RJS Valvular heart disease Richard Schilling St Mary’s Hospital London

RJS Valve disease Aetiology Clinical findings Investigations Management

RJS Heart Valve lesions Mitral stenosis Aortic stenosis Pulmonary stenosis Tricuspid stenosis Prosthetic stenosis Mitral regurgitation Aortic regurgitation Pulmonary regurgitation Tricuspid regurgitation Prosthetic regurgitation Mitral valve prolapse

RJS Mitral regurgitation - Aetiology Valve –Rheumatic fever –Endocarditis Mitral valve annulus –Dilation –Calcification Chordae tendinae –Rupture –Lengthening Papillary muscle –ischaemia –dilation

RJS Mitral regurgitation – pathophysiology  LV emptying  LA pressure (if acute, pulmonary odema)  LV filling  LVedd LV stretch  failure 

RJS Mitral regurgitation – Clinical Symptoms appear late –SOB –Fatigue –Right heart failure Signs –Full volume pulse –Pan systolic murmur radiating to apex –Right heart failure –Pulmonary hypertension

RJS Mitral Regurgitation Investigations –ECG p mitrale –Xray large heart, calcified mv annulus, pulmonary odema –Echocardiogram large LA, abnormal valve, MR –LV angio MR, large LA

RJS

Mitral Regurgitation Heart Failure Decrease afterload Replacement Anticoagulation Antibiotic prophylaxis

RJS Mitral Stenosis - Aetiology Rheumatic fever Congenital

RJS Mitral Stenosis - pathophysiology  LA pressure  Pulmonary pressure R Heart failure  LV function

RJS Mitral Stenosis – Symptoms/Signs SOB Haemoptysis Embolisation Mitral Facies AF, thready pulse  JVP RV heave

RJS Mitral Stenosis – Symptoms/Signs Opening snap Rumbling diastolic murmur Presystolic murmur

RJS

Mitral stenosis - Investigations ECG – AF Xray – Pulmonary congestion, large LA and R heart Echo – tight valve, high inflow large LA

RJS MS ECG

RJS MS x-ray

RJS MS echo

RJS MS Treatment Antibiotic prophylaxis Anticoagulation (AF) Digoxin (AF) Mitral Valvuloplasty Surgical Replacement

RJS Mitral Valvuloplasty

RJS Aortic Stenosis - aetiology Congenital – bicuspid valve Acquired –Rheumatic –Senile/degenerative

RJS Aortic Stenosis – pathophysiology LVH  Cardiac output on exercise LV dilatation and failure

RJS Aortic stenosis – symptoms/ signs Asymptomatic Angina Heart Failure Syncope Sudden Death

RJS Aortic stenosis – symptoms/ signs Slow rising pulse LV heave Ejection systolic murmur radiating to carotids

RJS Aortic Stenosis - investigations ECG – LVH Echo – LVH, calcified valve, high doppler velocity Angio – Ao valve gradient

RJS AS ECG

RJS Congenital AS

RJS Echo AS

RJS Doppler/Pressure Aortic stenosis

RJS Aortic stenosis - treatment Antibiotic prophylaxis Surgical replacement before heart failure

RJS Aortic valve replacement

RJS Aortic Regurgitaiton- aetiology Aortic valve –Rheumatic fever –Infective endocarditis –Bicuspid vlave Aortic dilation –Age related –Marfans –Dissection

RJS Aortic regurg - pathophysiology Increased Lved volume Increased stroke volume LV dilatation LV failure

RJS AR – symptoms/signs Often asymptomatic Chest pounding Prominent pulse Heart failure

RJS AR – symptoms/signs deMusset’s sign Collapsing pulse Displaced apex beat Early diastolic murmur

RJS Auscultation AR

RJS AR investigations ECG – LVH X-ray – abnormal aorta, large heart Echo – AR, LV dilation, dissection Angiogram – AR, LV dilation

RJS AR - xray

RJS AR - Echo

RJS AR - treatment Antibiotics Vasodilators Replacement – when LV begins to dilate or fail

RJS When to replace the aortic valve?

RJS When to replace the mitral valve When symptoms significant Before LV failure Before significant pulmonary hypertension

RJS Right heart valves Low pressure Tricuspid regurg (drug addicts) Pulmonary stenosis (congenital)