Transcript Valvular Heart Disease

Valvular Heart Disease
Vincent E. Friedewald, M.D.
Classification of Heart Disease
Congenital
Coronary
Electrical
Endomyocardial
Pericardial
Valvular
The Cardiac Valves
Cardiac Valve Anatomy
Valvular Heart Disease
Acute and Chronic
are
Different Diseases
Aortic Stenosis
Aortic Stenosis
Types
Valvular
Subvalvular
Supravalvular
Aortic Valve Stenosis
Aortic Valve Stenosis
Bicuspid
Rheumatic
Degenerative
Aortic Valve Stenosis
Age Relationship
Bicuspid Aortic Stenosis
Rheumatic Aortic Stenosis
Degenerative Aortic Stenosis
Degenerative Aortic Stenosis
Risk Factors
Elevated LDL-cholesterol
Diabetes mellitus
Systemic arterial hypertension
Cigarette smoking
Aortic Valve Stenosis
Symptoms
Often Asymptomatic
Angina pectoris
Dyspnea
Fatigue
Syncope
Aortic Valve Stenosis
Signs
ARTERIAL PULSE, GEN – RISE, SLOW
ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED
ARTERIAL PULSE, GEN – DOWNSLOPE GRADUAL
ARTERIAL PULSE, GEN – PULSE PRESSURE, NARROW
ARTERIAL PULSE, GEN – SHUDDER
ARTERY, CAROTID – THRILL
HEART, LV APEX – IMPULSE, PRESYSTOLIC
HEART, LSB MID – MURMUR, DIASTOLIC
HEART, LSB MID – MURMUR, SYSTOLIC
Aortic Valve Stenosis
Signs (cont)
HEART, LV APEX – CLICK, SYSTOLIC
HEART, LV APEX – IMPULSE, SUSTAINED
HEART, RSB UPPER – MURMUR, SYSTOLIC
HEART, RSB UPPER – CLICK, SYSTOLIC
HEART, SOUND A2 – ABSENT OR REDUCED
HEART, SOUND S1 – SOFT
HEART, SOUND S2 – SINGLE
HEART, SOUND S2 – SPLIT REVERSED (PARADOXICAL)
NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC
Aortic Valve Stenosis
Symptoms
FATIGUE
BREATHING – DIFFICULT WITH EFFORT (DYSPNEA)
CHEST, ANT – PAIN, NONPLEURITIC (ANGINA PECTORIS)
CHEST, ANT – PALPITATIONS
CONSCIOUSNESS – LOSS, SUDDEN (SYNCOPE)
CONSCIOUSNESS – LOSS, SUDDEN EFFORT (EFFORT SYNCOPE)
DIZZINESS – EFFORT
Aortic Valve Stenosis
Untreated Prognosis
Aortic Valve Stenosis
Chest X-Ray
Aortic Valve Stenosis
ECG
Aortic Valve Stenosis
Echo
Aortic Valve Stenosis
AV Pressure Gradient
Aortic Valve Stenosis
Medical RX
No drugs alter course – only valve repair/replacement
Antibiotic Prophylaxis
? Statins
For symptoms (if not candidate for valve replacement) – afterload reduction, i.e., nitroglycerine, used with caution to avoid
BP fall
Aortic Valve Stenosis
Surgical Rx
Valvotomy
Replacement
Artificial
Bioprosthesis
Minimally-invasive transfemoral
Aortic Valve Replacement
Transfemoral
Aortic Valve Stenosis
Complications
Atrial fibrillation
Aortic Dissection
Heart failure
Infective endocarditis
Myocardial infarction
Sudden death
Aortic Regurgitation
(Insufficiency)
Aortic Regurgitation
Etiologies
Primary aortic valve disease
Aortic root abnormalities (Dissection, Syphilis)
Connective tissue disorders (Marfan’s)
Infective endocarditis
Inflammatory disorders (SLE)
Tumors
Aortic Regurgitation
Symptoms
BREATHING – DIFFICULT , NOCTURNAL
BREATHING – DIFFICULT WITH EFFORT
CHEST, ANT – PAIN, NONPLEURITIC (ANGINA)
CHEST, ANT – PALPITATIONS
HEAD, GEN – PAIN
SWEATING – NOCTURNAL
Aortic Regurgitation
Signs
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED
ARTERIAL PULSE, GEN – DOUBLE
ARTERIAL PULSE, GEN – FALL, RAPID
ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE
ARTERIAL PULSE, GEN – RISE, RAPID
ARTERY, CAROTID – THRILL
ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING
Aortic Regurgitation
Signs (cont)
HEAD – BOBBING
HEART, LSB MID – MURMUR, DIASTOLIC
HEART, LSB MID – THRILL, DIASTOLIC
HEART, LV APEX – IMPULSE, INF DISPLACEMENT
HEART, LV APEX – IMPULSE, LAT DISPLACEMENT
HEART, LV APEX – IMPULSE, DIFFUSE
HEART, LV APEX – MURMUR, DIASTOLIC
HEART, RSB UPPER – MURMUR , SYSTOLIC
HEART, RSB UPPER – MURMUR, DIASTOLIC
Aortic Regurgitation
Signs (cont)
HEART, RSB UPPER – THRILL, SYSTOLIC
HEART, SOUND A2 – ABSENT OR REDUCED
HEART, SOUND S1 – SOFT
HEART, SOUND S2 – SPLIT REVERSED
HEART, SOUND S3 LV
MOUTH, UVULA – PULSATIONS
