Download Cardiovascular 22 – Heart Valve Disease

Cardio 22 – Heart Valve Disease
Anil Chopra
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Understand valve disease in the context of disease worldwide.
Know the main ways in which heart valves dysfunction.
Know the disease processes
Understand the effects of valve dysfunction on the heart
Understand the different clinical consequences of dysfunctioning heart valves.
Understand the principals of treatment.
Mitral Valve Disease
Mitral Stenosis
AETIOLOGY
 Rheumatic heart disease (over 50% due to rheumatic fever)  an inflammatory
disease that affects children and young adults.
 More common in women.
 Can also be caused by a congenital malformation.
 Valve orifice decreases from 5cm2 to 1cm2
 Left atrial pressure increases, as does pulmonary venous and pulmonary arteriole.
 Left atria hypertrophy (enlargement of cells in tissue) occurs, and as a result right
atria and ventricle hypertrophy.
SIGNS AND SYMPTOMS
 Dyspnoea (breathlessness)
 Palpitations (awareness of heartbeat)
 Systemic embolism (stroke)
 Pulmonary Oedema
 Haemoptysis (coughing up of blood)
 Atrial fibrillation
 Loud first heart sound
 Mid-late diastolic murmur
 Pink discolouration of upper cheeks (malar flush/mitral facies)
INVESTIGATIONS
 Chest X-Ray – shows small heart with enlarged left atrium. Pulmonary oedema
and hypertension seen if severe.
 Electrocardiogram (ECG) – shows bifid p-wave showing delayed LA activation
as well as atrial fibrillation.
 Echocardiogram – can show thickened leaflets, chordal thickening, aortic
thickening, diastolic dooming of AML.
 Cardiac catheterisation – show high diastolic pressure in left atrium than
ventricle (proportional to degree of stenosis).
TREATMENT
 Medicines which control heart rate (β-blockers) prevent systemic embolism, ease
left atrium pressure.
 Interventional treatment such as balloon mitral valvotomy. This is where a
catheter is introduced in the femoral vein, up to the right atrium, the inter-atrial
septum is punctured and a balloon is inflated in the place of the mitral valve to
open it up.
 Mitral valve replacement (only necessary if mitral regurgitation is present, and if
stenosis is severe).
Mitral Regurgitation
AETIOLOGY
 Can be acquired (due to rheumatism, prolapse, calcific degenerative, ischaemic)
or congenital (mitral cleft e.t.c.).
 When left ventricle contracts, some blood regurgitates into left atrium
 This results in a slight rise in left atrial pressure, and stroke volume is increased.
(as some of the blood foes back into LA).
SIGNS AND SYMPTOMS
 Dyspnoea (breathlessness)
 Palpitations (awareness of heartbeat)
 Orthopnoea (breathlessness when lying down)
 Fatigue
 Oedema
 Night cough
 Atrial fibrillation
 Jugular venous pressure raised
 Displaced heart opens
 Late-pan systolic murmur
 Prominent 3rd heart sound.
INVESTIGATIONS
 Chest X-Ray – may show left atrial and ventricular enlargement.
 Electrocardiogram (ECG) – shows left atrial delay (bifid P-waves), tall R waves
& deep S-waves.
 Echocardiogram – shows left atrial and ventricular dilation.
 Cardiac catheterisation – blood is seen regurgitating from LV to LA.
TREATMENT
 Continuous monitoring with echocardiogram when sufficiently severe, surgical
intervention by valve repair or replacement may be necessary.
Mitral Valve Prolapse
AETIOLOGY
 Floppy valve material, large leaflets, enlarged mitral annulus
 Incidence is familial
 Mitral valve leaflet folds into left atrium in left ventricle systole.
 Most patients are asymptomatic
 Thromboembolism can occur.
SIGNS AND SYMPTOMS
 Atypical chest pain (“Stabbing pain”)
 Palpitations
 Atrial and ventricular arrhythmias.
 Sudden cardiac death
 Mid-systolic click (due to sudden valve prolapse)
INVESTIGATIONS
 Chest X-Ray – normal
 Electrocardiogram (ECG) – normal.
 Echocardiogram – shows posterior movement of one or both mitral valve cusps
during systole.
TREATMENT
 Β-blockers.
 Anticoagulants to prevent Thromboembolism
 Mitral valve repair/replacement.
Aortic Valve Disease
Aortic Stenosis
AETIOLOGY
 Rheumatic cause.
 Calcific degenerative (deposition of calcium in tissue)
 Can be congenital
 Abnormal bicuspid aortic valve (one cusp fuses)
 Increased left ventricular pressure due to obstruction in LV emptying
 Ischaemia of LV myocardium. (worse when exercising)
SIGNS AND SYMPTOMS
 Exercise induced angina (heart pain) dyspnoea (breathlessness) and syncope
(fainting)
 Carotid pulse is slow rising.
 Obvious apex heart beat due to LV hypertrophy.
 Systolic murmur <>
 Ejection click of bicuspid valve.
INVESTIGATIONS
 Chest X-Ray – shows small heart with prominent dilated descending aorta
 Electrocardiogram (ECG) – shows LV hypertrophy and LA delay.
 Echocardiogram – shows calcified thick immobile aortic valve cusps. Can also
show LV hypertrophy.
 Cardiac Catheterisation – shows systolic pressure difference between aorta and
LV.
TREATMENT
 Surgery in the form of aortic valve replacement if severe.
Aortic Regurgitation
AETIOLOGY
 Also mainly caused by rheumatic fever.
 Infective endocarditis (inflammation of heart muscle)
 Can be congenitally abnormal valve e.g. bicuspid
 Associated with connective tissue disorders.
 Blood flows back into LV in diastole, LV enlarges.
SIGNS AND SYMPTOMS
 Generally do not occur until disease is severe.
 Rise in LV diastolic pressure.
 Heart pounding due to increase LV size.
 Angina & Dyspnoea
 Displaced heart apex & active apical beat
 High pitch early diastolic murmur
 Ejection systolic flow murmur
 Low diastolic blood pressure.
INVESTIGATIONS
 Chest X-Ray – LV enlargement and dilation of ascending aorta.
 Electrocardiogram (ECG) – LV hypertrophy (tall R waves inverted T-waves)
 Echocardiogram – shows vigorous cardiac contraction and dilated LV.
 Cardiac Catheterisation – assess degree of regurgitation.
TREATMENT
 Vasodilators & ACE inhibitors
 Surgery – aortic valve replacement.