VALVULA

R HEART
DISEASE
What Is Valvular
Heart Disease?
▶Heart valve disease
occurs when your
heart's valves do not
work the way they
should.
How Do Heart
Valves Work?
MAINTAIN
ONE-WAY BLOOD
FLOW THROUGH
YOUR HEART

▶ The four heart valves

make sure that blood
always flows freely in a
forward direction and
that there is no backward
leakage.
Heart
Valves
ANY DISEASE OF THESE VALVES ARE
CALLED AS VALVULAR HEART
DISEASE!
Types of valve
disease
 Valvular
Stenosis
THE VALVE OPENING NARROWS
 the valve leaflets may become fused or thickened that
the valve cannot open freely 🡲 obstructs the normal
flow of blood

EFFECTS:
the chamber behind the stenotic valve is subject to greater
stress
🡲 must generate more pressure (work hard) to force blood
through
the narrowed opening

 initially, the compensates for the additional

workload by gradual hypertrophy and dilation of the
 Valvular Regurgitation
LEAKAGE OR BACKFLOW OF BLOOD RESULTS
FROM INCOMPLETE CLOSURE OF THE VALVE
 due to:
- Scarring and retraction of valve
leaflets OR
- Weakening of supporting
structures

EFFECTS:
causes the to pump the same blood twice
(as the blood comes back into the chamber)
 the dilates to accommodate
more blood
 ventricular dilation and hypertrophy 🡲
eventually leads to
Principal
Causes
•Valve stenosis •Valve regurgitation

• Congenital • Congenital
• Rheumatic carditis • Rheumatic
• Senile degeneration carditis (acute or
chronic)
• Infective
endocarditis
• Valve ring
dilatation
(e.g. dilated
cardiomyopathy)
• Syphilitic aortitis
• Traumatic valve
rupture
• Damage to chordae and
Valvular Heart
Disease
1. MITRAL STENOSIS
2. MITRAL REGURGITATION
3. AORTIC STENOSIS
4. AORTIC REGURGITATION
5. TRICUSPID STENOSIS
6. TRICUSPID REGURGITATION
7. PULMONARY STENOSIS
8. PULMONARY
REGURGITATION
1. MITRAL STENOSIS
Aetiolog
y
▶ Almost always
rheumatic
in origin

▶ Older people: can

be caused by
heavy calcification
of mitral valve
congestion

▶ Congenital (rare)
Pathophysiology
Normal mitral valve
orifice is 5cm2 in
diastole & may be
reduced to 1cm2 in
severe mitral
stenosis
Pathophysiology
Pathophysiology
Pathophysiology
Pathophysiology
 Pathophysiology

Atrial fibrillation due

to progressive
dilatation of the LA
is very common.
Its onset often
precipitates
pulmonary
oedema

In co ntrast, a more
gradual rise in left
atrial pressure tends to
c a use an increase in
pulmonary vascular
resistance  pulmo. HTN
 RVH, TR RHF
Pathophysiology
Narrowing of mitral
valve

🡱 left Hypertroph 🢛 blood flow

atrial y left to left
pressure atrium ventricle
🡱 pulmonary
🢛 CO
pressure

pulmonary Left ventricular

congestion Fatigue
atrophy

🢛O2/CO2 exchange
(fatigue, dyspnea, Right-sided
orthopnea) failure
Clinical
features
Symptoms
▶ Breathlessness, cough (pulmonary congestion)

▶ C hest pain (pulmonary hypertension)

▶ Hemoptysis (pulmonary congestion or

hypertension)

▶ Fatigue (low cardiac output)

▶ Oedema, ascites (right heart failure)

▶ Palpitation (atrial fibrillation)

▶ Thromboembolic complications
Clinical
features
Signs
▶ Atrial fibrillation
▶ Mitral facies (abnormal flushing of the cheeks that
occurs from cutaneous vasodilation in the setting of
severe mitral valve stenosis)

▶ Auscultation - Loud first heart sound, opening snap

(created by forceful opening of mitral valve)

- Mid-diastolic murmur (apex)

▶ Crepitations, pulmonary edema, effusions
(raised pulmonary capillary pressure)

