Valvular Disease

Cindy Chan, MD

Normal heart

Disease of Aortic Valve

Aortic Stenosis (AS)

Etiology of ASEtiology of AS• Congenital (bicuspid)Congenital (bicuspid)

• RheumaticRheumatic

• “ “Senile” calcificSenile” calcific

Aortic StenosisAortic Stenosis

DiastoleDiastole SystoleSystole

RheumaticRheumatic SenileSenileCalcificCalcific

CongenitalCongenitalBicuspidBicuspid

Aortic StenosisAortic Stenosis

Rheumatic

BicuspidBicuspid

FishFishmouthmouth

““Senile” calcificationSenile” calcification

• < < age 65 = age 65 = congenitalcongenital

• >age 65 = >age 65 = “senile” calcific“senile” calcific

AortaAorta

LVLV120 mmHg120 mmHg

120 mmHg120 mmHg

NORMALNORMAL

AortaAorta

LVLV220 mmHg220 mmHg

120 mmHg120 mmHg

STENOSISSTENOSIS

AortaAorta

PressurePressure

What is the effect of increased pressure What is the effect of increased pressure on the LV?on the LV?

220 mmHg220 mmHg

AortaAorta

LVLV

LeftLeftventricular ventricular hypertrophyhypertrophy

LVHLVH( increased stiffness)( increased stiffness)

LV end-diastolicLV end-diastolic pressurepressure

CHFCHF

DemandsDemands

AnginaAngina

SystolicSystolicPressure loadPressure load

Clinical TriadClinical Triad of Aortic Stenosisof Aortic Stenosis

Heart FailureHeart Failure

AnginaAngina

SyncopeSyncope

SyncopeSyncopeInability to increase cardiacInability to increase cardiac output with exerciseoutput with exercise

Ventricular arrhythmiasVentricular arrhythmias

Aortic StenosisAortic StenosisNatural HistoryNatural History

Per

cen

t su

rviv

alP

erce

nt

surv

ival

Age

100

90

80

70

60

5050

Latent PeriodLatent Period

OnsetOnsetSevere SymptomsSevere Symptoms

40 50 60 7040 50 60 70

AverageAverageDeathDeath3-4 Years3-4 Years

Aortic StenosisNatural History

00 11 2 2 3 3 4 4 55

AnginaAngina

FailureFailureSyncopeSyncope

Per

cen

t su

rviv

alP

erce

nt

surv

ival

100100

9090

8080

7070

6060

5050

Physical findings of ASPhysical findings of AS• MurmurMurmur• SoundsSounds• CarotidCarotid• ApexApex

S1 S2

LV = Ao NormalNormalAoAo

LALA

S1 S2

Aortic Aortic StenosisStenosis

LV

Ao

LALA

Stenosis is a pressure gradient across a valve

LV

Ao

AorticAorticStenosisStenosis

S2S1

Crescendo-Crescendo-decrescendodecrescendo

Murmur mustMurmur mustbe crescendo-decrescendobe crescendo-decrescendoin timingin timing

Aortic Stenosis

• Timing =Timing = SystoleSystole

• Frequency = HighFrequency = High

• Location = R or L SBLocation = R or L SB

• Position = Leaning forwardPosition = Leaning forward

Ejection clickEjection clickEarly systolic soundEarly systolic sound

suggests bicuspid valvesuggests bicuspid valve

LV

Ao

AorticAorticStenosisStenosis

Crescendo-Crescendo-decrescendodecrescendo

S2

S1

EjectionEjectionClickClick

Carotid artery pulsationCarotid artery pulsation

NormalNormal AbnormalAbnormal “Pulsus parvus et tardus”Pulsus parvus et tardus”

This is a clue to help determine AORTIC STENOSISThis is a clue to help determine AORTIC STENOSIS

Summary of Physical FindingsSummary of Physical Findings

• Harsh crescendo - decrescendo murmur Harsh crescendo - decrescendo murmur

(often radiating into the neck)(often radiating into the neck)

• Ejection click (if pliable)Ejection click (if pliable)

• Carotid - pulsus parvus et tardusCarotid - pulsus parvus et tardus• Apical impulse - S4Apical impulse - S4

Opening snap, early ejection systolic

S4 (atrial gallop)S4 (atrial gallop) Forceful left atrial contractionForceful left atrial contraction

May feel at apexMay feel at apex

DI ASTOLIC ABNORMALITY OF LVDI ASTOLIC ABNORMALITY OF LV

( LV compliance)( LV compliance)

