1. Valvular Heart Disease Jagdish Butany MBBS,MS,FRCPC. Prof.,Dept Lab Med & Pathobiol. Pathologist,UHN/TGH. Physical Therapy 5 Nov 2007.

2. Valvular Disease-Objectives Understanding of: Normal Heart Valve Structure Normal Heart valve Function Diseases of Heart Valves Complications of Heart Valve Dysfunction Treatment

3. Valvular Disease A.V. Valves: –Tricuspid –Mitral Semilunar: –Pulmonic –Aortic

4. Valvular Disease Principles: –Valves are living structures with blood flow and endothelial covering –Complex apparatus (MV + TV) –Complex structural attachments (AV)

5. Valvular Disease-Objectives Understanding of: Normal Heart Valve Structure Normal Heart valve Function Diseases of Heart Valves Complications of Heart Valve Dysfunction Treatment

6. Valvular Disease Dysfunction: –Stenosis –Incompetence –Combination

7. Valvular Disease - Dysfunction Etiology: –Congenital Acquired: –Inflammatory –Degenerative –Neoplastic –Iatrogenic

8. Valve Disease - Inflammatory Rheumatic Infective Endocarditis

9. Valve Disease Rheumatic Heart Disease Damage: –Myocardial-acute effects –Valvular-chronic and substantive effects

10. Valve Disease - Rheumatic Fever (1) Acute immune mediated inflammatory disease Involves multiple organs Follows Group A Hemolytic Streptococcal Pharyngitis (Approximately 3%) Acute: Rheumatic Carditis

11. Valve Disease - Rheumatic Fever (2) Clinical Symptoms;General or Systemic Other: –Multiorgan –See Jones Criteria for Diagnosis Sequelae: Chronic Rheumatic Valvular Disease

12. Valve Disease - Rheumatic Carditis Pathology: Myocardium Acute: –Focal lesions (Aaschoff Bodies) –Mononuclear Cells (mainly lymphocytic) –Macrophages –Anitchkov cells –Multinucleated giant cells

13. Valve Disease - Rheumatic Acute: –Pericarditis with Aaschoff bodies Valves: –Verrucae - Rough Zone –Fibrin deposits

14. Valve Disease - Rheumatic Chronic: –Myocardium: Focal scars –Valves Leaflet fibrosis Leaflet retraction Commissural fusion Calcification Chordal fusion/calcification –Orifice

15. Aortic Valve - Stenosis Acquired: Rheumatic Congenital: –Bicuspid Valve –Unicommissural Valve –Unicuspid - “Dome” valve –Subvalvular (HOCM) –Supravalvular (Atresia) –Subaortic Ring Degenerative

16. Mitral Valve - Stenosis Acquired: Rheumatic Congenital: Cortriatriatum Endocardial Bands

17. Aortic Valve - Stenosis Acquired: Rheumatic Congenital: –Bicuspid Valve –Unicommissural Valve –Unicuspid - “Dome” valve –Subvalvular (HOCM) –Supravalvular (Atresia) –Subaortic Ring Degenerative

18. Mitral Valve - Incompetence Rheumatic (with “fixed” stenosis) Myxomatous change (“floppy”) Annular dilatation Annular calcification Infective endocarditis

19. Mitral Valve - Incompetence Rheumatic (with “fixed” stenosis) Myxomatous change (“floppy”) Annular dilatation Annular calcification Infective endocarditis

20. Aortic Valve - Incompetence Fixed stenosis Myxomatous change “Annular” dilatation Sinotubular dilatation [Ascending aortic dilatation]

21. Valvular Disease-Objectives Understanding of: Normal Heart Valve Structure Normal Heart valve Function Diseases of Heart Valves Complications of Heart Valve Dysfunction Treatment

22. Valve Lesions Sequelae: –Turbulent Blood Flow Effects ? Infection Heart Failure

23. Valve Disease: Infective Endocarditis Microbial colonization or infection (also endocardium) “Vegetations” on valve tissue: –Thrombus –Dead Cells –Inflammatory cells –Bacteria Tissue destruction

24. Pathology of SBE Early: –Vegetation, friable, bulky –Tissue damage +/- Pathogenesis: –Bacterial colonies in blood –Site of entry ? –Endothelial damage –Thrombi –Infection

25. Valve Disease - Infective Endocarditis Virulent Bug: –Rapid or acute infective endocarditis –Death: days to weeks Low Virulence Bug: –Subacute bacterial endocarditis

26. Valve Disease - SBE Infection: –Previously Normal Valve –Previously Abnormal Valve –Rheumatic –Congenital –Myxomatous –Calcified / Degenerative –Prosthetic Valves

27. Valvular Disease-Objectives Understanding of: Normal Heart Valve Structure Normal Heart valve Function Diseases of Heart Valves Complications of Heart Valve Dysfunction Treatment

28. Valve Disease - Infective Endocarditis Treatment: –General /supportive –Antibiotics –Valve replacement

29. Valve Disease - Surgery AValve Repair BValve Replacement –Mechanical –Biological –Porcine –Pericardial

30. Valve Replacement Bioprostheses or Tissue Valves Porcine Homograft Pericardial [Duramater] Autografts

31. Valve Replacement Mechanical valves –Ball in cage –Disc (single leaflet) –Bileaflet N.B. All need lifelong anticoagulation

32. Valvular Disease-Objectives Understanding of: Normal Heart Valve Structure Normal Heart valve Function Diseases of Heart Valves Complications of Heart Valve Dysfunction Treatment

33. Heart Disease Regardless of Cause: The End Result is Heart Failure!!!