Valvular Heart Disease Vincent E. Friedewald, M.D.

Classification of Heart Disease Congenital Coronary Electrical Endomyocardial Pericardial Valvular

The Cardiac Valves

Cardiac Valve Anatomy

Valvular Heart Disease Acute and Chronic are Different Diseases

Aortic Stenosis

Aortic Stenosis Types Valvular Subvalvular Supravalvular

Aortic Valve Stenosis

Bicuspid Rheumatic Degenerative

Aortic Valve Stenosis Age Relationship

Bicuspid Aortic Stenosis

Rheumatic Aortic Stenosis

Degenerative Aortic Stenosis

Risk Factors Elevated LDL-cholesterol Diabetes mellitus Systemic arterial hypertension Cigarette smoking

Aortic Valve Stenosis Symptoms Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope

Aortic Valve Stenosis Signs ARTERIAL PULSE, GEN – RISE, SLOW ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN – DOWNSLOPE GRADUAL ARTERIAL PULSE, GEN – PULSE PRESSURE, NARROW ARTERIAL PULSE, GEN – SHUDDER ARTERY, CAROTID – THRILL HEART, LV APEX – IMPULSE, PRESYSTOLIC HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – MURMUR, SYSTOLIC

Aortic Valve Stenosis Signs (cont) HEART, LV APEX – CLICK, SYSTOLIC HEART, LV APEX – IMPULSE, SUSTAINED HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – CLICK, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SINGLE HEART, SOUND S2 – SPLIT REVERSED (PARADOXICAL) NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

Aortic Valve Stenosis Symptoms FATIGUE BREATHING – DIFFICULT WITH EFFORT (DYSPNEA) CHEST, ANT – PAIN, NONPLEURITIC (ANGINA PECTORIS) CHEST, ANT – PALPITATIONS CONSCIOUSNESS – LOSS, SUDDEN (SYNCOPE) CONSCIOUSNESS – LOSS, SUDDEN EFFORT (EFFORT SYNCOPE) DIZZINESS – EFFORT

Aortic Valve Stenosis Untreated Prognosis

Aortic Valve Stenosis Chest X-Ray

Aortic Valve Stenosis ECG

Aortic Valve Stenosis Echo

Aortic Valve Stenosis AV Pressure Gradient

Aortic Valve Stenosis Medical RX No drugs alter course – only valve repair/replacement Antibiotic Prophylaxis ? Statins For symptoms (if not candidate for valve replacement) – after-load reduction, i.e., nitroglycerine, used with caution to avoid BP fall

Aortic Valve Stenosis Surgical Rx Valvotomy Replacement Artificial Bioprosthesis Minimally-invasive transfemoral

Aortic Valve Replacement Transfemoral

Aortic Valve Stenosis Complications Atrial fibrillation Aortic Dissection Heart failure Infective endocarditis Myocardial infarction Sudden death

Aortic Regurgitation (Insufficiency)

Aortic Regurgitation Etiologies Primary aortic valve disease Aortic root abnormalities (Dissection, Syphilis) Connective tissue disorders (Marfan’s) Infective endocarditis Inflammatory disorders (SLE) Tumors

Aortic Regurgitation Symptoms BREATHING – DIFFICULT, NOCTURNAL BREATHING – DIFFICULT WITH EFFORT CHEST, ANT – PAIN, NONPLEURITIC (ANGINA) CHEST, ANT – PALPITATIONS HEAD, GEN – PAIN SWEATING – NOCTURNAL

Aortic Regurgitation Signs ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED ARTERIAL PULSE, GEN – DOUBLE ARTERIAL PULSE, GEN – FALL, RAPID ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE ARTERIAL PULSE, GEN – RISE, RAPID ARTERY, CAROTID – THRILL ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING

HEAD – BOBBING HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – THRILL, DIASTOLIC HEART, LV APEX – IMPULSE, INF DISPLACEMENT HEART, LV APEX – IMPULSE, LAT DISPLACEMENT HEART, LV APEX – IMPULSE, DIFFUSE HEART, LV APEX – MURMUR, DIASTOLIC HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – MURMUR, DIASTOLIC Aortic Regurgitation Signs (cont)

HEART, RSB UPPER – THRILL, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SPLIT REVERSED HEART, SOUND S3 LV MOUTH, UVULA – PULSATIONS NAILS – PULSATIONS NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC

Aortic Regurgitation – Chronic Chest X-Ray

Aortic Regurgitation Echo

Aortic Regurgitation Medical Rx Vasodilators to reduce systolic BP Antibiotic prophylaxis

Aortic Regurgitation Surgical Rx Aortic valve replacement

Mitral Regurgitation (Insufficiency)