S4 (atrial gallop)

DIASTOLIC ABNORMALITY OF LVDIASTOLIC ABNORMALITY OF LV Apical impulseApical impulse

NORMALNORMAL

S1S1 S2S2 S1S1 S2S2S4S4

ABNORMALABNORMAL

S4S4

S4

Laboratory testsLaboratory testsin Aortic Stenosisin Aortic Stenosis

• Chest x-rayChest x-ray - - LV prominenceLV prominence

• EKG - LVHEKG - LVH• Echocardiogram -Echocardiogram -EtiologyEtiology

SeveritySeverity

LV size & functionLV size & function

EchocardiogramEchocardiogram

Major diagnostic testMajor diagnostic test

Echocardiogram in ASEchocardiogram in AS AnatomyAnatomy• Detect calcificationDetect calcification

• Evaluate opening of valveEvaluate opening of valve

PhysiologyPhysiology• Quantitative obstructive gradientQuantitative obstructive gradient

• Allow calculation of valve areaAllow calculation of valve area

The use ofThe use ofDoppler EchoDoppler Echo

VelocityVelocity

5 M /sec5 M /sec

AortaAorta

LVLV220 mmHg220 mmHg

120 mmHg120 mmHg

GradientGradient

Doppler Echo in Aortic Stenosis

Pressure Gradient:Pressure Gradient:

Pressure = 4 x VelocityPressure = 4 x Velocity

Example:Example: Velocity = 5 Meters/ secVelocity = 5 Meters/ sec

Pressure Gradient= 4 x 5 x 5 = 100 mmHgPressure Gradient= 4 x 5 x 5 = 100 mmHg

2

Continuity Equation

Velocity X Area = Velocity X AreaLVOT Aortic Valve

= = 5 M/sec5 M/sec1.0 M/sec x 5 cm1.0 M/sec x 5 cm22

? Aortic valve area = 1.0 cm 22x x ??

Aortic ValveAortic Valve AreaArea

Normal 3 .0 cm2Normal 3 .0 cm2Mild AS 1.5 - 2.0Mild AS 1.5 - 2.0Moderate AS 1.0 - 1.5Moderate AS 1.0 - 1.5Severe AS <1.0Severe AS <1.0

Catheterizationifif

Non-invasive tests are equivocalNon-invasive tests are equivocal

Age > 50 (to detect CAD)Age > 50 (to detect CAD)

Catheterization in A.S.

S1 S2 S1

Left Ventricle to Aorta Left Ventricle to Aorta Pressure GradientPressure Gradient

LV

Ao

220 m220 mmHg

120 120 mm Hg

Antibiotic prophylaxisAntibiotic prophylaxis• Dental, GI or GU proceduresDental, GI or GU procedures

• AmoxicillinAmoxicillin

Indications for SurgeryIndications for Surgery

=

SymptomsSymptoms+

Critical stenosisCritical stenosisGradient > 50mmHgGradient > 50mmHg

AorticAortic valve area < 0.8 cm2valve area < 0.8 cm2oror

Prosthetic valvesProsthetic valves MechanicalMechanical Ball valve Ball valve

Tilting diskTilting disk

Bileaflet (St.Jude)Bileaflet (St.Jude)

TissueTissue PorcinePorcine

HomograftHomograft

Tissue valveTissue valve

Starr- EdwardsStarr- Edwards

““Ball inBall in a cage”a cage”

MechanicalMechanical

Tissue

AdvantagesAdvantages DisadvantagesDisadvantages

MechanicalMechanical Long lastingLong lasting Need anticoagulationNeed anticoagulation

TissueTissue No anticoagulation DegeneratesNo anticoagulation Degenerates

Ross procedureRoss procedure

Aortic position = Aortic position = Pulmonic autograftPulmonic autograftPulmonic position = Pulmonic position = Pulmonic homograftPulmonic homograft

Complications of Prosthetic heart valves

• ThromboembolismThromboembolism• Bleeding Bleeding 22 to anticoagulation to anticoagulation• Prosthetic valve dysfunctionProsthetic valve dysfunction• Periprosthetic regurgitationPeriprosthetic regurgitation• EndocarditisEndocarditis Serious - 5%/yr Death - 1-2%/yrSerious - 5%/yr Death - 1-2%/yr

oo

Aortic Aortic RegurgitationRegurgitation

Abnormalities of valve leafletsAbnormalities of valve leaflets CongenitalCongenital RheumaticRheumatic EndocarditisEndocarditisAbnormalities of aortic rootAbnormalities of aortic root Aortic dissectionAortic dissection Marfan’s syndromeMarfan’s syndrome SyphilisSyphilis

