
■ Palpable G4(S4).
■ Aortic thrill at the base of the heart.

Question 25

AS-Auscultation

Answer 25

■ Systolic ejection click(bicuspid) ■ Paradoxically split S2. ■ Systolic ejection murmur. ■ In older patients ejection murmur is atypical, heard at the apex as seagull sound – Gallavardin phenomenon. ■ Ejection murmur decreased when LV failure occurs

Question 26

AORTIC VALVE REPLACEMENT

Answer 26

``` TAVI= Transcatheter Aortic Valve Implantation SLIDE 30 ```

Question 27

AORTIC REGURGITATION

Answer 27

Definition: Incomplete closure of the aortic cusps in diastole and regurgitation of blood from the aorta to the left ventricle. Aortic regurgitation can be acute or chronic.

Question 28

AORTIC REGURGITATION-Etiology

Answer 28

SLIDE 32

Question 29

AORTIC REGURGITATION-Pathology

Answer 29

``` ■ Dilatation of the annulus AR. ■ Valves can show – Thickening – Shortening – Comisural lesions – Calcification, . ■ LV – dilated – hypertrophied. ■ LV dysfunction ```

Question 30

AORTIC REGURGITATION-Symptoms

Answer 30

``` ■ Pounding of the head or palpitations. ■ Dyspnea on exertion. ■ Orthopnea, paroxysmal nocturnal dyspnea. ■ Fatigue and weakness. ■ Angina pectoris ```

Question 31

AORTIC REGURGITATION-peripheral signs

Answer 31

■ Pulse pressure –elevated. ■ Corrigan pulse- celer et altur. ■ Atrerial hyperpulsatility: ■ Musset sign-bobbing of the head with each heartbeat. ■ Traube sign-pistol-shot heard over the femoral artery. ■ Duroziez sign-systolic murmur fem.a.when compressed proximally, diastolic distally. ■ Quincke pulse-capillary pulsations detected pressing a glass over the patients lips. ■ Arterial dance- carotid pulsations. ■ Waterhammer sign-pulsatons of the forearm when pressed. ■ Landolfi sign – intermittant pupillary hippus – miosis in systole, midriasis in diastole

Question 32

AORTIC REGURGITATION-physical examination

Answer 32

■ The chest may rock, cardiac impulse may be visible. ■ Diastolic thrill-severe AR. ■ S1 usually soft. ■ Systolic ejection murmur. ■ Early or immediate, blowing descrescendo diastolic murmur, after S2. ■ IN severe AR the murmur is holodiastolic. ■ Austin-Flint murmur of functional mitral stenosis. ■ Signs of left or global heart failure

Question 33

Tricuspid regurgitation

Answer 33

Definition: incapacity of the tricuspid valve to close completely during systole, resulting in regurgitation of blood from the right ventricle to the right atrium.

Question 34

Tricuspid regurgitation -etiology

Answer 34

■ Primary TV disease: – Congenital:Ebstein anomaly – Rheumatic, assoc. with mitral disease. – Infective endocarditis. – Iatrogenic: pacemaker wire trauma. – Degenerative:TV prolapse. ■ Secondary TV disease: – RV dilatation – Pulmonary hypertension. – Cardiomyopathies – Segmental RVdysf. Due to ischemia, ARVD

Question 35

Tricuspid regurgitation-symptoms

Answer 35

■ TR is not associated with any complaint until the late phases of the disease when RV dysfunction develops resulting in overt rihgt heart failure syndrome. ■ Symptoms: fatigue, right upper quadrant discomfort, dyspepsia due to gut congestion

Question 36

Tricuspid regurgitation – | physical examination

Answer 36

``` ■ Edema of the lower limbs. ■ Ascites. ■ Jugular congestion ■ Cachexia due to low cardiac output ■ Right parasternal lift. ■ Systolic pulsa ```

Question 37

Tricuspid regurgitation | Auscultation

Answer 37

SLIDE 42

Question 38

Tricuspid stenosis

Answer 38

■ Rare condition ■ Etiology: rheumatic in most of the cases. ■ Simptoms and general signs similar to those met in TR. ■ Auscultation: low to medium pitched diastolic rumble with inspiratory accentuation, localized to the lower sternal border.

Question 39

Pulmonary valve dissease

Answer 39

■ Apart from congenital conditions is very rare. ■ Congenital: PV stenosis, Pulmonary atresia, Bicuspid valve, Infundibular(subvalvular pulmonary stenosis), Idiopathic dilatation of the pulmonary artery. ■ Acquired: reheumatic, Infective endocarditis, carcinoid heart disease, pulmonary hypertension, iatrogenic-Ross operation.

Question 40

Pulmonary stenosis –physical examination

Answer 40

■ Mild stenosis - systolic ejection click+early systolic murmur. ■ Severity progresses the murmur gets louder and peaks later in systole. ■ S2 is splitted with dealyed pulmonary component, but with further widening in inspiration