Mitral Regurgitation Etiologies Congenital deformities Degenerative, i.e., myxomatous Endomyocardial fibroelastosis Mitral annular calcification Papillary muscle dysfunction – ischemic heart disease Rheumatic

Mitral Regurgitation Etiologies (cont) Ergotamine toxicity Carcinoid syndrome Radiation Rx SLE Diet-drug therapy

Mitral Regurgitation Papillary Muscles

Mitral Regurgitation Leaflet Prolapse (MVP Syndrome)

Mitral Regurgitation Calcified Annulus

Mitral Regurgitation Symptoms BREATHING – DIFF, EFFORT FATIGUE SKIN, GEN – TEMPERATURE, COOL SWEATING – EXCESSIVE

Mitral Regurgitation Signs ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN - FALL, RAPID ARTERIAL PULSE, GEN - RISE, RAPID CHEST, ANT LEFT - BULGE HEART, LV APEX - IMPULSE, FORCEFUL HEART, LV APEX - IMPULSE, DIFFUSE

Mitral Regurgitation Signs (cont) HEART, LV APEX - IMPULSE, SUSTAINED HEART, LV APEX - MURMUR, DIASTOLIC HEART, LV APEX - MURMUR, SYSTOLIC HEART, SOUND P2 - LOUD HEART, SOUND S3 LV SKIN, GEN - TEMPERATURE, COOL

Mitral Regurgitation 2-D Echo

Mitral Regurgitation Doppler Echo

Mitral Regurgitation Complications Atrial fibrillation Pulmonary hypertension LV dysfunction Infective endocarditis

Mitral Regurgitation Medical Rx Antibiotic prophylaxis ACEIs (functional form of MR) Beta-blockers (functional form of MR)

Mitral Regurgitation Surgical Rx Mitral repair Mitral valve replacement

Mitral Stenosis

Mitral Stenosis Increased LA Pressure

Mitral Stenosis Etiologies Rheumatic Rare: Congenital Chest radiation Left atrial myxoma Mucopolysaccharidosis Severe mitral annular calcification

Mitral Stenosis Symptoms ABDOMEN, GEN – PAIN BREATHING – DIFF, NOCTURNAL BREATHING – DIFF, EFFORT BREATHING – DIFF, RECLINING FLAT BREATHING – DIFF, RESTING BREATHING – RAPID CHEST, ANT – PAIN, NONPLEURITIC CHEST, ANT – PALPITATIONS COUGH – CHRONIC, NONSPECIFIC FATIGUE SPUTUM – BLOODY

Mitral Stenosis Signs ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED BREATH SOUNDS, GEN – WHEEZES EXTREMITIES, LOWER BILATERAL - EDEMA HEART RATE – RAPID HEART, LSB LOWER – IMPULSE, SYSTOLIC

Mitral Stenosis Signs (cont) HEART, LSB LOWER – MURMUR, DIASTOLIC HEART, LSB MID – PERCUSSION, DULLNESS HEART, LV APEX – MURMUR, DIASTOLIC HEART, LV APEX – OPENING SNAP, MITRAL HEART, LV APEX – THRILL, DIASTOLIC HEART, RSB – SOUND, SYSTOLIC EJECTION HEART, RSB UPPER – MURMUR, DIASTOLIC HEART, SOUND P2 – LOUD

Mitral Stenosis Signs (cont) HEART, SOUND P2 – PALPABLE HEART, SOUND S1 – SOFT HEART, SOUND S1 – LOUD LIVER – ENLARGED SKIN, CHEEKS – COLOR, PINK PURPLE SKIN, GEN – COLOR, BLUE VENOUS PULSE, JUGULAR - A WAVE, LARGE VENOUS PULSE, JUGULAR – ELEVATED

Mitral Stenosis Chest X-ray

Mitral Stenosis Echo

Mitral Stenosis LA Thrombus

Mitral Stenosis ECG

Mitral Stenosis Complications Atrial fibrillation Infective Endocarditis Peripheral embolism Pulmonary hypertension

Mitral Stenosis Medical RX Antibiotic prophylaxis Anticoagulation for Atrial fibrillation Prior embolic event Documented LA thrombus Arrhythmia control

Mitral Stenosis Surgical RX Invasive valvuloplasty Percutaneous valvotomy Valve replacement

Mitral Stenosis Invasive Valvuloplasty

Mitral Stenosis Surgical RX – Valvuloplasty with Balloon Catheter

Valvular Heart Disease Follow up Antibiotic prophylaxis New symptoms Change in symptoms Change in physical findings Echocardiography/other imaging

Thank you!