AortaAorta

In diastole, aortic valve is not In diastole, aortic valve is not competent to hold up pressurecompetent to hold up pressure or volumeor volume

DiastolicDiastolic Volume load Volume load

LV dilatationLV dilatationLV end-diastolicLV end-diastolic pressurepressure

CHFCHF

DemandsDemands

Rarely,anginaRarely,angina

ASAS = = Pressure overloadPressure overload = =

LV HLV Hypertrophyypertrophy

ARAR = = Volume overloadVolume overload = = LV DilatationLV Dilatation

SystolicSystolic

DiastolicDiastolic

AortaAorta

In diastole, aortic valve is not In diastole, aortic valve is not competent to hold up pressurecompetent to hold up pressure or volumeor volume

Low diastolic pressure = incompetent valveLow diastolic pressure = incompetent valve

High systolic pressure = large stroke volumeHigh systolic pressure = large stroke volume

Therefore, wide pulse pressureTherefore, wide pulse pressure

i.e. 200 / 40 mmHgi.e. 200 / 40 mmHg

Physical findings of ARPhysical findings of AR• Wide pulse pressure 200/40Wide pulse pressure 200/40

• CardiomegalyCardiomegaly

• MurmurMurmur

• Peripheral findings ofPeripheral findings of

wide pulse pressurewide pulse pressure

Aortic Regurgitation

Early diastolicEarly diastolic high-pitchedhigh-pitched blowing murmurblowing murmur

LVLV

AoAo

LALA

S1S1 S2S2

Aortic Regurgitation

• Timing =Timing = Early DiastoleEarly Diastole

• Frequency = HighFrequency = High• Location = R or L SBLocation = R or L SB• Position = Position = Leaning forwardLeaning forward

“Wide pulse pressure” Wide pulse pressure” signssigns

• Head bob (deMusset’s)Head bob (deMusset’s)

• Uvula (Muller’s)Uvula (Muller’s)

• Finger capillaries (Quincke’s)Finger capillaries (Quincke’s)

• Brachial (Waterhammer)Brachial (Waterhammer)

• Femoral to & fro (Duroziez’s)Femoral to & fro (Duroziez’s)• Carotid double beating Carotid double beating (pulsus bisferiens)(pulsus bisferiens)

Aortic Regurgitation

• Treatment– Acute – surgery– Chronic – afterload reduction with ACE-I– Surgery if:

• Symptomatic• LV dysfunction (EF <55% or LV end-systolic dimension >5.0

cm)• Aortic root diameter >4.5cm in Marfan or >5.0 in non-Marfan

pt (avoid rapid expansion)– Often requires aortic root repair– No percutaneous approaches (unlike AS)

Acute Acute Aortic RegurgitationAortic Regurgitation

Severe acuteSevere acute ARAR

Surgical emergencySurgical emergency

Infective endocarditisInfective endocarditis

AcuteAcute versusversusChronicChronic

CHRONIC

AortaAortaAortaAorta

ACUTE

LVLVLVLV

LALA

Massivepulmonary edema

Small stiff LVSmall stiff LV

Acute vs ChronicAcute vs Chronic

Cardiomegaly No YesCardiomegaly No Yes

Wide pulse No YesWide pulse No Yes pressurepressure

Natural HistoryNatural HistoryAR AR 10 year survival10 year survival

Mild >90%Mild >90% Severe ~50%Severe ~50%

Heart failure 90% Heart failure 90% <2 yrs<2 yrs

Follow-upFollow-up• Regular clinical evaluationRegular clinical evaluation

• Periodic assessment of Periodic assessment of

LV functionLV function

• Antibiotic prophylaxisAntibiotic prophylaxis

• Medical rx - diureticsMedical rx - diuretics

afterload-lowering afterload-lowering

BREAK

Disease of Mitral Valve

Cindy Chan, MD

Mitral Stenosis

Normal Anatomy

Mitral Stenosis

Atrial fibrillation Atrial fibrillation 50-80%50-80%

Mitral Stenosis

If mild-mod MS (valve area 1.8 cm2 – 1.3 cm2), asymptomatic or DOE

If severe MS (valve area < 1.0 cm2), pulm HTN, low CO, right HF

Mitral Stenosis

S1 S2

LV

LA

OSOS

Mid-diastolic Rumble

Pre-systolic accentuation

Mitral Stenosis

Timing = Mid DiastoleFrequency = LowLocation = ApexPosition = Left lateral decubitus

