Valvular Heart Disease. Kul

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Valvular Heart Disease

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Valvular Heart Disease
Dr.Suhaemi,SpPD, Finasim

Types







Mitral Stenosis
Mitral Regurgitation
Mitral Valve Prolapse
Aortic Stenosis
Aortic regurgitation
Tricuspid valve
• Tricuspid stenosis
• Tricuspid regurgitation

Tricuspid Valve

Mitral Valve:
hockey stick
appearance
indicating
Rheumatic Valve
Disease
Valve area varied
between 1.4 to
1.6
Exercise Echo was
done

Rheumatic Heart Disease




Inflammatory process that may affect
the myocardium, pericardium and or
endocardium
Usually results in distortion and
scarring of the valves

Rheumatic Heart Disease


Subjective
symptoms
• Prior history of

rheumatic fever
• General malaise
• Pain – may or may
not be present



Objective
symptoms
• Temperature
• Murmurs
• Dyspnea
• Polyarthritis

Rheumatic Heart Disease


Diagnosis
• H/P
• WBC and ESR
• C-reactive protein
• Cardiac enzymes
• EKG
• Chest x-ray
• Echo
• Cardiac cath
• Cardiac output

Rheumatic Heart Disease


Nursing Care
• Vital signs
• Rest and quiet environment
• Give antibiotics, digitalis, and diuretics
• Provide adequate nutrition
• Monitor I/O
• Explain treatment and home care

Mitral Stenosis









Usually results from rheumatic carditis
Is a thickening by fibrosis or calcification
Can be caused by tumors, calcium and thrombus
Valve leaflets fuse and become stiff and the
cordae tendineae contract
These narrows the opening and prevents normal
blood flow from the LA to the LV
LA pressure increases, left atrium dilates, PAP
increases, and the RV hypertrophies
Pulmonary congestion and right sided heart
failure occurs
Followed by decreased preload and CO decreases

Mitral Stenosis, cont.






Mild – asymptomatic
With progression – dyspnea, orthopneas,
dry cough, hemoptysis, and pulmonary
edema may appear as hypertension and
congestion progresses
Right sided heart failure symptoms occur
later
S/S
• Pulse may be normal to A-Fib
• Apical diastolic murmur is heard

2-D Echo showing heavily calcified
Mitral valve leaflets and Mitral stenosis

3-D Echo of Mitral Stenosis

LA view

LV view

Real Time TTE of MS
A

C

B

LA

D

E

F

G

Mitral
Management Principles
Stenosis

Severe MS
is usually symptomatic
Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority
PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
PMC in skilled centers has a mortality of < 1%
Success of PMC depends on the pre-PMC valve anatomy

Commissural calcification is a predictor of suboptimal outcome

Complications: severe MR, embolization and cardiac perforatio

Mitral
Management Principles
Stenosis
• Surgical treatment
- commissurotomy (only occasionally indicated,
usually PMC)
- valve replacement

Mitral Regurgitation










Primarily caused by rheumatic heart disease, but
may be caused by papillary muscle rupture form
congenital, infective endocarditis or ischemic
heart disease
Abnormality prevents the valve from closing
Blood flows back into the right atrium during
systole
During diastole the regurg output flows into the LV
with the normal blood flow and increases the
volume into the LV
Progression is slowly – fatigue, chronic weakness,
dyspnea, anxiety, palpitations
May have A-fib and changes of LV failure
May develop right sided failure as well

Mitral Valve Anatomy

Pathophysiology






Hemodynamic changes much more
pronounced than in chronic MR due
to lack of time for adaptation
The abrupt increase in left atrial
pressure is transmitted to the
pulmonary circulation
Cardiac output falls and systemic
vascular resistance increases

Echo performed…

Mitral Valve Prolapse








Cause is variable and may be associated
with congenital defects
More common in women
Valvular leaflets enlarge and prolapse into
the LA during systole
Most are asymptomatic
Some may report chest pain, palpitations
or exercise intolerance
May have dizziness, syncope and
palpitations associated with dysrhythmias
May have audible click and murmur

Mitral Valve Prolapse
Types
• Women 20 to 50 years
• Low BP, orthostatic hypotension, palpitations, chest pain
• Mid systolic click, maybe mid systolic murmur
• Echo:
- thickened, redundant leaflets
- leaflet excursion (prolapse) into LA in systole
- redundant chordae tendinae, trivial or mild MR
• Little progression of MR, Abx prophylaxis

Mitral Valve Prolapse
Types
• Men 40 to 70 years
• Myxomatous and thickened MV
• Significant leaflelt prolapse
• Significant MR, progressive MR
• Complications: Chordal rupture, Afib
• Endocarditis prophylaxis
• Surgery for MR often required
Classic or non-classic combined MVP equal in male and
females. More complications in MEN

Transthoracic echocardiographic image in parasternal
long-axis view, showing posterior mitral leaflet bowing
backward and prolapsing into left atrium during systole.
LV=left ventricle. LA=left atrium. PML=posterior mitral
valve leaflet.