▶ RV heave, loud P2 (pulmonary

hypertension)
Mitral
stenosis

…Lub
Hoot…
Investigations
▶ ECG: - right ventricular hypertrophy  tall R
waves

▶ Chest x-ray: - enlarged LA & appendage

- signs of pulmonary venous congestion

▶ ECHO: - thickened immobile cusps

- reduced valve area
- enlarged LA
- reduced rate of diastolic filling of LV

▶ Doppler: - pressure gradient across mitral valve

▶ C ardia c c atheterization: - coronary artery disease

- pulmonary artery pressure
- mitral stenosis and
Managemen
t Medicall Surgically
y
▶ Anticoagulant ▶ Mitral balloon
To reduce the risk
valvuloplasty***
of systemic
embolism
▶ Mitral valvotomy

▶ Digoxin, beta
blockers, or rate ▶ Valve replacement
limiting ca lcium
antagonists
To control ventricular rate
in atrial fibrillation

▶ Diuretic
To control pulmonary
congestion
Balloon
mitral
valvuloplast
y
2. MITRAL REGURGITATION
Mitral
regurgitation
Incomplete closure of mitral
valve
Aetiolog
y Rheumatic disease is the principal cause
▶
(in
countries where disease is common)

▶ Mitral valve prolapse

▶ Dilatation of the LV and mitral valve ring

(e.g. coronary artery disease,
cardiomyopathy)

▶ Damage to valve cusps and chordae

(e.g. rheumatic heart disease, endocarditis)

▶ Ischaemia or infarction of papillary

muscle (MI)
Pathophysiology
Pathophysiology
Incomplete closure of
mitral valve

Backflow of blood to
the left atrium

🢛 vol. of blood ejected

🡱 Left atrial pressure
by left ventricle

🢛 CO Left atrial hypertrophy

🡱 Pulmonary pressure

🡱 Right ventricular
Right-sided heart
pressure
failure
Mitral
regurgitation
mitral valve prolapse
▶ A.k.a ‘floppy’ mitral valve

▶ One of the most common

cause of mild mitral
regurgitation

▶ Caused by
▶ congenital anomalies
▶ degenerative
myxomatous changes
▶ feature of connective tissue
disorders like Marfan’s
syndrome
Mitral
regurgitation
mitral valve prolapse
▶ Mildest form:
▶ Valve remains competent but
bulges back into atrium during
systole  mid- systolic click but no
murmur

▶ In the presence of regurgitant

valve:
▶ Click is followed by a late systolic
murmur, which lengthens as the
regurgitation becomes more
severe

▶ Severe form:
▶ Progressive elongation of chordae
Clinical
Manifestations
SYMPTOMS
 Fatigue & weakness – due to 🢛 C O – predominant
complaint

 Exertional dyspnea & cough – pulmonary congestion

 Palpitations – due to atrial fibrillation (occur in 75% of pts.)

 Edema, ascites – Right-sided heart failure

 Clinical

Manifestations
SIGNS
Atrial fibrillation

 Cardiomegally

 Apical pansystolic murmur +/- thrill

 Soft S1, apical S3

 Signs of pulmonary venous congestion (crepitations,

pulmonary edema, effusions)

 Signs of pulmonary hypertension & right heart failure

Mitral
regurgitation

…Hoot
Dub…
Investigations
▶ ECG: - left atrial hypertrophy
- left ventric ular hypertrophy

▶ Chest x-ray: - enlarged LA,LV

- pulmonary venous congestion
- pulmonary oedema

▶ ECHO: - dilated LA,LV

- structural abnormalities of mitral valve (e.g. prolapse)

▶ Doppler: - detects and quantifies regurgitation

▶ Cardia c catheterization: - dilated LA,LV

- mitral regurgitation
- pulmonary hypertension
- coexisting coronary artery
disease
Managemen
t Medicall Surgically To treat
y▶ Vasodilators ▶ Mitral valve repair mitral
(e.g. ACE inhibitors) valve
OR prolapse
▶ Mitral valve
▶ Diuretics replacemen
t

▶ If atrial
fibrillation
presents,
▶
Anticoagulant
▶ Digoxin
3. AORTIC STENOSIS
Aortic Stenosis
Narrowing of the aortic
valve
Aetiology

▶ INFANTS, ▶ MIDDLE-AGED TO
CHILDREN, ELDERLY
ADOLESCENTS • Senile
• C ongenital aortic degenerative
aortic stenosis
stenosis
• • C alcification of
C ongenital bicuspid valve
subvalvular aortic
stenosis • Rheumatic aortic
• C ongenital stenosis
subvalvular aortic
stenosis

