Download Valvular Heart Disease

VALVULAR HEART DISEASE
AORTIC VALVE
Background

Trileaflet structure

Usual pathology is either:
o
Calcification with functional and structural stenosis or
o
Destruction of the leaflets with resultant insufficiency
Aortic Stenosis (AS)

Causes
1. Senile calcific stenosis
2. Calcification of a congenital (bicuspid) valve
3. Rheumatic heart disease (secondary to RFi)

The pathology is that of CONCENTRIC LEFT VENTRICULAR HYPERTROPHY due to
ventricular dilatation as a result of outflow obstruction

Symptoms include
1. SOB
2. Angina
3. Syncope
4. Those of CHF – orthopnoea, PND, oedema

Signs include a
1. Holosystolic murmur at the right second ICS radiating to the carotids
2.
3. Weak and delayed peripheral pulses

CXR shows minimal changes initially but cardiomegaly later.

Diagnosis is by ECHO and if +ve then cardiac catheterisation (inc pressure across valve)

Indications for surgery:
1. Symptoms
2. Increase in left ventricular end systolic volume

Procedure of choice is Aortic Valve Replacement (AVR), repair may be done rarely and with poor
short term results. AVR may be accomplished with either a mechanical or bioprosthetic heart valve.
Prognosis poor – life expectancy 2-3 years, the greatest risk is that of sudden cardiac death.
Aortic Regurgitation / Insufficiency (AI)

Casues include (>40) aortic degeneration, (<40 y/o) Marfan's syndrome.

Most frequently presents in combination with Aortic Stenosis. Other etiologies incl:


o
endocarditis
o
aneurysm
o
congenital (bicuspid)
o
luetic
o
traumatic
o
rheumatic
o
atherosclerotic
o
ankylosing spondylitis
o
dissection
o
iatrogenic
Symptoms usually include:
o
SOB
o
Palpitations
o
Angina.
Signs include:
o
Diastolic murmur
o
Bobbing head
o
Wide pulse pressure (collapsing pulse)
o
Slow rising pulse

CXR shows signs of congestive heart failure or/and cardiomegaly (cor bovinum)

Indications for surgery include:
1. Symptoms
2. Increase end systolic volume

Procedure is Aortic Valve Replacement (AVR).
The Mitral Valve
Background

The usual etiology for pathology is post-rheumatic heart disease. The next most common etiology
and growing is myxomatous degeneration.

The mitral valve sits anatomically between the aortic valve, the circumflex artery and the coronary
sinus.
Mitral Valve Stenosis (MS)

Usual etiology is RHD.

Symptoms are:
1. SOB
2. Angina
3. PND, orthopnoea, oedema, syncope - all part of CHF.

Left atrium will progressively dilate until very large, this can lead to atrial fibrillation and clot
formation.

Historically, pregnant females with MS at delivery would have cardiovascular collapse and require
left thoracotomy and closed commissurotomy.

Diagnosis is by ECHO and cardiac cath.

Indications for surgery include symptoms, presence of transvalvular gradient by cath of > 4 mm Hg.

Surgical correction involves:
1. open commissurotomy or repair plus annular ring
2. mitral valve replacement
Mitral Regurgitation (MR)

Usual etiology is rheumatic heart disease, endocarditis, but most commonly now in the US is
myxomatous degenertion and prolapse (floppy valve disease).

Patient will present with symptoms of CHF.

Eventually LV will become compromised because of regurgitant fraction creating a progressive
cardiac dilatation.

A systolic murmur will be heard at the apex radiating to axilla

Indications for surgery are symptoms of CHF.

Surgery may include:
1. Valvuloplasty with implantation of annular ring
2. Mitral valve replacement.

Even with surgery, LV may be so compromised that patient may not come off CPB or continue with
symptoms of CHF.
Rheumatic Fever – condition affecting children aged 5-15. It follows Group A Streptococcal pharangeal infection. Due to
antibody-mediated autoimmune where antibodies against the bacteria cross react to cause multi-organ failure, particularly
pancarditis and rheumatism. Pancarditis may cause valvular damage that predisposes to bacterial endocarditis later in life.
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