Aortic Stenosis







Valve becomes stiff and fibrotic, impeding blood flow with LV
contraction
Results in LV hypertrophy, increased O2 demands, and
pulmonary congestion
Causes – rheumatic fever, congenital, arthrosclerosis
Atherosclerosis and calcification is primary cause in the
elderly
Complications – right sided heart failure, pulmonary edema,
and A-fib
S/S – Early: dyspnea, angina, syncope
Late: marked fatigue, debilitation, and
peripheral cyanosis, crescendodecrescendo
murmur is heard

Aortic
Diagnosis
Stenosis
Clinical

- pulsus parvus et tardus (absent in hypertensives and elderly
- systolic thrill and typical heaving apical impulse
- S4 and late peaking ejection systolic murmur
- paradoxical split of 2nd HS in severe AS
- other auscultatory signs modified by co-existing disease
ECG
- LVH with strain
CXR
- dilated ascending aorta (post-stenotic dilatation)
- Valve calcification

Aortic
Management Principles
Stenosis
• Asymptomatic
- no specific therapy
- endocarditis prophylaxis
- if appropriate, rheumatic fever prophylaxis
• Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm)
- Normal physical activity
- No specific therapy, restoration of NSR in case of AFib
- approx. progression is a decrease by 0.1 sq cm per year
- annual echo follow-up

Aortic
Management Principles
Stenosis
• Nonsurgical (Balloon vavuloplasty)
- only a palliative treatment
- high risk elderly patients or as an emergent
procedure

Cardiac MRI and CT

Indications for Surgery

Indications for Surgery

Aortic Regurgitation









Aortic valve leaflets do not close properly during diastole
The valve ring that attaches to the leaflets may be dilated,
loose, or deformed
The ventricle dilates to accommodate the ^ blood volume
and hypertrophies
Causes: infective endocarditis, congenital, hypertension,
Marfan’s
May remain asymptomatic for years
Develop dyspnea, orthopnea, palpitations, ,and angina
May have ^ systolic pressure with bounding pulse
Have a high pitch, blowing, decrescendo diastolic murmur

Example of a Jet of Aortic Regurgitation, as Shown by Color-Flow Imaging

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Example of Quantitation of Aortic Regurgitation by the Convergence of the Proximal Flow

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Classification of the Severity of Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Guidelines for Indications for Surgery in Patients with Severe Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Assessment for Valve
Dysfunction


Subjective symptoms









Fatigue
Weakness
General malaise
Dyspnea on exertion
Dizziness
Chest pain or discomfort
Weight gain
Prior history of rheumatic heart disease

Assessment, cont.


Objective symptoms
• Orthopnea
• Dyspnea, rales
• Pink-tinged sputum
• Murmurs
• Palpitations
• Cyanosis, capillary refill
• Edema
• Dysrhythmias
• Restlessness

Diagnosis






History and physical findings
EKG
Chest x-ray
Cardiac cath
Echocardiogram

Medical Treatment





Nonsurgical management focuses on
drug therapy and rest
Diuretic, beta blockers, digoxin, O2,
vasodilators, prophylactic antibiotic
therapy
Manage A-fib, if develops, with
conversion if possible, and use of
anticoagulation

Interventions










Assess vitals, heart sounds, adventitious breath
sounds
^ HOB
O2 as prescribed
Emotional support
Give medications
I/O
Weight
Check for edema
Explain disease process, provide for home care
with O2, medications

Surgical Management of Valve
Disease


Mitral Valve
• Commissurotomy
• Mitral Valve Replacement
• Balloon Valvuloplasty



Aortic Valve Replacement

Mechanical Valve

Mechanical Valve

Porcine Valve

Tissue Valve

Tissue Valve

Initial studies

Eur Heart J 2002 (23) 1045-1049





First report of left sided percutaneous valve implants by
Bonhoeffer
• Use of bovine jugular vein containing a valve which was
dissected and sutured into a stent in lambs
• Valve initially implanted in descending aorta for acute
aortic insufficiency model.
Orientation and orthotopic position optimized in further
animal models
In vitro testing showed a satisfactory durability for up to 2
yrs.

Schematic views of device







Left - 3 parts of device are
represented separately (from
top: platinum stent, nitinol
stent, and valve).
Middle - Fully expanded device
is shown longitudinally and
axially.
Righ - diagrams demonstrate
where nitinol and platinum
stents are attached, which
allowed stepwise approach.

From: Boudjemline: Circulation, Volume 105(6).February 12, 2002.775778

Newly designed stent crimped on outer balloon of delivery system before
being covered. Notice spontaneous expansion of nitinol stent.
Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

(1) Whole system advanced in left ventricle.
(2) Device then uncovered, deploying nonsutured part of nitinol stent.
Free wires of nitinol stent positioned in bottom of native leaflet.
(3) Balloons are inflated to expand platinum stent
(4) Finally deflated, and retrieved, leaving device in position.
Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

Percutaneous Heart Valve
(PHV)
14 mm in length
Trileaflet
Tissue valve made of
three equal size sections
of bovine pericardium
The percutaneous valve crimped
over the 30-mm-long balloon before
implantation

From: Cribier: Circulation, Volume 106(24).December 10, 2002.3006-3008

JACC (2004) 43:1082-7

JACC (2002) 39:1664-1669

Summary


Percutaneous Valvuloplasty
• MV valvuloplasty efficacious in carefully selected patients
• AV valvuloplasty
 Only transient improvement and high restnosis rate in adult
population
 Last resort or bridge to surgery in patients with severe calcified AS
• PV valvuloplasty
 mainly in pediatric population
 Well-accdepted treatment for PS and good f/u results



Percutaneous Valve repair
• Currently investigational devices for MR only
• Still early stage with no published results (that I know of) in human



Percutaneous valve replacement/implantation
• Early stages with very limited data on human
• Promising results for PV in pediatric population
• Limited but promising data in human for AV implant in non-surgical
candidates
• Larger scale clinical trials and long term data needed
• Unanswered questions regarding ideal material, paravalvular leaks,
durability, complications and more.



Overall, percutaneous valve intervention is an exciting field in
interventional cardiology but still at an infantile stage with potentially
immense clinical application!

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