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

2. Classification of Heart Disease Congenital Coronary Electrical Endomyocardial Pericardial Valvular

3. The Cardiac Valves

4. Cardiac Valve Anatomy

5. Valvular Heart Disease Acute and Chronic are Different Diseases

6. Aortic Stenosis

7. Aortic Stenosis Types Valvular Subvalvular Supravalvular

8. Aortic Valve Stenosis

9. Bicuspid Rheumatic Degenerative

10. Aortic Valve Stenosis Age Relationship

11. Bicuspid Aortic Stenosis

12. Rheumatic Aortic Stenosis

13. Degenerative Aortic Stenosis

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

15. Aortic Valve Stenosis Symptoms Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope

16. 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

17. 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

18. 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

19. Aortic Valve Stenosis Untreated Prognosis

20. Aortic Valve Stenosis Chest X-Ray

21. Aortic Valve Stenosis ECG

22. Aortic Valve Stenosis Echo

23. Aortic Valve Stenosis AV Pressure Gradient

24. 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

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

26. Aortic Valve Replacement Transfemoral

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

28. Aortic Regurgitation (Insufficiency)

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

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

31. 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

32. 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)

33. 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

34. Aortic Regurgitation – Chronic Chest X-Ray

35. Aortic Regurgitation Echo

36. Aortic Regurgitation Medical Rx Vasodilators to reduce systolic BP Antibiotic prophylaxis

37. Aortic Regurgitation Surgical Rx Aortic valve replacement

38. Mitral Regurgitation (Insufficiency)

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

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

41. Mitral Regurgitation Papillary Muscles

42. Mitral Regurgitation Leaflet Prolapse (MVP Syndrome)

43. Mitral Regurgitation Calcified Annulus

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

45. 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

46. 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

47. Mitral Regurgitation 2-D Echo

48. Mitral Regurgitation Doppler Echo

49. Mitral Regurgitation Complications Atrial fibrillation Pulmonary hypertension LV dysfunction Infective endocarditis

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

51. Mitral Regurgitation Surgical Rx Mitral repair Mitral valve replacement

52. Mitral Stenosis

53. Mitral Stenosis Increased LA Pressure

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

55. 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

56. 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

57. 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

58. 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

59. Mitral Stenosis Chest X-ray

60. Mitral Stenosis Echo

61. Mitral Stenosis LA Thrombus

62. Mitral Stenosis ECG

63. Mitral Stenosis Complications Atrial fibrillation Infective Endocarditis Peripheral embolism Pulmonary hypertension

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

65. Mitral Stenosis Surgical RX Invasive valvuloplasty Percutaneous valvotomy Valve replacement

66. Mitral Stenosis Invasive Valvuloplasty

67. Mitral Stenosis Surgical RX – Valvuloplasty with Balloon Catheter

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

69. Thank you!