Mid diastolic murmur

Blood Stasis in the Left AtriumTransesophageal Echo

Left Atrial Appendage ClotTransesophageal Echo

Mitral Stenosis

• Treatment– If total valve score 8 or less, ballon

valvuloplasty– If >8 or with combined stenosis & regurg,

valve replacement

Valve score

• 1-4 points for– Mitral leaflet thickening– Mitral leafley mobility– Submitral scarring– Commissural calcium

Mitral Regurgitation

Mitral Valve Regurgitation

If acute, pulm edemaIf acute, pulm edema

Atrial fibrillationAtrial fibrillation

Mitral Regurgitation

LALA

LV

S1S1 S2Systole S1Murmur should beholosystolic

Mitral Regurgitation

Timing = Pan SystolicFrequency = HighLocation = ApexPosition = L lateral decubitusRadiation = Axilla

Holosystolic murmur

S3 (Ventricular gallopS3 (Ventricular gallop sound)sound)

• Timing- Early diastolicTiming- Early diastolic

• Frequency- LowFrequency- Low

• Rarely palpableRarely palpable

S3

Diagnosis

• EKG: there may be left atrial enlargement with chronic MR, atrial fibrillation or normal sinus rhythm

• Echo: accurate, non-invasive technique to assess cardiac chamber and valve anatomy and function. The etiology of MR may be diagnosed (i.e., ruptured chordae, valve prolapse, ischemia inducing a wall motion abnormality to name a few). Doppler echo detects the regurgitant flow and allows estimates of its severity.

• Cardiac catheterization: this allows for hemodynamic evaluation of the cardiac chambers and valves as well as determine the presence of coronary disease. Cardiac catheterization is done particularly when surgery is contemplated.

Mitral Regurgitation

• Treatment– Acute – emergent surgery– Chronic – surgery if symptomatic, EF <60%, or

LV end-systolic diameter >4.5 cm

Mitral Valve Prolapse

Mitral Valve Prolapse

• Epi– Found in up to 10% healthy young women (most

commonly female)– Associated with collagen diseases (Marfan’s, Ehlers-

Danlos)– Associated with skeletal deformities (pectus excavatum

or scoliosis)• S/S

– Usually asymptomatic– Mid-systolic clicks (with late systolic murmur if

leaflets fail to come together)– CP, dyspnea, fatigue, palpitations

Myxomatous Mitral Valve with Mitral Valve Prolapse

Diagnosis

• EKG: usually normal• Echo: There are specific echo criteria that define

mitral valve prolapse. The echo demonstrates the myxomatous nature and redundancy of the valve structure. It reveals the prolapsing motion of the valve in real-time. Doppler echo demonstrates associated mitral regurgitation. This along with clinical features makes the diagnosis of this disorder

Mitral Valve Prolapse

• Treatment– BB to tx hyperadrenergic state– Valve repair favored over replacement– Include shortening of chordae, chordae trasfers,

wedge resection of redundant valve tissue, mitral annular ring

Other valvular diseases…

Tricuspid Stenosis

• Etiology– Rheumatic– Carcinoid syndrome

• S/S– Diastolic rumble at lower left sternal border,

opening snap, large a wave– R heart failure (hepatomegaly, ascites,

dependent edema)

Tricuspid Stenosis

• Dx– Echo

• Tx– Valvuloplasty ineffective (often with residual

TR)– Replacement (severe when mean diatolic

pressure gradient >5 mmHg

Tricuspid Regurgitation

• Etiology– RV dilatation from any cause (pulm HTN, severe

PR, cardiomypathy, MI, L heart failure, Ebstein anomaly)

• S/S– Holosystolic murmur at LSB, increases with

inspiration, c-v wave in jugular venous pulsations, S3

– RV failure

Tricuspid Regurgitation

• Dx– Echo

• Tx– Diuretics– Tx L HF, pulm HTN– If surgery for other reasons, tripcuspid

annuloplasty

Pulmonic Stenosis

• Etiology– Often assoc with other cardiac lesions– Often with domed or dysplastic valve (eg Noonan syndrome)– Increased resistance to RV outflow, then elevated RV pressure, the

limited pulm blood flow

• S/S– Asympotmatic if mild (PV-PA peak gradient < 30 mmHg)– Moderate (30-50) to severe (>50) experience DOE, CP, syncope,

and RV failure– Loud, harsh systolic murmur, radiates to L shoulder, increases

with inspiration, ejection click (which decreases with inspiration), parasternal lift (from RVH), thrill, S4, prominent a wave

