Download Mitral valve replacement

Valvular heart
Dr. Hesham K. Rashid, MD
Ass. Professor of Cardiology
Benha University
Mitral stenosis
 Etiology :
1. Rheumatic heart
2. Rare congenital
3. Lutembacher’s syndrome (MS + ASD).
4. Senile calcify mitral valve .
 Hemodynamic effects:
1. Increase LA pressure that leading to its
dilatation
2. Lung congestion.
3. Reactive pulmonary arteriolar
vasoconstriction:
- Decrease pulmonary congestion.
- Initiate pulmonary hypertension.
4. LA dilatation produce AF & pressure
symptoms
Clinical picture:
Symptoms:
1. Mild cases may be asymptomatic.
2. Moderate to severe cases present with
symptoms of pulmonary congestive symptoms
3. Palpitation (irregular) AF.
4. Manifestation of pulmonary hypertension
- low cardiac output.
- right hypochondrial pain & GIT upset.
- bilateral edema of lower limb .
5. Pressure symptoms: hoarseness of voice ,
dysphagia , and dyspnea
Signs :
1. Apex is normal in position & slapping
(hypokinitic ) in character.
2. Palpable first heart sound
3. Accentuated first heart sound.
4. Opening snape after second heart sound
5. Diastolic rumbling murmur at the apex
6. Severe cases with pulmonary hypertension
manifestation of low cardiac out put can be seen
as peripheral cyanosis – malar flash at the
cheeks
Investigations
1. Chest X- ray :show straight left border of the
heart due to LA dilatation(mitralization )& double
contour.
2. Echocardiography :show thick leaflets
dilated LA & can calculate mitral valve area
Complications :
1. Atrial fibrillation
2. LA thrombus & systemic embolizations
3. Infective endocarditis.
4. Recurrence of rheumatic activity
5. Pulmonary hypertension
Management :
A- Medical treatment in minimal symptomatic
patients:
- Diuretic to relieve lung congestion
- Control rate of AF and give also oral
anticoagulant.
- Prophylaxis against recurrence by LA penicillin.
- Prophylaxis against infective endocarditis.
- Follow up the patient by Echocardiography.
B- surgical treatment :
- Open commissurotomy.
- Closed commissurotomy.
- Valve replacement.
C- percutaneous balloon mitral valvloplasty
Percutaneous balloon mitral valvuloplasty
Mitral regurgitation
 Etiology :
1. Rheumatic fever causing :
- fibrosis & deformity of valve leaflets.
- shortening of chordae tendinae .
2. Dilatation of the LV & mitral valve ring (functional)
3. Dysfunction of papillary muscles: due to ischemia ,
infarction.
4. Less common causes as:
- congenital abnormalities.
- endocarditis.
- HOCM
- Mitral valve prolapse (degenerative disease )
 Heamodynamic effect :
1. Regurgitated jet from LV to LA during systole
leading to LA dilatation.
2. Transmission of large volume from LA to LV
produce hyperdynamic heart.
3. LV dilated and ending by failure if the regurge is
severe & prolonged.
4. LV failure leading to pulmonary congestion and if
this is prolonged , pulmonary hypertension occurs
5. Atrial fibrillation may occur due to LA dilatation
 Clinical picture:
symptoms:
1. For many years , patients with mild or moderate
mitral regurge are asymptomatic or complain
only of palpitation.
2. Symptoms of pulmonary congestion appear due
to LV failure .
3. Symptoms of low cardiac output may occur due
to pulmonary hypertension
 Signs :
1. Hyperdynamic apex and may be displaced
2.
3.
4.
5.
6.
outward and downwards.
Systolic thrill at the apex.
Pansystolic murmur at the apex & propagated to
the axilla
Faint first heart sound.
Third heart sound at the apex.
Signs of LV failure as bilateral basal crepitation.
 DD : the causes of pansystolic murmur :
1. Mitral regurge.
2. Tricuspid regurge.
3. VSD.
 DD :from other causes of systolic murmur;
1. Mitral regurge.
2. Aortic stenosis.
 Investigations:
1.Plain chest X-ray:
- LV enlargement .
