Valvular heart diseases Flashcards
Introduction
-Valvular heart disease from chronic rheumatic fever is still the commonest cardiac
disease in the developing world, occurring at the younger age.
-It causes significant morbidity and mortality due to lack of appropriate preventive and
therapeutic intervention.
-It accounts for 42 % of cardiac patients attending hospitals in Ethiopia.
-Generally, patients with stenotic valvular lesions can be monitored clinically until
symptoms appear. In contrast, patients with regurgitate valvular lesions require careful echocardiographic monitoring for left ventricular function and may require surgery even if
no symptoms are present.
-Aside from antibiotic prophylaxis, very little medical therapy is available for patients with valvular heart disease; surgery is the treatment for most symptomatic lesions or for
lesions causing left ventricular dysfunction even in the absence of symptoms. However surgical management is unavailable for most patients who are suffering from valvular heart diseases in Ethiopia
explain Aortic Stenosis (AS) , causes , Clinical features ,Physical Examination ,Echocardiography , Chest X-ray , Management , Prognosis
-causes : Aortic stenosis could be caused by
1.Rheumatic carditis
2.Congenital stenosis of aortic valve or
3.Senile/calcific aortic stenosis which is idiopathic results in calcification and degeneration of the aortic leaflets
4.Persons born with a bicuspid aortic valve are predisposed to develop aortic stenosis.
-Clinical features :Initially there is an extended latent period during which the patient is asymptomatic. This is followed by the classic symptoms of AS:
1.Angina
2.Exertional syncope and
3.Dyspnea
-Physical Examination
1.The most common physical sign of aortic stenosis is a systolic ejection murmur at left at the 2nd intercostals space that radiates to the neck. In mild aortic stenosis, the murmur
peaks early in systole, but as the severity of stenosis increases, the murmur peaks progressively later in systole and may become softer as cardiac output decreases
2.As the stenosis worsens, the aortic component of the second heart sound may become diminished.
3.The timing and amplitude of the carotid pulse correlate with the severity of aortic stenosis. Later in the disease, the carotid upstrokes become diminished and delayed (parvus et tardus)
-Echocardiography
1.Echocardiography with Doppler provides an accurate assessment of aortic valve area and transvalvular gradient and also can be used to estimate left ventricular hypertrophy
and ejection fraction
-Chest X-ray: may demonstrate valve calcification
-Management : we have 2 pathway medical and surgical
1-Medical Therapy:
1.1 Is not effective and treatments with digitalis or cautiously administered diuretics may only reduce symptoms.
1.2 Patients with severe aortic stenosis should limit vigorous physical activity.
1.3 Patients with aortic stenosis are at moderate risk for development of endocarditis and should receive endocarditis prophylaxis before selected procedures.
2-Surgical Therapy : Aortic valve replacement is the only effective treatment that will relieve this mechanical obstruction.
-Prognosis :
1.The survival of patients with aortic stenosis is nearly normal until the onset of symptoms, when survival rates decrease sharply.
2.Although the rate of progression of aortic stenosis is variable and difficult to predict approximately 75 percent of patients with aortic stenosis will be dead three years after the onset of symptoms if the aortic valve is not replaced
explain Aortic Regurgitation (AR) , causes ,Physical Examination ,Echocardiography ,Management ,
-causes : Aortic regurgitation results from disease affecting the aortic root or aortic leaflets, preventing their normal closure.
Common causes of aortic regurgitation include:
1.Endocarditis
2.Rheumatic fever
3.Collagen vascular diseases
4.Aortic dissection
5.Syphilis
6.Bicuspid aortic valves are also prone to regurgitation.
NB!
1.In chronic aortic regurgitation, the stroke volume is increased, which in turn causes systolic hypertension, high pulse pressure and increased afterload. The afterload in aortic regurgitation may be as high as that occurring in aortic stenosis.
2.Patients may be asymptomatic until severe left ventricular dysfunction has developed. The initial signs of aortic regurgitation are subtle and may include decreased functional capacity or
fatigue. As the disease progresses, the typical presentation is that of left-sided heart failure: orthopnea, dyspnea and fatigue.
3.Systolic dysfunction is initially reversible, with full recovery of left ventricular size and function after aortic valve replacement. Over time, however, progressive chamber enlargement with
decreased contractility make recovery of left ventricular function and improved survival impossible, even with surgery.
-Physical Examination:
1.A diastolic blowing murmur heard along the left sternal border is characteristic of aortic regurgitation. A diastolic rumble may also be heard over the apex.
