Gwada Normal Valve Function Maintain forward flow and prevent backward of blood flow Valves open and close in response to pressure differences gradients between cardiac chambers What Is ID: 908837
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Slide1
Valvular heart disease
Dr. Rehab F. Gwada
Slide2Normal Valve Function
Maintain forward flow and prevent backward of blood flow.Valves open and close in response to pressure differences (gradients) between cardiac chambers.
Slide3What Is Valvular Heart Disease?
Heart valve disease occurs when your heart's valves do not work the way they should.The disease can affect the valve and derange its function in two ways:
Reduction in the orifice of the valve called
stenosis
which limits the forward blood flow
Backward leak of blood due to inefficient closing of the valve called
regurgitation or insufficiency
.
Slide4What Are the Types of Valve Disease?
Slide5Slide6The valves affected most commonly by the disease are aortic and mitral valves. The pulmonary and tricuspid valves are affected less often
.
Slide7What Causes Valvular Heart Disease?
idiopathic valvular
degeneration,
unknown cause.
Congenital
valve disease
.
Most often affects the aortic or
pulmonary valve.
Rheumatic fever
Endocarditis
Other causes of valve disease include
:
coronary artery disease, heart attack,
cardomyopathy
, syphilis, hypertension , and connective tissue diseases.
Rheumatic fever
Is an inflammatory disease that can develop as a complication of inadequately treated strep throat or scarlet fever.
Which are
caused by a streptococcus bacterium
infection.
Develop
in younger children and adults
.
The cardiac
manifestation
of rheumatic fever
is focal
inflammatory involvement of the interstitial tissue in all 3 layers of the
heart(pan-
carditis
)
The pathognomonic feature of pancarditis is the presence of Aschoff nodules.
Slide9Aortic Regurgitation
Aortic regurgitation is incompetency of the aortic valve causing blood flow from the aorta into the left ventricle during diastole ..
Slide10Signs
systolic BP increases while diastolic BP decreases, creating a widened pulse pressurethe LV impulse displaced downward and laterallynormal 1st heart sound (S1)loud, sharp
or slapping 2nd
heart sound (S2)
The
murmur
of AR is blowing, high-pitched
, diastolic
.
Slide11Symptoms
AR may be acute or chronic.
In chronic AR, left ventricular (LV) volume and stroke volume gradually increase because the LV receives aortic blood regurgitated in
diastole
in addition to blood from
the
pulmonary veins and left atrium leading to
LV hypertrophy
this is
asymptomatic for years.
These changes may ultimately cause
arrhythmias, heart failure (HF), or
cardiogenic
shock.
Progressive exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitations
develop.
Slide12signs
(Musset's sign) Visible signs include head bobbing(slapping, water-hammer, or collapsing pulse)
Palpable signs include a large-volume pulse with rapid rise and fall.
(Corrigan's sign)
pulsation of the carotid arteries
(Mayne's sign)
BP findings may be a fall in diastolic BP of > 15 mm Hg with arm elevation
(pistol-shot sound, or
Traube's
sign)
Auscultatory
signs include a sharp sound heard over the femoral pulse
Slide13Aortic Stenosis
Aortic stenosis (AS) is narrowing of the aortic valve obstructing blood flow from the left ventricle to the ascending aorta during systole.A valve area of 0.5 to 1.0 cm2 represents severe stenosis
; an area < 0.5 cm2 represent critical
stenosis
Slide14Symptoms
The left ventricle (LV) gradually hypertrophies in response to AS. Significant LV hypertrophy and, with progression, may lead to decreased contractility, ischemia, or fibrosis, any of which may cause heart failure (
HF
).
AS produces low
cardic
output ultimately results in
syncope, angina, and
exertional
dyspnea
; heart failure and arrhythmias {
ventricular fibrillation } may develop
Slide15Signs
A decreased carotid and peripheral pulsation . Systolic ejection murmur
.
