valvular heart lesions
Post on 07-May-2015
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A S Y N O P S I S
VALVULAR HEART LESIONS
MITRAL STENOSIS (MS)
• Normal 4-6 cm2
• Stenosis <4 cm2
• Symptoms <2 cm2
• Severe stenosis <1 cm2
• Causes:-• Rheumatic heart disease• Calcification• Congenital• Lutembacher’s syndrome (acquired MS+ASD)• Carcinoid tumour metastases
MS
• Pathophysiology:-• LA outlet obstruction• LA pressure ↑, LA dilatation• LV filling ↓, dependent on LA contraction
• Symptoms:-• ↑ing DoE, haemoptysis, cough, chest pain(Pulm cong,
PAH)• Fatigue, pedal edema, ascites (Rt sided HF)• Palpitation (AF)• Systemic embolism:- CVA, Renal, Mesenteric, Peripheral
ischaemia
MS EXAMINATION
• Signs:-• Malar flush (AV anastamoses, venous stasis)• JVP ↑ (RVH, TR, PAH)• Pulse – SR, low volume, AF• Apex – localized tapping• RV – heaving, sustained (PAH, RVH)• Loud palpable S1, opening snap, loud P2 (PAH)• Mid-diastolic, rough, rumbling apical murmur +
presystolic accentuation• Graham Steele – EDM (func PR)
MS INVESTIGATIONS
• CXR:-• Enlarged LA• PVH, PAH, pulm edema• Calcified mitral valve
• ECG:-• Bifid P (P mitrale)• RVH – RAD, tall R V1
• ECHO:-• Mitral valve – area, severity, calcific, mobility• PR, TR• Atria – size, LA thrombus• Ventricles – size, function
• CAG – prior to MVR
MS TREATMENT
• Diuretics (HF)• Digoxin, β-blocker, CCB, anticoag (AF)• Rheumatic fever prophylaxis• IE prophylaxis• Surgery – medical fails/not feasible• Trans-septal balloon valvotomy• Closed valvotomy• Open valvotomy• MVR
MITRAL REGURGITATION (MR)
• Abnormality of:-• Valve leaflets• Valve annulus• Chordae tendinae• Papillary muscles• Left ventricle
• Pathophysiology:-• Part of stroke vol back to LA• LA overload• CO ↓
MR
• Acute:-• Large vol back to LA, acute LA press ↑• PVH, pulm edema• Next LV enlarges, maintain stroke vol & CO
• Chronic:-• LA dilates, LA press N/slight ↑• Less PVH & pulm edema
MR CAUSES
• Myxomatous valvular degeneration• Ischaemic HD• Rheumatic HD• Infective endocarditis• DCM, HCM• Autoimmune – SLE• Collagen vascular – Marfan’s, Ehler Danlos• Congenital – 1o ASD• Drugs – Fenfluramine, cabergoline
MR SYMPTOMATOLOGY
• Slow progress – No symp for years• Sense forceful heartbeat - ↑ stroke volume• Fatigue, lethargy, cardiac cachexia - ↓ CO• Dyspnoea, orthopnoea –PVH, a/c pulm edema• Later – dyspnoea, ascites, pedal edema, ↑ JVP,
palpitation (RVH, PAH, AF)• Sub a/c IE – PUO
MR EXAMINATION
• Pulse:-• AF• SR, N/low volume
• Apex:-• Forceful• Systolic thrill
• Auscultation:-• S1 soft, S3+• Apical PSM. Radiating to axilla
• JVP ↑ if RV failure
MR INVESTIGATION
• CXR:-• Cardiomegaly, LA & LV enlarged, valve calcific
• ECG:-• AF, SR, bifid P mitrale, LVH
• ECHO:-• LA & LV dilated• Valve leaflet motion• Papillary muscle anatomy & function• Regurg jet direction, severity
MR TREATMENT
• Mild MR – asymp – conservative• Vasodilators - ↓ pre & afterload• Diuretics – HF• Anticoag, antiarrhythmics – AF• β blockers – atrial arrhythmia• ICD – vent arrhythmia• Endocarditis prophylaxis• Symptomatic = Sx (prevent LVD)• MV repair – Sx, clip• MV replacement
