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

2. Mitral stenosis Etiology : Rheumatic heart Rare congenital
Lutembacher’s syndrome (MS + ASD).
Senile calcify mitral valve .

3. Hemodynamic effects:
1. Increase LA pressure that leading to its dilatation
2. Lung congestion.
Reactive pulmonary arteriolar vasoconstriction:
- Decrease pulmonary congestion.
- Initiate pulmonary hypertension.
LA dilatation produce AF & pressure symptoms

6. 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

7. 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

10. Investigations
1. Chest X- ray :show straight left border of the heart due to LA dilatation(mitralization )& double contour.

11. 2. Echocardiography :show thick leaflets dilated LA & can calculate mitral valve area

12. Complications : Atrial fibrillation
LA thrombus & systemic embolizations
Infective endocarditis.
Recurrence of rheumatic activity
Pulmonary hypertension

13. 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.

14. B- surgical treatment :
Open commissurotomy.
Closed commissurotomy.
Valve replacement.
C- percutaneous balloon mitral valvloplasty

16. Percutaneous balloon mitral valvuloplasty

17. Mitral regurgitation

18. 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 )

19. 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

20. 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

21. 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.

23. DD : the causes of pansystolic murmur :
Mitral regurge.
Tricuspid regurge.
VSD.
DD :from other causes of systolic murmur;
Aortic stenosis.

24. 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

25. Complications:
LV failure.
Pulmonary hypertension.
AF.
Thrombus formation.
Rheumatic activity.
Infective endocarditis.

26. 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

27. - 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

28. 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.

29. Hemodynamic effect (1) -Very low diastolic pressure.
(2) -High systolic pressure.
(3) -Wide pulse pressure (peripheral signs)
(4) -LV dilatation & hypertrophy.
(5) -LV failure.

30. 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

31. 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 .

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

35. Complications : Infective endocarditis.
Recurrence of rheumatic activity .
Left ventricular failure.

36. 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.

37. 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.

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

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

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

42. Investigations
Plain X-ray :
- calcifications.
- Post stenotic dilatation.
- Signs of HF at end stage

43. 2. ECG:
- signs of LVH & strain.
- Arrhythmias

44. 3. Echocardiography:
- degree of stenosis
- LVH
- LV dimensions &
function

45. 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