. A palpable 4th heart sound (S4), felt best at the apex
Systolic
BP may be high with mild or moderate AS and fall as
AS
becomes more severe.
Mitral Regurgitation
Mitral regurgitation (MR) is incompetency of the mitral valve causing blood flow from the left ventricle (LV) into the left atrium during systole
Slide17Mitral Regurgitation
Regurge of blood into LA during systoleLA dilation and hypertrophyPulmonary congestionRV failure LV dilation and hypertrophy-to accommodate increased preload and decreased CO
Slide18Symptoms
Most patients with chronic MR are initially asymptomatic and develop symptoms insidiously as the LA enlarges, pulmonary BP increases, and LV remodeling occurs. dyspnea,
fatigue (due to heart failure),
palpitations (often due to AF); rarely,
patients present with
endocarditis
(
eg
, fever, weight loss,….).
Signs develop only when MR becomes moderate to severe affected .
Slide19Signs
sustained left parasternal movement due to expansion of an enlarged LA.
LV impulse
is
displaced downward and to the left
suggests LV hypertrophy and dilation.
(S1) may be soft or absent
if valve leaflets are rigid but is usually present if the leaflets are not rigid.
(S3), loud at the apex
in proportion to the degree of MR, reflects a greatly dilated LV.
(S4)
is characteristic of recent ruptured
chordae
, when the LV has not had enough time to dilate.
Apansystolic
murmur, heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position
Slide20Slide21Mitral Valve
Stenosis
the narrowing of the orifice of the
mitral valve
of the
heart
]
Slide22Mitral Stenosis
The normal area of the mitral valve orifice is 4 to 6 cm2
.
An area
of
2
to
1
cm2
reflects
moderate to severe
MS and often causes
exertional
symptoms
. An area < 1 cm2 represents critical stenosis and may cause
symptoms during rest
.
Left
atrial
(LA) size and pressure
increase
progressively
to compensate for MS
;
pulmonary venous and capillary pressures also
increase
and may cause secondary
pulmonary hypertension
, leading to right ventricular (
RV) heart failure
and
tricuspid and
pulmonic
regurgitation.
Valvular
change with LA enlargement predisposes to
atrial
fibrillation (AF), a risk factor for
thromboembolism
.
Slide23Symptoms
many patients are asymptomatic until they become pregnant or AF develops. Initial symptoms
are usually those of heart failure (
eg
,
exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue
). They typically do not appear until 15 to 40 yr after an episode of rheumatic fever
Palpitation
Chest pain
Hemoptysis
Thromboembolism in later stages when the left atrial volume is increased (i.e., dilation). leads to increase risk of
atrial
fibrillation
, which increases the risk of blood stasis .This increases the risk of coagulation.
Ascites
and edema and
hepatomegaly (if right-side heart failure develops)Fatigue and weakness increase with exercise and pregnancy.Less common symptoms include:hoarseness due to compression of the left recurrent laryngeal nerve by a dilated LA or pulmonary artery
Slide24Mitral Valve Prolapse (MVP)
It is a very common condition, affecting 1 to 2 % of the population.
MVP causes the leaflets of the mitral valve to flop back into the left atrium during the heart's contraction.
MVP
also causes the tissues of the valve to become abnormal and stretchy, causing the valve to leak. The condition rarely causes symptoms and usually doesn't require treatment.
Slide25Slide26symptoms
MVP is usually asymptomatic, although chest pain, dyspnea, and symptoms of sympathetic excess (eg, palpitations, dizziness, syncope, migraines, anxiety) may develop.
Slide27Pulmonary regurge
Pulmonic (pulmonary) regurgitation (PR) is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastoleThe most common cause is pulmonary hypertension.
Slide28Symptoms
PR may contribute to development of right ventricular (RV) hypertrophy and eventually RV dysfunction–induced heart failure (HF), but in most cases, pulmonary hypertension contributes to this complication much more significantlyPR is usually
asymptomatic
. A few patients develop symptoms and signs of RV dysfunction
–
induced HF
Slide29Pulmonic stenosis
is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole. Pulmonic stenosis (PS) is most often congenital and affects predominantly children;
Slide30Symptoms
When symptoms develop, they resemble those of aortic stenosis (syncope, angina, dyspnea).