BARLOW’S SYNDROME (MVP)
• Pathophysiology:-• Large leaflet/ annulus• Long chordae• Papillary muscle dysfunction
• Seen max in young females• Associations:-• Marfan’s• Thyrotoxicosis• RHD, IHD, ASD, HCM
• Findings – early systolic click, PSM +/-
AORTIC STENOSIS (AS)
• LV outflow obstruction
• Causes:-• Calcific degeneration – elderly, male, DM, HTN, DLP• Congenital bicuspid vlave• Rheumatic HD• Misc –• CKD• Paget’s of bone• Radiation• Familial hypercholesterolemia
AS PATHOPHYSIOLOGY
• LV emptying obstructed• LV pressures ↑• LV hypertrophy (press overload)• LV ischaemia – angina, arrhythmia, HF• Exertion –• CO rises very little• Worsens angina and fatigue• Syncope/presyncope
• Later LA press ↑, PVH = dyspnoea
AS SYMPTOMS
• When AV area <⅓ normal• Exertional symptoms• Angina = 4 years• Syncope = 3 years• Dyspnoea = 2 years• Heart failure = 1.5 years• Cachexia, fatigue = end-stage
AS EXAMINATION
• Pulse – SR, low vol, slow rising (parvus et tardus)• Apex – undisplaced, heaving• Aortic area – systolic thrill• Auscultation:-• Ejection click• Soft A2, reversed split +/-• S4• Systolic, low pitched, ejection (crescendo-decrescendo)
murmur – aortic area, radiating to carotids
AS INVESTIGATION
• CXR:-• Cardiac size N, HF = cardiomegaly• AV calcification• Dilated ascending aorta
• ECG:-• SR, Vent arrhythmia• LVH + strain = ST ↓, T ↓, Left leads
• ECHO:-• AV area, calcific, jet velocity, severity• LVH, dysfunction• Aorta dilatation
• MRI/CT:-• Aortic aneurysm, dilatation, coarcation
AS TREATMENT
• Asymptomatic:-• Regular follow-up ECHO
• IE prophylaxis• Valvotomy:-• Buys time, improves LV temporarily• Childhood, adolescents mainly
• Surgery:-• Symptomatic• Aorta gross/rapidly progressing dilatation• AV replacement – open, percutaneous
AORTIC REGURGITATION (AR)
• Pathophysology:-• Blood ejected into aorta in systole• Leaks back into LV in diastole• DBP ↓• LV volume overload• ↑ Stroke vol to maintain effective CO• LV dilatation, later dysfunction
AR CAUSES
• Acute:-• Rheumatic fever• Infective endocarditis• Aortic dissection• Rupture sinus of valslva• Prosthetic valve failure
• Chronic:-• Rheumatic heart disease, syphilis, HTN• Bicuspid valve, valve calcification, subvalvular VSD• Arthritides – reactive, ankylosing spondylitis, rheumatoid• Marfan’s, osteogenesis imperfecta
AR SYMPTOMS
• Late in disease, when LV fails• Pounding of heart• ↑ Stroke volume & force of contraction
• Angina• DoE• Arrhythmias +/-
AR EXAMINATION
• Pulse:-• SR, large vol, collapsing• Water hammer/Corrigan’s pulse
• BP:-• SBP ↑, DBP ↓• Wide pulse pressure
• Apex:- Displaced down & out (LV dilatation)
• Sounds:-• High pitched EDM at Lt sternal border• ESM at aortic area, radiating to carotids• MDM at apex (Austin-Flint)
AR PERIPHERAL SIGNS
• Light-house – Flushing & blanching forehead• Landolfi’s – Pupillary size alternation• Becker’s – Retinal artery pulsation• De Musset’s – Head nodding• Muller’s – Uvula pulsation• Corrigan’s – Dancing carotids• Quincke’s – Capillary pulsation in nails• Locomotor brachii• Rosenbach’s – Liver pulsations• Gerhardt’s – Spleen pulsations• Traube’s – Pistol shot sounds over femorals• Duroziez’s – Systolic & diastolic murmurs over femorals• Hill’s – SBP popliteal>brachial
