Ass. Professor of Cardiology Valvular heart Dr. Hesham K. Rashid, MD Ass. Professor of Cardiology Benha University

Mitral stenosis Etiology : Rheumatic heart Rare congenital Lutembacher’s syndrome (MS + ASD). 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: Mild cases may be asymptomatic. Moderate to severe cases present with symptoms of pulmonary congestive symptoms Palpitation (irregular) AF. 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 : Apex is normal in position & slapping (hypokinitic ) in character. Palpable first heart sound Accentuated first heart sound. Opening snape after second heart sound Diastolic rumbling murmur at the apex 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 : Atrial fibrillation LA thrombus & systemic embolizations Infective endocarditis. Recurrence of rheumatic activity 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 : Rheumatic fever causing : - fibrosis & deformity of valve leaflets. - shortening of chordae tendinae . Dilatation of the LV & mitral valve ring (functional) Dysfunction of papillary muscles: due to ischemia , infarction. Less common causes as: - congenital abnormalities. - endocarditis. - HOCM - Mitral valve prolapse (degenerative disease )

Heamodynamic effect : Regurgitated jet from LV to LA during systole leading to LA dilatation. Transmission of large volume from LA to LV produce hyperdynamic heart. LV dilated and ending by failure if the regurge is severe & prolonged. LV failure leading to pulmonary congestion and if this is prolonged , pulmonary hypertension occurs Atrial fibrillation may occur due to LA dilatation

Clinical picture: symptoms: For many years , patients with mild or moderate mitral regurge are asymptomatic or complain only of palpitation. Symptoms of pulmonary congestion appear due to LV failure . Symptoms of low cardiac output may occur due to pulmonary hypertension

Signs : Hyperdynamic apex and may be displaced 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 : Mitral regurge. Tricuspid regurge. VSD. DD :from other causes of systolic murmur; 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: LV failure. Pulmonary hypertension. AF. Thrombus formation. Rheumatic activity. Infective endocarditis.

A - Medical treatment: Prophylaxis against endocarditis. Prophylaxis against rheumatic activity ACE inhibitor . Diuretic in case of lung congestion Patient with AF : - digitalis to control rate. - oral anticoagulant

- Mitral valve repair :in case of wide annulus , rupture chordae. 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 : The vast majority due to : rheumatic fever . 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: Mild & moderate case may be complaint from palpitation for a long time. Manifestations of LV failure as dyspnea , orthopenia ,PND Angina in severe cases only

Signs : High systolic pressure & very low diastolic pressure Peripheral pulse has the following characters: - High volume. - marked arterial pulsations in the neck(corrigan´s) - water hummer pulse -pistol shot femoral. Hyperdynamic apex & is displaced outward and downward Long early diastolic murmur immediately after second heart sound at second aortic area .

Investigations 1- Plain chest X-ray. 2- ECG. 3- Echocardiography

Complications : Infective endocarditis. Recurrence of rheumatic activity . 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 : Rheumatic : it is more common in males Congenital : bicuspid aortic valve. Senile sclerosis : in old age. The valvular aortic stenosis should be differentiated from other causes of LV outflow obstructions as: Sub-aortic membrane. HOCM. Supra-valvular stenosis.

Hemodynamic effect Mild stenosis may be asymptomatic Severe cases cause LVH & end by failure due to pressure overload . Low cardiac output. Myocardial ischemia.

Symptoms : Mild case asymptomatic. Low cardiac output. Myocardial ischemia Manifestation of left ventricular failure late. Sudden death in severe case due to arrhythmia

Signs: Plateau pulse Low pulse pressure. Sustained apex. Systolic thrill. Ejection systolic murmur Soft delayed aortic component

Investigations 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 : Medical : - prophylaxis against rheumatic activity & infective endocarditis in rheumatic cases. - Anti-failure treatment at end stage HF. Surgical : aortic valve replacement . Balloon aortic dilatation in severe child cases