Pulmonic Stenosis

• Dx– Echo

• Tx– Percutaneous balloon valvuloplasty if

symptomatic or resting peak gradient >50 mmHg

Pulmonic Regurgitation

• Classification– High-pressure causes (pulm HTN)– Low-pressure causes (dilated pulm annulus,

carcinoid plaque, post-surgical repair)

• S/S– Diastolic murmur, widely split S2, S3

Pulmonic Regurgitation

• Dx– Echo

• Tx– Primary cause

One more thing about valve replacement…

• Bioprosthetic valves – life expectancy 10-15 years (less for younger pts & pts on HD)– No anticoagulation

• Mechanical valves – longer life expectancy– Mitral: INR 2.5-3.5 (greater risk of

thrombosis)– Aortic: INR 2.0-2.5

Some physical exam skills….

Description of Murmur

a. Loudness

b. Pitch

c. Timing

d. Location - Radiation

Description of MurmurDescription of Murmur

Loudness: GRADELoudness: GRADE

II IIIIIIIIIIIVIV VVVIVI

Soft - not heard initiallySoft - not heard initiallySoft- heard initiallySoft- heard initiallyLoudLoudLoud with thrill - feltLoud with thrill - feltLoud with one edge Loud with one edge Loud- without stethLoud- without steth

Ph

ysio

logi

cP

hys

iolo

gic

Ab

nor

mal

Ab

nor

mal

LocationLocationPulmonicPulmonic

MitralTricuspidTricuspid

AorticAortic

How do you tell

systole from diastole?

Wiggers DiagramWiggers Diagram

S1S1 S2S2SystoleSystole S1S1DiastoleDiastole

LubbLubb DupDup

AoAo

LVLV

LALA

S2SystoleSystoleS1S1 S1S1 DiastoleDiastole

NormalNormal

SystoleSystoleS1S1 S2 S1S1DiastoleDiastole

TachycardiaTachycardia

QRS of EKGQRS of EKG

Carotid upstrokeCarotid upstroke

Apical impulseApical impulse

Heart soundsHeart soundsS1S1 S2S2SystoleSystole

Must first tell systole from diastoleMust first tell systole from diastole

TIMING OFTIMING OF MURMURSMURMURS

• SYSTOLICSYSTOLICMitral RegurgitationMitral RegurgitationTricuspid RegurgTricuspid Regurg Aortic StenosisAortic StenosisPulmonic StenosisPulmonic StenosisASDASDVSDVSDHOCM (IHSS)HOCM (IHSS)Flow (innocentFlow (innocent))

• DIASTOLIC

Mitral StenosisMitral Stenosis

Tricuspid StenosisTricuspid Stenosis

Aortic RegurgitationAortic Regurgitation

Pulmonic Regurg Pulmonic Regurg

S2S2

LVLV

AoAo

LALA

OS S3S3S1S1 S4S4 S1S1

Diastolic soundsDiastolic sounds

LOW FREQUENCYLOW FREQUENCY

S3S3

S4S4 The murmur of Mitral StenosisThe murmur of Mitral Stenosis

BellBell

S1S1 S2S2SystoleSystole S1S1DiastoleDiastole

LubbLubb DupDup

S1S1 S2S2SystoleSystole S1S1DiastoleDiastole

LubbLubb DupDup

S4S4 S3S3

LOW FREQUENCYLOW FREQUENCY

S3S3

S4S4

TimingTiming LocationLocation

EARLYEARLY DIASTOLEDIASTOLE

LATELATE DIASTOLEDIASTOLE

APEXAPEX

APEXAPEX

S4S4

S4S4,S1... S2,S1... S2

““aa Stiff….Wall” Stiff….Wall”

S3S3

S1…S2,S1…S2,S3S3

““Slurp…..ing Slurp…..ing inin

S4S4 S3S3

S4S4,S1... S2 S1…S2,,S1... S2 S1…S2,S3S3

““aa Stiff Wall” Stiff Wall” ““Slurp ing Slurp ing inin

ManeuversIntervention Hypertrophic

Obstructive

Cardiomyopathy

Aortic Stenosis Mitral Prolapse

Valsalva Up Down Up

Standing Up Down Up (and earlier onset)

Handgrip or squatting

Down Up Down

Thanks!