- signs of pulmonary congestion.
2.ECG:
- P mitral.
- LV dilatation.
3.Echocardiography:
- determine degree of regurge.
- LV dimensions .
- EF
 Complications:
1. LV failure.
2. Pulmonary hypertension.
3. AF.
4. Thrombus formation.
5. Rheumatic activity.
6. Infective endocarditis.
A - Medical treatment:
1. Prophylaxis against endocarditis.
2. Prophylaxis against rheumatic activity
3. ACE inhibitor .
4. Diuretic in case of lung congestion
5. Patient with AF :
- digitalis to control rate.
- oral anticoagulant
B- Surgical treatment : for symptomatic severe regurge
- Mitral valve repair :in case of wide annulus , rupture
chordae.
- Mitral valve replacement : for destructive valve
Aortic regurge
 Etiology :
1. The vast majority due to : rheumatic fever .
2. Rare causes :
- Congenital heart disease.
- Infective endocarditis.
- Trauma.
- Dissecting aneurysm.
- Ankylosing spondylitis.
- Syphilis.
- Marfan syndrome.
Hemodynamic effect
(1) -Very low diastolic
pressure.
(2) -High systolic pressure.
(3) -Wide pulse pressure
(peripheral signs)
(4) -LV dilatation &
hypertrophy.
(5) -LV failure.
 C/P:
 Symptoms:
1. Mild & moderate case may be complaint from
palpitation for a long time.
2. Manifestations of LV failure as dyspnea ,
orthopenia ,PND
3. Angina in severe cases only
 Signs :
1. High systolic pressure & very low diastolic pressure
2. Peripheral pulse has the following characters:
- High volume.
- marked arterial pulsations in the neck(corrigan´s)
- water hummer pulse
-pistol shot femoral.
3. Hyperdynamic apex & is displaced outward and
downward
4. Long early diastolic murmur immediately after
second heart sound at second aortic area .
Investigations
1- Plain chest X-ray.
2- ECG.
3- Echocardiography
 Complications :
1. Infective endocarditis.
2. Recurrence of rheumatic activity .
3. Left ventricular failure.
 Treatments :
A- Medical treatment :
- long acting penicillin
- prophylaxis against endocarditis.
- on severe LV failure use digitalis . Diuretic , ACEI
B- Surgery :
aortic valve replacement on severe symptomatic
cases before LV failure.
Aortic stenosis
 Causes :
1. Rheumatic : it is more common in males
2. Congenital : bicuspid aortic valve.
3. Senile sclerosis : in old age.
 The valvular aortic stenosis should be
differentiated from other causes of LV outflow
obstructions as:
A) Sub-aortic membrane.
B) HOCM.
C) Supra-valvular stenosis.
Hemodynamic effect
1. Mild stenosis may be
asymptomatic
2.Severe cases cause
LVH & end by failure
due to pressure
overload .
3. Low cardiac output.
4.Myocardial ischemia.
 Symptoms :
1. Mild case asymptomatic.
2. Low cardiac output.
3. Myocardial ischemia
4. Manifestation of left ventricular failure late.
5. Sudden death in severe case due to arrhythmia
•Signs:
1. Plateau pulse
2.Low pulse pressure.
3. Sustained apex.
4.Systolic thrill.
5.Ejection systolic
murmur
6.Soft delayed aortic
component
Investigations
1. Plain X-ray :
- calcifications.
- Post stenotic
dilatation.
- Signs of HF at end
stage
2. ECG:
- signs of LVH & strain.
- Arrhythmias
3. Echocardiography:
- degree of stenosis
- LVH
- LV dimensions &
function
 Treatment :
1. Medical :
- prophylaxis against rheumatic activity &
infective endocarditis in rheumatic cases.
- Anti-failure treatment at end stage HF.
2. Surgical : aortic valve replacement .
3. Balloon aortic dilatation in severe child cases