2.The peripheral signs of hyperdynamic circulation indicate severe disease. Some of these
include:
o Wide pulse pressure
o Collapsing pulse ( water hammer pulse )
o Quincke’s pulse (alternating blanching and erythema of the nailbed with gentle pressure applied)
o De musset’s sign (head bobbing)
o Pistol shot over the femoral artery
-Echocardiography
1.Echocardiography with Doppler ultrasonography provides information about aortic valve morphology and aortic root size, and a semiquantitative estimate of the severity of aortic
regurgitation .It provides valuable information about left ventricular size and function.
-Management : we have 2 pathway medical and surgical
1.Medical Treatment
1.1 Diuretics
1.2 Digoxine: may be indicated in patients with severe regurgitation and dilated left ventricle without frank LV failure.
1.3 Salt restriction
1.4 Vasodilators: afterload reduction with vasodilators has been shown to improve left ventricular performance and reduce aortic regurgitation. ACE inhibitors are the preferred
vasodilators. Therapy with long acting nifedipine in particular has been shown to delay the need for surgery by two to three years.
1.5 Endocarditis prophylaxis is essential for all patients with AR as their infection tolerance is poor.
2-Surgical management: aortic valve replacement is the definitive treatment for patients with AR. There are two important points to consider in deciding the timing of surgery.
2.1 Patients with chronic AR usually don’t become symptomatic until after the development of myocardial dysfunction
2.2 When delayed too long, surgical treatment often does not restore normal LV function.
NB! There for appropriate timing is necessary for surgical intervention. Aortic regurgitation should be corrected if the symptoms are more than mild. Compelling evidence supports surgical correction before the onset of permanent left ventricular damage, even in asymptomatic patients.
explain Mitral Stenosis (MS), general idea ,Physical Examination , Complication of MS ,Echocardiography , Chest X-ray , Management
-general idea :
1.Mitral stenosis is sequelae of rheumatic heart disease primarily affecting women.
2.Mitral stenosis has a progressive, lifelong course that is slow and stable in the early years, with rapid acceleration later in life.
3.It is very common in the developing countries manifesting below the age of 20 whereas there is generally a latent period of 20 to 40 years between the occurrence of rheumatic fever and of mitral stenosis in developed countries.
4.Elevated left atrial pressure eventually causes pulmonary vasoconstriction, pulmonary hypertension and compromise of right ventricular function.
5.Many patients remain asymptomatic until atrial fibrillation develops or until pregnancy occurs, when there is increased demand on the heart.
6.Symptoms are generally those of left-sided heart failure: dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. Patients may also present with hemoptysis, signs of
right-sided heart failure, and embolic phenomena like stroke.
-Physical Examination :
1.An apical rumbling, mid-diastolic murmur is characteristic and will immediately follow an opening snap, if present. The rumble is loudest in early diastole but, in patients with mild
mitral stenosis or mitral stenosis with low cardiac output, the murmur may be difficult to hear. It can be accentuated by placing the patient in the left lateral decubitus position
and using the bell of the stethoscope. Brief exercise (such as walking in the hallway) may also accentuate the murmur.
2.A loud first heart (S1) sound is common.
3.A right ventricular lift, elevated neck veins, ascites and edema are later signs of right ventricular overload with pulmonary hypertension.
-Complication of MS :
1.Atrial fibrillation
2.Thromboembolism
3.Right sided hear failure
-Echocardiography: is the study of choice for diagnosing and assessing the severity of mitral stenosis
-Chest X-ray : may show left atrial enlargement and sign of pulmonary congestions.
-Management : we have two classification In asymptomatic patients and In patients with symptoms
1-In asymptomatic patients
1.1Annual evaluation (history and physical examination, as well as a chest x-ray and ECG).
1.2 Endocarditis prophylaxis
1.3 Secondary prophylaxis for rheumatic fever
2-In patients with symptoms:
-Medical treatment :
1.Diuretics may be helpful in reducing left atrial pressure and decreasing symptoms.
2.Digoxin: is indicated for patients with atrial fibrillation to control the heart rate, since tachycardia will further decrease left ventricular filling, reduce cardiac output and
increase left atrial pressure, leading to more symptoms.
3.Anticoagulants such as Warfarin may be indicated in patients with Left atrium and atrial fibrillation.
-Surgical management: improves survival and reduce symptoms.
