Valvular Heart Disease Read Robbins 588-594 Web atlas: Valvular Heart Disease Heart Sound Program (on all student computers-- same authors on web site: www.blaufuss.org/tutorial/indextut.html

Valvular Heart Disease Stenosis - failure of a valve to open completely - impeding forward flow Insufficiency - failure of a valve to close completely - allowing reversed flow(also called regurgitation) Congenital or acquired

Aortic Stenosis Calcific aortic Stenosis (degeneration) Congenital abnormality - bicuspid valve Rheumatic HD ( rare <10%) Never syphilis Moderate LVH

Normal aortic valve – opened

Normal aortic valve – shut

Chronic rheumatic aortic stenosis (&probably insufficiency) Note fusion of leaflets

Chronic rheumatic AS - very fibrotic and fusion of leaflets

Calcific Aortic Stenosis Most due to age related degeneration Congenital bicuspid valve 1-2% of population LVH Angina and syncope

Valvular Degeneration caused by Calcification Valves stressed by highly repetitive mechanisms 40 million cycles /year Substantial tissue deformations at each cycle High pressure gradients All lead to thickening and in some individuals massive calcification Tend to be advanced age (except for bicuspid valves)

Chronic calcific aortic Stenosis- a degenerative Process Note: the cusps are not fused Globes of calcium make it impossible for the leaflets to close.

Bicuspid aortic Valve- becomes calcified

Bicuspid aortic valve -now virtually Non-moving due to the massive dystrophic calcification

Aortic Insufficiency ASVD & hypertension- degenerative aortic dilation Collegen disorders (Marfan’s, E-D etc) Infectious Endocarditis (acute) Rheumatic HD (rare) - usually stenosis also Syphilis (rare today) Leads to: Massive LVH, CHF

AI- bacterial endocarditis with destruction of leaflet

AI- destruction of valve leaflets due to bacterial endocarditis

Mitral Stenosis Chronic rheumatic endocarditis - almost always Congenital abnormalities Lead to: CPC of lung Atrial fibrillation mural thrombosis

Normal mitral valve Chronic rheumatic endocarditis

Chronic rheumatic endocarditis – mitral stenosis

Chronic rheumatic stenosis

Mitral Insufficiency Mitral valve prolapse Papillary muscle dysfunction (MI) Rheumatic HD - post inflammatory scaring (usually MS also) Infective endocarditis Leads to LVH Mitral annular calcification

Abnormalities of the Mitral Valve Valve Leaflets Chordae Tendineae Papillary Muscles Mitral Annulus

Abnormalities of the Valve Leaflets Rheumatic Heart Disease shortening, rigidity, deformity and retraction of the leaflets Infective Endocarditis Perforation and retraction(healing)

Abnormalities of the Mitral Annulus Dilation normally the mitral annulus constricts during systole. A dilated left ventricle will result in dilation of the mitral annulus and result in mitral regurgitation.

Abnormalities of the Mitral Annulus Calcification of annulus one of the most common cardiac abnormalities found at autopsy. Usually of little consequence but may immobilize the basal portions of the MV leaflets preventing their normal excursion.

Abnormalities of the Chordae Tendineae Rupture primary infective endocarditis trauma rheumatic fever Lenghtening of the chordal structures may occur with MV prolapse allowing excessive billowing of the MV leaflets

Mitral Valve Prolapse Enlarged leaflet balloons into left atrium Midsystolic clicks heard Valve may become incompetent Late systolic murmur 3% of population 6:4 female:male ratio Most no untoward effects

Mitral valve prolapse

Myxomatous degeneration in a patient With mitral valve prolapse

Mitral Valve Prolapse Complications Most have no untoward effects - 3% have complications Infectious endocarditis Mitral insufficiency Arrhythmias Stroke or other systemic infarct Sudden death (very rare)

Mitral valve prolapse with rupture of chordae tendinae

Damaged papillary muscle causing mitral regurgitation Complete rupture from MI Muscle dysfuction due to MI

Complications of Artificial Valves Paravalvular leak Thromboembolism Infective endocarditis Structural deterioration Occlusion by tissue overgrowth

Summary Mitral Stenosis : Rheumatic Heart Disease Mitral insufficiency: myxomatous degeneration (mitral valve prolapse), damaged papillary muscle due to infarct Aortic stenosis: calcification of normal and congenitally bicuspid aortic valves Aortic insufficiency: dilation of the ascending aorta, related to hypertension and aging