Slide31Tricusped regurge
is insufficiency of the tricuspid valve causing blood flow from the right ventricle to the right atrium during systole. The most common cause is dilation of the right ventricle
Slide32Symptoms and signs
are usually absent, but severe TR can cause neck pulsations, a holosystolic murmur, right ventricular–
induced heart failure or
atrial
fibrillation.
TR is usually benign and does not require treatment, but some patients require valve repair or replacement.
Slide33How Are Valve Diseases Diagnosed?
symptomsphysical examthe doctor may order diagnostic tests. These may include:Echocardiography
Transesophageal
echocardiography
recent advances is the development of probes which can be advanced into the esophagus and take the images from the close proximity of the heart
Cardiac catheterization
(also called an angiogram)
Radionuclide scans
Magnetic resonance imaging
(MRI)
Slide34Goals of treatment
There are three goals of treatment for heart valve disease: protecting the valve from further damage
lessening
symptoms
repairing
or replacing valves.
Slide35Protecting the valve from further damage.
Patient is still at risk for endocarditis
, even if
his valve
is repaired or replaced through surgery. To protect
himself, give him the following advices:
Know the type and extent of your valve disease.
Tell all your doctors and dentist you have valve disease.
Call your doctor if you have symptoms of an infection.
Take good care of your teeth and gums.
Take antibiotics before you undergo any procedure that may cause bleeding.
Take your medications. Follow your doctor's instructions.
See your heart doctor for regular visits, even if you have no symptoms.
Slide36Strategies for treatment
Slide37How Is Heart Valve Disease Treated?
Common Types of MedicationsDiuretics Antiarrhythmic Vasodilators
ACE
inhibitors
A
type of vasodilator used to treat
high blood
pressure
and
heart failure
Beta
blockers
Treat
high blood pressure and lessen the heart's work by helping the heart beat slower and less forcefully. Used to decrease palpitations in some patients.
Anticoagulants
Slide38Surgery and Other Procedures
Surgical options include heart valve repair or replacement. Heart valves may also be repaired by other procedures such as percutaneous balloon
valvotomy
.
Slide39Treatment
Valve Surgery (repair): Various technique can be used: (
eg
:
Leaflet repair, Use of prosthetic rings and etc).
to optimize the valve orifice making sure that the valve is no longer
stenotic
or
regurgitant
.
Generally, repairs are preferred over replacements.
Slide40Valve replacement:
It occur ,When the valve is severely damaged and it is not possible to repair. The artificial valves are of three types
a mechanical (metallic) valve
a valve made from animal tissue
or a human valve removed from the human cadaver and frozen to preserve its integrity (cryopreservation).
The mechanical valve is the most durable but it has the disadvantage
of the risk of blood clot formation
.
Valve repair or replacement with tissue valves have the advantage that blood clot formation is not a risk.
The decision about the type of the artificial heart valve is made by the cardiologist and surgeon
.
Slide41Indications for MV Replacement in Severe MR
ANY Symptoms at rest or exercise with (repair if feasible)Asymptomatic:If
EF <60%
If new onset
atrial
fibrillation
Slide42Indications for Surgical Treatment of AR
ANY Symptoms at rest or exerciseAsymptomatic treatment if:EF drops below 50% or
LV
becomes
dilated
Slide43Indications for Mitral valve
MS))replacementANY SYMPTOMATIC
Patient with NYHA Class III or IV Symptoms
Asymptomatic
moderate or Severe
MS
Slide44Indications for Surgery in Aortic Stenosis
Any SYMPTOMATIC patient with severe AS (includes symptoms with exercise)Any patient with decreasing EF
Any patient undergoing CABG with moderate or severe AS
Slide45Question?