AR INVESTIGATIONS
• CXR:-• LVH• Ascending aorta dilatation & calcification• AV calcific
• ECG:- LVH• Tall R & deep T ↓ in left side leads• Deep S right side leads
• ECHO:-• Dilated aortic arch• LV – dilatation, dysfunction• Severity of AR• TEE – Aortic valve & aortic root
• MRI & CT – Assess thoracic aorta & root
AR TREATMENT
• Rx for specific cause• A/c AR – vasodilators, inotropes• LV dysfunction – ACEi• Surgery:-• Before LVD sets in – not completely reversible• Before significant symptoms develop• A/c severe AR• Symptomatic c/c severe AR• LVD present• LV dilatation present• Along with other cardiac Sx
TRICUSPID STENOSIS (TS)
• Uncommon• Women > men• Associated mitral & aortic valve disease• Causes:-• RHD• Carcinoid
• Pathophysiology:-• RA emptying impaired, CO ↓• RA press ↑• Venous congestion (↑JVP, hepatomeg, ascites, pedal
edema)
TS
• Symptoms:-• Abd pain + swelling• Pedal edema• Left sided failure symptoms
• Signs:-• ↑ JVP, pedal edema• Pulsatile liver, hepatomegaly• Rumbling MDM @ lower LSE, louder on inspiration• Tricuspid OS
TS INVESTIGATIONS
• CXR:-• Prominent right atrial bulge
• ECG:-• Peaked, tall P waves (>3 mm) in lead II (RAE)
• ECHO:-• Thickened & immobile tricuspid valve
TS TREATMENT
• Medical:-• Diuretic therapy• Salt restriction
• Surgical:-• Tricuspid valvotomy• Tricuspid valve replacement is often necessary• Other valves usually also need replacement
TRICUSPID REGURGITATION (TR)
• RA pressure overload
• Causes:-• Functional-• RV dilatation• Cor pulmonale, MI, pulmonary HTN
• Organic-• RHD• IE• Carcinoid syndrome • Congenital - Ebstein’s anomaly
TR
• Symptoms:-• Right heart failure
• Signs:-• Large jugular venous c & v waves• Hepatomegaly + pulsates in systole• Lt parasternal heave (RVH)• Blowing PSM @ LSE, best heard on inspiration • AF common
• ECHO:-• Dilated RV• Thickened tricuspid valve
TR TREATMENT
• Functional – Medical Rx
• Severe organic:-• TV repair – plasty, plication• TV replacement
PULMONARY STENOSIS (PS)
• Causes:-• Congenital – most common (isolated, ToF)• RHD• Carcinoid
• Pathophysiology:-• RV press overload• RVH, then RAH• Rt heart failure
PS
• Symptoms:-• Mild – asymptomatic• Moderate – fatigue, syncope, dyspnoea +/-• Severe – incompatible
• Signs:-• JVP – prominent a wave• Lt parasternal heave• Delayed, soft P2 + pulmonary ejection click• Harsh midsystolic ejection murmur @ 2nd Lt ICS, best
heard on inspiration, thrill +• RV S4
PS
• Investigations:-• CXR:-• Prominent pulmonary artery
• ECG:-• RAH – Tall P right leads• RVH – Tall R right leads
• ECHO:-• Doppler – stenotic flow• RVH• RA hypertrophy/enlargement
• Treatment:-• Pulmonary valvotomy (balloon,direct surgery)
PULMONARY REGURGITATION (PR)
• Most common acquired pulm valve defect• Pulm HTN most common cause (annular
dilatation)• Decrescendo diastolic murmur• No symptoms• Treatment rarely needed
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