1. Valvular Heart Disease Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P. Director of Non-Invasive Cardiology Long Island Cardiovascular and Internal Medicine Manhasset, N.Y.

7. Calcified Ao Valve 2 nd to acquired AoV Stenosis

8. Severely calcified tricuspid valve from an elderly patient

10. Phonogram of a 20yoa women with moderate AoV congenital stenosis with a bicuspid valve, presenting with an ejection click, increased A2 and systolic ejection murmur

11. Phonogram of a 20yoa male with severe non-calcified AoVS. Seen here is a paradoxical splitting of S2, late systolic ejection murmur and prominent S4. The LV is noted to have a low volume and a slow up swing of the carotid pulse.

12. Apexcardiogram of the severe AoVS showing a sustained “a” wave, causing a palpable S4 gallop (the non-compliant ventricle)

13. 70yoa male with sever AoVS, note the absence of both the ejection click and Ao second sound (circled). Also there is a slow up swing of the carotid pulse.

15. The window to the inner world – The Eyes – Note the multiple calcific emboli in the retina of this elderly patient presenting with amaurosis fugax – Patient was Dx with severe acquired AoVS

23. Catheter gradients are reported as peak to peak pressure differences This is not a true measurement of pressure drop off across the AoV because they do not occur at the same time Echocardiogram is ideal for pressure drop off across the valve The two should be used together to evaluate the patient for validation studies Peak to Peak pressure diff Pressure Drop off

25. Percutanous valvuloplasty with a prophylactic RV Pacemaker to combat bradycardia during the procedure

26. Ross Procedure

27. Survival in the elderly (ave age of 60) after a AoV replacement (AVR)

28. Pt with Marfan’s syndrome

29. Marfan’s with type-A Ao dissection

35. Growth the heart muscle A – Infant’s heart weighing about 15gm and LV is 7gm B – Adult’s weighing 300gm and 100gm respectively C – Athlete's is 500gms and 200gm D – Concentric Hypertrophy – 650gms and 400gms E – Decompensated Eccentric Hypertrophy – 900gms and 500gms – fewer myocytes are noted, replaced by fibrotic scar tissue

36. rhrhrhrh

51. Pre and Post op CXR of a patient with AoV Regurgitation Note the decrease in long and short diameters from the Starr-Edwards valve replacement procedure

52. Typical LVH associated with AoVR with a strain pattern and tall T-waves

54. LV wall stress can be reduced with ACE-I or hydralazines, but only ACE-I are noted to decrease LV mass index and improve EF’s more effectively

57. % Survival Rates

59. Patient with overt pulmonary edema. Note the characteristic “batwing sign” on the CXR – fluid distribution

62. Top – myxomatous MV Bottom – Nl MV

67. Phonogram of severe FMV and MVR

68. Echo of an FMP with MVP in diastole

69. Note the MV prolapsing into the LA

70. LV cineangiography in the RAO and LAO projection

71. LV Ventriculogram of a pt with MR

75. It’s not just the heart S/S of FMV/MPV is a dynamic inter- relationship between the Cardiac, Neuroendocrine and Autonomic Nervous System

79. Pulse and Reflected wave velocities in an elastic Ao

80. What about in a stiff ventricle?

83. Phonogram with simultaneous ECG of a pt post MV repair – note the absence of a murmur (pre-op below)

87. Quick, what’s this ECG showing?

94. B-S Single Tilting Disk

95. M-H Single Tilting Disk – Contains a Teflon sewing ring, titanium housing and carbon coated disks

96. St. Jude Bi-leaflet Tilting Disk

97. C-E Stented porcine Bioprosthesis

98. Hancock II Stented Bioprosthesis

99. C-E Stented Pericardial Bioprosthesis

101. Toronto Stentless Porcine Valve

102. Ausculatory Finding With Prosthetic Valves

104. The St. Jude Heart Valve has regurgitant flow that is perpendicular to the valve Regurgitation is noted at the disk margins and the extremes of the closure line

108. Prosthetic valves are prone to perforate

113. TEE of an endocarditis originating from the prosthetic valve

114. Another View

121. Any one know what Dressler’s syndrome is?

123. Vegetations on a MV 2 nd to Infective Endocarditis from H. Flu

124. Strep. Sanguis (or any pathogen) can cause occlusive coronary embolization of the coronary ostium

125. Subungual hemorrhages (splinter hemorrhages) are indicative of Acute infective endocarditis

126. If you see needle tracks – think infective endocarditis (tricuspid perforation is common with IVDA)

127. Does everybody see the vegetation on the posterior leaflet, in this patient with severe MVP?