NAILS – PULSATIONS
NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC
Aortic Regurgitation – Chronic
Chest X-Ray
Aortic Regurgitation
Echo
Aortic Regurgitation
Medical Rx
Vasodilators to reduce systolic BP
Antibiotic prophylaxis
Aortic Regurgitation
Surgical Rx
Aortic valve replacement
Mitral Regurgitation
(Insufficiency)
Mitral Regurgitation
Etiologies
Congenital deformities
Degenerative, i.e., myxomatous
Endomyocardial fibroelastosis
Mitral annular calcification
Papillary muscle dysfunction – ischemic heart disease
Rheumatic
Mitral Regurgitation
Etiologies (cont)
Ergotamine toxicity
Carcinoid syndrome
Radiation Rx
SLE
Diet-drug therapy
Mitral Regurgitation
Papillary Muscles
Mitral Regurgitation
Leaflet Prolapse (MVP Syndrome)
Mitral Regurgitation
Calcified Annulus
Mitral Regurgitation
Symptoms
BREATHING – DIFF, EFFORT
FATIGUE
SKIN, GEN – TEMPERATURE, COOL
SWEATING – EXCESSIVE
Mitral Regurgitation
Signs
ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED
ARTERIAL PULSE, GEN - FALL, RAPID
ARTERIAL PULSE, GEN - RISE, RAPID
CHEST, ANT LEFT - BULGE
HEART, LV APEX - IMPULSE, FORCEFUL
HEART, LV APEX - IMPULSE, DIFFUSE
Mitral Regurgitation
Signs (cont)
HEART, LV APEX - IMPULSE, SUSTAINED
HEART, LV APEX - MURMUR, DIASTOLIC
HEART, LV APEX - MURMUR, SYSTOLIC
HEART, SOUND P2 - LOUD
HEART, SOUND S3 LV
SKIN, GEN - TEMPERATURE, COOL
Mitral Regurgitation
2-D Echo
Mitral Regurgitation
Doppler Echo
Mitral Regurgitation
Complications
Atrial fibrillation
Pulmonary hypertension
LV dysfunction
Infective endocarditis
Mitral Regurgitation
Medical Rx
Antibiotic prophylaxis
ACEIs (functional form of MR)
Beta-blockers (functional form of MR)
Mitral Regurgitation
Surgical Rx
Mitral repair
Mitral valve replacement
Mitral Stenosis
Mitral Stenosis
Increased LA Pressure
Mitral Stenosis
Etiologies
Rheumatic
Rare:
Congenital
Chest radiation
Left atrial myxoma
Mucopolysaccharidosis
Severe mitral annular calcification
Mitral Stenosis
Symptoms
ABDOMEN, GEN – PAIN
BREATHING – DIFF, NOCTURNAL
BREATHING – DIFF, EFFORT
BREATHING – DIFF, RECLINING FLAT
BREATHING – DIFF, RESTING
BREATHING – RAPID
CHEST, ANT – PAIN, NONPLEURITIC
CHEST, ANT – PALPITATIONS
COUGH – CHRONIC, NONSPECIFIC
FATIGUE
SPUTUM – BLOODY
Mitral Stenosis
Signs
ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW
ARTERIAL PRESSURE, GEN – LOW
ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW
ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED
BREATH SOUNDS, GEN – WHEEZES
EXTREMITIES, LOWER BILATERAL - EDEMA
HEART RATE – RAPID
HEART, LSB LOWER – IMPULSE, SYSTOLIC
Mitral Stenosis
Signs (cont)
HEART, LSB LOWER – MURMUR, DIASTOLIC
HEART, LSB MID – PERCUSSION, DULLNESS
HEART, LV APEX – MURMUR, DIASTOLIC
HEART, LV APEX – OPENING SNAP, MITRAL
HEART, LV APEX – THRILL, DIASTOLIC
HEART, RSB – SOUND, SYSTOLIC EJECTION
HEART, RSB UPPER – MURMUR, DIASTOLIC
HEART, SOUND P2 – LOUD
Mitral Stenosis
Signs (cont)
HEART, SOUND P2 – PALPABLE
HEART, SOUND S1 – SOFT
HEART, SOUND S1 – LOUD
LIVER – ENLARGED
SKIN, CHEEKS – COLOR, PINK PURPLE
SKIN, GEN – COLOR, BLUE
VENOUS PULSE, JUGULAR - A WAVE, LARGE
VENOUS PULSE, JUGULAR – ELEVATED
Mitral Stenosis
Chest X-ray
Mitral Stenosis
Echo
Mitral Stenosis
LA Thrombus
Mitral Stenosis
ECG
Mitral Stenosis Complications
Atrial fibrillation
Infective Endocarditis
Peripheral embolism
Pulmonary hypertension
Mitral Stenosis
Medical RX
Antibiotic prophylaxis
Anticoagulation for
Atrial fibrillation
Prior embolic event
Documented LA thrombus
Arrhythmia control
Mitral Stenosis
Surgical RX
Invasive valvuloplasty
Percutaneous valvotomy
Valve replacement
Mitral Stenosis
Invasive Valvuloplasty
Mitral Stenosis
Surgical RX – Valvuloplasty with Balloon
Catheter
Valvular Heart Disease
Follow up
Antibiotic prophylaxis
New symptoms
Change in symptoms
Change in physical findings
Echocardiography/other imaging
Thank you!