▶ YOUNG ADULTS
TO MIDDLE-
AGED
• C alcification and
fibrosis of congenitally
bicuspid aortic valve
Pathophysiology
Pathophysiology
Stiffening/Narrowing of
Aortic Valve

Left ventricular Incomplete emptying

hypertrophy of left atrium

Compression of 🢛 CO
coronary Pulmonary
arteries congestion

🡱 Myoca rdial Right-sided heart

🢛 O2 supply failure
O2 needs

Myoca rdial
ischemia
(chest pain)
Clinical
features
Symptoms
▶ Mild or moderate stenosis: usually
asymptomatic

▶ Exertional dyspnea

▶ Angina (due to demands

CARDINA
of
L
hypertrophied LV) SYMPTOM
S
▶ Exertional syncope
C O fails to
rise
to meet
▶ Sudden death demand

▶ Episodes o acute pulmonary

oedema
Clinical
features
Signs
▶ Ejection systolic murmur

▶ Slow-rising ca rotid pulse

▶ Thrusting apex beat (LV pressure overload)

▶ Narrow pulse pressure

▶ Signs of pulmonary venous congestion (e.g.

crepititions)
Investigations
▶ ECG: - left ventricular hypertrophy
- left bundle branch block

▶ Chest x-ray: - may be normal

- enlarged LV & dilated ascending aorta (PA view)
- calcified valve on lateral view

▶ ECHO: - calcified valve with restricted opening, hypertrophied LV

▶ Doppler: - measurement of severity of stenosis

- detection of associated aortic regurgitation

▶ Cardiac catheterization: - to identify asst. coronary artery

disease
- may be used to measure
Managemen
t Asymptomatic aortic stenosis  kept under review
▶
(as the development of angina,
syncope, symptoms of low C O or
heart failure
has a poor prognosis and is an
indication for prompt surgery)
▶ Moderate/severe stenosis  evaluated every 1-2 years
with Doppler echocardiography (to detect progression in
severity)

▶ Symptomatic severe aortic stenosis  valve

replacement

▶ Congenital aortic stenosis  aortic balloon

valvuloplasty

▶ Atrial fibrillation or post valve replacement

4. AORTIC REGURGITATION
Cause
s
▶ Congenital:
▶ Bicuspid valve or disproportionate cusps

▶ Acquired:
▶ Rheumatic disease
▶ Infective endocarditis
▶ Trauma
▶ Aortic dilatation (marfan’s syndrome,
aneurysm, dissection, syphilis)
Pathophysiology
Pathophysiology
Incomplete closure of
the aortic valve

Backflow of blood to
Left ventricle

Left ventricular 🡱 Left atrial

hypertrophy & pressure
dilation
Left-sided heart Left atrium
failure hypertrophy
(late stage)
🡱 Pulmonary
🢛 CO pressure

🡱 Right
Right-sided heart
ventricular
failure
pressure
Clinical
features
Symptoms
▶ Mild or moderate aortic regurgitation:
▶ Usually asymptomatic (because compensatory ventricular
dilatation&hypertrophy occur)

▶ Awareness of heartbeat, ‘palpitations’

particularly when lying on the left side,
which results from increased in stroke
volume

▶ Severe aortic regurgitation:

▶ Breathlessness
▶ Angina
 Clinical
features
Signs
▶ Pulses: ▶ Other
▶ Large volume or ‘collapsing’ pulse signs:
▶ Displaced,
heaving apex
▶ Low diastolic and increased pulse beat (volume
pressure overload)
▶ Bounding peripheral pulse ▶ Pre-systolic
▶ Capillary pulsation in nail beds: impulse
Quincke’s sign ▶ 4th heart sound
▶ Femoral bruit(‘pistol shot’): Duroziez’s sign ▶ Crepitations
▶ Head nodding with pulse: de Musset’s (pulmonary
▶ Murmurs:
sign venous
congestion)
▶ Early diastolic murmur
▶ Systolic murmur (increased stroke
volume) c haracteristic murmur is best heard
to the left sternum during held
▶ Austin Flint murmur (soft mid- expiration
diastolic)
Investigations
▶ ECG: initially normal,
later left ventricular hypertrophy & T-wave
inversion

