Valvular Diseases Causes of valve regurgitation congenital, senile degeneration, acute and chronic rheumatic carditis, infective endocarditis, syphilitic aortitis traumatic valve rupture, damage to chordae and papillary muscles (e.g. in MI), dilated valve ring (e.g. dilated CMP) Causes of valve stenosis congenital, senile degeneration rheumatic carditis Common clinical scenarios Young people: functional murmurs, MVP, AS Old people: aortic sclerosis, aortic stenosis

Mitral Stenosis Symptoms Signs pulmonary congestion: dyspnea, cough, hemoptysis (also due to PE) chest pain (PH), edema and ascites (RVF) fatigue (low COP), palpitation (AF), thromboembolic complications Signs inspection: mitral facies palpation: tapping apex (palpable first heart sound), RV heave (PH) auscultation: loud first heart sound, loud P2 (PH), opening snap, rumbling mid-diastolic murmur, presystolic accentuation atrial fibrillation, raised pulmonary capillary pressure: crepitations, pulmonary edema, effusion

Mitral Stenosis ECG CXR Echo Doppler Cardiac catheterization LA hypertrophy, RVH, AF CXR enlarged LA, pulmonary venous congestion Echo thick immobile cusps, reduced valve area, reduced rate of LV diastolic filling Doppler pressure gradient across MV, pulmonary artery pressure Cardiac catheterization pulomnary wedge pressure, pressure gradient between LA and LV

Mitral Stenosis Medical management Mitral balloon valvoplasty digoxin for AF + BB or CA diuretics for pulmonary congestion anticoagulant to reduce the risk of systemic emboli antibiotic prophylaxis against infective endocarditis Mitral balloon valvoplasty significant symptoms isolated MS no to trivial MR mobile non-calcific valve / subvalvular apparatus on echo LA free of thrombus Mitral valve surgery closed mitral valvotomy open mitral valvotomy mitral valve replacement: mechanical, bioprosthesis [St. Jude (bi-leaflet), Carpentier-Edwards (porcine), Medtronics (single leaflet, open)]

Mitral Regurgitation Causes Symptoms Signs mitral valve prolapse (myxomatous changes) is the most common cause in developed world damage to cusps: rheumatic valve disease, IE, congenital cleft mitral valve damage to chordae: rheumatic valve disease, IE, trauma, degenerative damage to papillary: ischemia, infarction, infiltrative, HCM damage of annulus: calcification, IE (abscess) dilation of MV ring: IHD, CMP, acute rheumatic valve Symptoms dyspnea, edema, ascites, fatigue, palpitations (AF, increased stroke volume), thromboembolic complications Signs jerky pulse (AF), displaced apex (hyperdynamic circulation) 3rd heart sound, apical pansystolic murmur with or without thrill signs of pulmonary congestion and pulmonary hypertension

Mitral Regurgitation ECG CXR Echo Doppler Cardiac catheterization LAH, LVH, AF CXR enlarged LA, enlarged LV, pulmonary venous congestion Echo dilated LA and LV, dynamic LV, structural abnormalities (e.g. MVP) Doppler detects and quantifies MR Cardiac catheterization dilated LA and LV, MR, assess PH, detect co-existing CAD

Mitral Regurgitation Medical (mild and moderate cases) Surgical diuretics, vasodilators (e.g. ACEI) digoxin and anticoagulant (for AF) antibiotic prophylaxis (for IE) Surgical MV valvoplasty (repair) MV replacement Indications for surgery worsening symptoms progressive cardiomegaly deterioration of LV function: EF < 60%, LVEDD > 55 Complications of artificial valves IE, thromboembolic complications, hemolysis, valve dysfunction

Mitral Regurgitation Emergency minor criteria for surgery in isolated severe chronic MR any symptoms of heart failure or suboptimal exercise tolerance test flail mitral leaflet left atrial diameter > 45 mm paroxysmal atrial fibrillation abnormal exercise end-systolic volume index or ejection fraction MVP asymptomatic, acute MR (ruptured chordae), chronic MR, CHF mid-systolic click, late systolic murmur or pan-systolic murmur increased risk for IE, arrhythmias, embolic stroke and TIA (small), sudden death (rare)

Aortic Stenosis Causes young patient: thick congenital bicuspid valve, unicuspid valve, supravalvular stenosis, subvalvular stenosis (discrete, diffuse) middle age: thick bicuspid valve, rheumatic disease old age: thick degenerative valve, calcification of bicuspid valve, rheumatic AS

Aortic Stenosis Symptoms Signs Severity angina, exertional pre-syncope and dizziness, dyspnea, impaired exercise tolerance, episodes of acute pulmonary edema, sudden death other signs of LVF (systolic and diastolic dysfunction) Signs slow-rising carotid pulse, narrow pulse pressure, thrusting apex beat (LV pressure overload) ejection systolic murmur, basal crepitations Severity indicated by: diamond-shaped murmur, anacrotic pulse, paradoxical S2, S4 (LVH), S3 (LVF) not indicated by: intensity, presence of thrill