1.Open commissurotomy or
2.Mitral valve reconstruction or
3.Mitral valve replacement
explain Mitral Regurgitation (MR) , Causes , Pathophysiology ,symptoms ,Physical Examination ,Echocardiography ,Chest X-ray ,Management
-Causes of chronic mitral regurgitation include:
1. Rheumatic fever
2. Infective endocarditis
3. Degenerative valvular disease (mitral valve prolapsed).
4. Myocardial infarction affecting papillary muscles.
-Pathophysiology: Chronic mitral regurgitation is a state of volume overload leading to the development of left ventricular hypertrophy. The left atrium also enlarges to accommodate the regurgitate volume. This compensated phase of mitral regurgitation varies in duration but may last many years. The prolonged state of volume overload may eventually lead to decompensate mitral regurgitation. This phase is characterized by impaired left ventricular function, decreased ejection fraction and
pulmonary congestion.
-symptoms :The common symptoms are:
1.Fatigue, Exertional dyspnea and orthopnea are the most common complaints.
2.Right sided heart failure with painful hepatic congestion, peripheral edema may occur in patients with MR who have associated pulmonary hypertension.
-Physical Examination :
1. A soft first heart sound ( S1 is generally absent ) and a widely split second heart sound may be present.
2. An S3 gallop indicates severe disease but does not necessarily indicate heart failure
3. There may be displacement of the left ventricular impulse
4. A holosystolic murmur that may radiate to the axilla, the upper sternal borders or the subscapular region is apparent on physical examination.
-Echocardiography : can be used to determine the etiology and morphology of mitral regurgitation, which are important in determining suitability for mitral valve repair.
-Chest X-ray: Enlargement of LA and LV , Pulmonary venous congestion and interstitial edema and Kerley-B lines .
-Management :
1-Medical Treatment:
1.1 Diuretics
1.2 Digoxin: may be indicated in patients with severe regurgitation and dilated left ventricle without frank LV failure.
1.3 Salt restriction
1.4 Vasodilators: afterload reduction with vasodilators has been shown to improve left ventricular performance.. ACE inhibitors are the preferred vasodilators.
1.5 Treatment of atrial fibrillation if it occurs
1.6 Endocarditis prophylaxis is important essential..
2-Surgical Treatment: Mitral valve replacement is the definitive treatment.
2.1 In patients with chronic mitral regurgitation, left ventricular damage can occur while the patient remains asymptomatic. Therefore, surgery is indicated if left ventricular dysfunction has begun to develop, even in the absence of symptoms.
2.2 Patents with MR who are asymptomatic and whose LV function are normal are not considered to be candidates for surgical treatment.
explain Tricuspid Regurgitation (TR) , ,causes , Clinical features ,Echocardiography , Management: ,
-causes :
1.TR is functional and secondary to marked dilatation of tricuspid annulus The most common cause of TR is pulmonary hypertension as result of left sided cardiac failure or pulmonary parenchymal/vascular disease.
2.Less common causes include rheumatic HD, right sides myocardial infarction , and endocarditis in IV drug abusers.
-Clinical features
1.In patients with pulmonary HTN symptoms of pulmonary congestion diminish, but the symptoms of right sided heart failure are intensified such as peripheral edema and ascites.
2. Patients will have prominent jaguar venous distention
3. Holosystolic murmur at the left lower sternal border.
4. Pulsatile liver and
5. More prominent ascites than edema is a common finding
-Echocardiography : It is a very useful study, and it differentiates primary from secondary TR.
-Management:
1.Treatment of the underlying cause of heart failure usually reduces the severity of functional TR.
2. Surgical treatment as indicated for primary TR.
explain Mitral Valve Prolapse, DF , causes , Clinical futures , Management
-DF : Mitral valve prolapse occurs when varying portions of one or both leaflets of the mitral valve extend or protrude abnormally above the mitral annulus into the left atrium.
-causes :
1.Redundant or excessive mitral valve tissue
2.Congenital diseases such as Marfan’s syndrome ,
osteogenesis imperfecta.
-Clinical futures
1.MVP is more common in females and more common in the age group of 14-30.
2.The clinical course is often benign
3.Most patients are asymptomatic and may remain so for their entire lives.
4.Some patients may manifest with features of Mitral regurgitation
5.Arrhythmias like premature ventricular contractions and ventricular tachycardias may
occur as complications.
6,The mid-systolic click, often accompanied by a late systolic murmur, is the auscultatory hallmark of mitral valve prolapse.
-Management :
1.Asymptomatic patients may need only reassurance
2.Symptomatic patients with thickening of mitral valve
o Endocarditis prophylaxis is
o B- blockers sometimes may relive chest pain
3. Sever symptoms from secondary MR : surgical treatment may be needed ( mitral valve repair and or rarely replacement. )
