Download Heart Valve Disease

Heart Valve Disease
Zoltán Pozsonyi, MD
3rd Dep. of Internal Medicine
Semmelweis Univeryity
Budapest, Hungary
References
• Braunwald: Textbook of Cardiology
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General considerations in HVD
Aortic valve stenosis
Aortic valve regurgitation
Mitral valve stenosis
Mitral valve regurgitation
Prosthetic valve
Aortic valve stenosis
AS
Symptoms
• Heart failure
– dyspnoe, oedema, exercise intolerance
• Angina
– imbalance between oxigene need and supply
• Syncope
– exercise induced
• Sudden cardiac death
AS
Low flow-low grade AS
Aortic valve regurgitation
Hemodynamics of aortic regurgitation.
A, Normal conditions.
C, Hemodynamic changes occurring in chronic compensated aortic regurgitation
are shown. Eccentric hypertrophy produces increased end-diastolic volume
(EDV), which permits an increase in total as well as forward stroke volume. The
volume overload is accommodated and left ventricular filling pressure is
normalized. Ventricular emptying and end-systolic volume (ESV) remain
normal.
D, In chronic decompensated aortic regurgitation, impaired left ventricular
emptying produces an increase in end-systolic volume and a fall in ejection
fraction (EF), total stroke volume, and forward stroke volume. There is further
cardiac dilation and reelevation of left ventricular filling pressure.
AR Symptoms
• Asymptomatic pt, normal EF
– SCD: 0,2 %/y
• Symptomatic pt
– 10-20%/y
• Dilating LV, first reversible, later
irrreversible systolic dysfunction
Survival without surgery in 242 patients with chronic aortic regurgitation
Aortic root dilation
Mitral valve stenosis
Rheumatic mitral stenosis.
There are severe valvular changes, including
marked fibrosis and calcification of the
mitral valve leaflets and severe chordal
thickening and fusion into pillars of fibrous
tissue
MS
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Rheumatic heart disease
MVA: normally 4-5 cm2
Symptoms: <1,5 cm2
20-40 years of latent disease
Symptomatic pt: 10 y mortality: 50-100%
Severe pulmonary HT: 3 years
MS
Percutaneous balloon mitral valvotomy
Natural history of 159 patients
with isolated mitral stenosis
(solid blue line) or mitral
regurgitation (solid purple line)
who were not operated on (even
though the operation was
indicated) compared with
patients treated with valve
replacement for mitral stenosis
(dashed blue line) or mitral
regurgitation (dashed purple
line).
Mitral valve regurgitation
Myxomatous mitral valve in a patient with
severe mitral regurgitation, viewed from the
left atrium.
MR
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Primer (MP, chordal rupture) vs secunder (DCM)
Dilating LV, compensated for years
6-10 years: complains
Severe MR: mortality 6-7% yearly
Bad prognosis: NYHA III_IV, low EF
Graph of the late survival of patients who
underwent surgical correction of mitral
regurgitation as a function of the preoperative
echocardiographic ejection fraction (EF).
Parasternal long-axis twodimensional echocardiographic
images in mitral valve prolapse
Plots of overall survival compared for
mitral repair and replacement groups in
patients who had (left) or did not have
(right) associated coronary artery bypass
grafting (CABG).
Prosthetic valve
Mechanical heart valves.
A, The Starr-Edwards
caged-ball valve.
B, The Omniscience
valve.
C, The Medtronic-Hall
valve.
D, The St. Jude bileaflet
valve.
E, The CarboMedics
bileaflet valve
Bioprosthetic valves.
A, Hancock porcine
valve;
B, CarpentierEdwards porcine
valve;
I, Autologous
pericardial valve.
Structural deterioration of bioprosthetic valves.
Long term complications
• Thrombosis
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Prosthetic, metallic valves
PVT
often lethal
obstructive, non obstructive
1%/y
• Infective endocarditis
– 30% mortality
• Dysfunction
– calcification (bioprosthetic valve)
• Paravalvular leak
– regurgitation, intravascular haemolysis
Estimates of freedom from structural valve deterioration
(SVD) for patients undergoing porcine (A) and bovine
pericardial (B) aortic valve replacement who are stratified
according to age
Bridging therapy of VKA with
UFH or LMWH
IE profilaxis
• Pts with prosthetic valves
• IE in medical history
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