▶ Chest x-ray: - cardiac dilatation, maybe aortic

dilatation
- features of left heart failure

▶ ECHO: - dilated LV
- hyperdynamic LV
- fluttering anterior mitral leaflet

▶ Doppler: - detects reflux

▶ C ardia c c atheterization: - dilated LV

- aortic regurgitation
Managemen
t Treatment may be required for underlying
▶
conditions, such as endocarditis or syphilis

▶ Aortic regurgitation with symptoms aortic valve

replacement (may be combined with aortic
root replacement and coronary bypass
surgery)

▶ Asymptomatic patients  annually follow up

with echocardiography for evidence of
increasing ventricular size

▶ Systolic BP should be controlled with vasodilating

drugs, such as nifedipine or ACE inhibitors
5. TRICUSPID STENOSIS
Tricuspid
Stenosis
▶ usually occurs together with aortic or
mitral stenosis

▶ may be due to rheumatic heart disease

(<5%)

▶ 🢛 blood flow from right atrium to right

ventricle
⮡ 🢛 right ventricular output
⮡ 🢛 left ventricular filling 🡲 🢛
co
Tricuspid
Stenosis
Symptoms Sign
▶ symptoms of right- s
▶ Raised JVP
sided heart failure
- hepatomegaly
▶ Mid-diastolic murmur
- ascites (best heard at lower left
or right sternal edge)
- peripheral edema
- neck vein
engorgement

▶ 🢛 co – fatigue,
hypotension
Tricuspid
Stenosis
Management

▶ Valve replacement
▶ Valvotomy
▶ Balloon
valvuloplasty
6. TRICUSPID REGURGITATION
Tricuspid Regurgitation
 common, and is most frequently ‘functional’ as
a result of enlargement of right ventricle

 an insufficient tricuspid valve allows blood to flow

back into the right atrium 🡲 venous congestion
& 🢛 right ventricular output 🡲
🢛 blood flow towards the lungs
Tricuspid Regurgitation

causes
primar secondary
▶y Rheumatic heart disease ▶ Right ventricular
dilatation due to
chronic left heart
▶ Endocarditis, failure (‘functional
particularly tricuspid regurgitation’)
in injection drug-users

▶ Right ventricular
▶ Ebstein’s congenital infarction
anomaly
▶ Pulmonary
hypertension (e.g.
cor pulmonale)
Tricuspid
Regurgitation
Symptoms Sign
▶ Usually non-specific s
▶ Raised JVP

▶ Tiredness (reduced ▶ Pansystolic murmur (left

forward flow) sternal edge)

▶ Oedema ▶ Pulsatile liver

▶ Hepatic
enlargement
(venous
congestion)
Tricuspid
Regurgitation
Management

▶ Correction of the cause of right ventricular

overload (if TR is due to right ventricular
dilatation)
▶ Use of diuretic and vasodilator treatment of CCF

▶ Valve repair
▶ Valve replacement
7. PULMONARY STENOSIS
Pulmonary
Stenosis
Symptoms Sign
▶ Fatigue, dyspnea s Ejection systolic
▶ murmur
(loudest at the left upper
on exertion, sternum & radiating
cyanosis towards the left shoulder)

▶ Murmur often preceded

▶ Poor weight gain or by an ejection sound
(click)
failure to thrive in
infants
▶ May be wide splitting of
second heart sound (delay
in ventricular ejection
▶ Hepatomegaly,
ascites, edema ▶ May be a thrill (best felt
when patient leans forward
and breathes out)
Investigations
▶ ECG: - right ventricular hypertrophy

▶ Chest x-ray: - post-stenotic dilatation in the pulmonary

artery

▶ Doppler echocardiography is the definitive

investigation
Managemen
t Mild to modearate isolated pulmonary stenosis is
▶
relatively common and does not usually progress
or require treatment

▶ Severe pulmonary stenosis  percutaneous

pulmonary
balloon valvuloplasty
OR
surgical valvotomy
8. PULMONARY
REGURGITATION
Pulmonary
Regurgitation
 A rare condition

 Usually associated with pulmonary hypertension

which may be
• Secondary of the disease of left side of the heart
• Primary pulmonary vascular disease
• Eisenmenger’s syndrome

 Blood flows back into right ventricle 🡲 right

ventricle and atrium hypertrophy 🡲 symptoms of
right-sided heart failure

 Trivial PR is a frequent finding in normal individuals

and has
no clinical significance
Referenc
e

▶ For videos of
heart murmurs:
https://www.youtu
be.com/playlist?list
=PLB7F86984222A1
F
7C
▶THANK YOU