Aortic Stenosis ECG CXR Echo Doppler Cardiac catheterization LVH, LBBB, normal CXR enlarged LV, dilated ascending aorta, calcified AV, normal Echo calcified AV with restricted opening, thickened LV walls Doppler detects AR, estimates gradient Cardiac catheterization systolic gradient between LV and aorta, post-stenotic dilation of aorta, detects AR if present, detect presence of CAD

Aortic Stenosis Medical Surgical Mechanical versus bioprosthetic valve prophylaxis against IE anticoagulants if in AF diuretics for pulmonary congestion (cautiously) vasodilators are contraindicated Surgical mechanical AV replacement: symptomatic with normal COP and valve gradient > 50 bioprosthesis: symptomatic elderly (disk valve, caged-ball valve, bio-prosthetic valve) aortic balloon valvoplasty: congenital AS Mechanical versus bioprosthetic valve mechanical: durable, large orifice, best in left side, high thromboembolic potential, chronic warfarin therapy bioprosthetic: not durable, small orifice/functional stenosis, best in tricuspid orifice, low thromboembolic potential, consider in elderly

Aortic Regurgitation Congenital: Acquired bicuspid AV, cystic medial necrosis (Marfan, Ehlers-Danlos, osteogenesis imperfecta, pseudoxanthoma elasticum) Acquired rheumatic heart disease, dilated aorta degenerative, connective tissue disorders (ankylosing spondylitis, rheumatoid arthritis, Reiter, giant-cell arteritis), syphilis (chronic aortitis) acute AR: infective endocarditis, trauma, dissecting aneurysm

Aortic Regurgitation Symptoms Signs (peripheral) Signs (central) mild to moderate: asymptomatic, palpitations severe: dyspnea, orthopnea, PND, chest pain (noctural and exertional angina) if aortic diastolic pressure < 40 Signs (peripheral) Quincke sign: capillary pulsation Corrigan sign: water hammer pulse Bisferens pulse (AS/AR > AR) DeMusset sign: systolic head bobbing Mueller sign: systolic pulsation of uvula Durosier sign: femoral retrograde bruits Traube sign: pistol shot femorals Hill sign: lower extremity BP > upper extremity BP by > 20 mmHg (mild), > 40 mmHg (moderate), > 60 mmHg (severe) widened pulse pressure Signs (central) apex: enlarged, displaced, hyperdynamic (forcible nonsustained), palpable S3, Austin-Flint murmur diastolic murmur: length correlates with severity (chronic), in acute murmur shortens as DP=LVEDP, mitral pre-closure

Aortic Regurgitation ECG CXR Echo Doppler Cardiac catheterization LVH, T inversion CXR cardiac dilation, aortic dilation, pulmonary congestion Echo dilated LV, hyperdynamic LV, fluttering AML Doppler detects reflux Cardiac catheterization dilated LV, AR, dilated aortic root Assessing severity more severity with more peripheral signs and larger LV S3, Austin-Flint murmur, LVH, radiological cardiomegaly

Aortic Regurgitation Medical Surgical Criteria for replacement diuretics for pulmonary congestion, vasodilators (ACEI) prophylaxis against IE, treatment of underlying cause (e.g. IE, syphilis) Surgical AV replacement: mechanical or bioprosthesis aortic root replacement: for dilated aortic root (Marfan, syphilis, dissecting aneurysm) if LVEDD > 55, EF > 55%, FS > 27% Criteria for replacement symptoms: congestive heart failure, declining exercise tolerance on exercise testing, angina anatomy: LV dysfunction (EF < 50%), progressive LV dilation or decline in EF on serial studies, severe dilation (LVDD > 75 mm, LVSD > 55 mm, aortic root dimension > 50)

Tricuspid Stenosis Causes Clinical rheumatic: almost always have associated MS (signs of PH), isolated TS is rare, uncorrected TS worsens survival chance for patients undergoing surgery for AV or MV carcinoid: mainly affects TV and PV Clinical similar to MS, JVD, edema, ascites, hepatomegaly rumbling diastolic murmur with opening snap accentuated with respiration

Tricuspid Regurgitation Causes functional overload: pulmonary hypertension, RV dilation from infarction or myopathy structural leaflet abnormalities: infectious endocarditis, congenital (Ebstein anomaly), acquired (carcinoid, plantain diet, ergot drugs) Clinical asymptomatic (tolerated for years), JVD high-pitch blowing holosystolic murmur varying with respiration (Rivero-Carvallo sign) in xyphoid area complications: right heart failure, renal failure Treatment none to treat underlying condition diuretics, salt restriction valve replacement, rings Markers of severity large pulsations in neck, pulsatile enlarged liver, widespread edema (anasarca, Michelin tire man), RV S3 (increases with respiration)

Pulmonary Stenosis typically congenital RVH valvular, supravalvular, subvalvular (infundibular) RVH harsh systolic ejection murmur at 2nd left interspace (crescendo-decrescendo), thrill

Pulmonary Regurgitation Causes PH (most common) IE, rheumatic disease, carcinoid heart disease congenital defects, trauma physiological is normal variant Assessment color flow doppler: right atrial enlargement, right ventricular volume overload typical murmur: low-pitched diastolic murmur heard at left sternal border increasing with inspiration PH murmur: high-pitched blowing diastolic murmur at left parasternal border (Graham-Steele murmur)