Valvular Heart Disease

1
Valvular Heart Disease
2
Types

• Mitral Stenosis
• Mitral Regurgitation
• Mitral Valve Prolapse
• Aortic Stenosis
• Aortic regurgitation
• Tricuspid valve is affected infrequently
• Tricuspid stenosis causes Rt HF
• Tricuspid regurgitation causes venous overload

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Tricuspid Valve
4
Rheumatic Heart Disease

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

5
Rheumatic Heart Disease, cont.

• Subjective symptoms
• Prior history of rheumatic fever
• General malaise
• Pain may or may not be present

• Objective symptoms
• Temperature
• Murmurs
• Dyspnea
• polyarthritis

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Rheumatic Heart Disease

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

7
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

8
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

9
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

10
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

11
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

12
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, crescendo-
  decrescendo murmur is heard

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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, Marfans
• 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

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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

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Assessment, cont.

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

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Diagnosis

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

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Medial 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

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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

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Surgical Management of Valve Disease

• Mitral Valve
• Commissurotomy
• Mitral Valve Replacement
• Balloon Valvuloplasty
• Aortic Valve Replacement

21
Mechanical Valve
22
Mechanical Valve
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Porcine Valve
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Tissue Valve
25
Tissue Valve
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Cardiac murmurs

• Cardiac murmurs are often the first sign of
  underlying valvular disease.
• May be systolic or diastolic, pathological or
  benign.
• Systolic murmurs may be due to physiological
  increases in blood velocity or might indicate as
  yet asymptomatic cardiac disease.
• Diastolic murmurs are almost always pathological
  and require further evaluation.
• An ECG and CXR, although readily available tests,
  provide limited diagnostic information.

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Echocardiography

• Echocardiography can evaluate valve function by
  the following imaging modalities
• 2-D Valve motion and morphology
• LV size and function.
• Doppler Blood flow velocity valve
  gradients haemodynamic data.
• Colour flow Valvular regurgitation

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Management of cardiac murmurs

• Murmur cardiac symptoms refer to cardiologist.
• In asymptomatic patients with cardiac murmurs, an
  echo is indicated in the following
  instances
• - Murmur abnormal cardiac signs
• - Murmur abnormal ECG or CXR
• - Diastolic or continuous murmurs
• - Pansystolic or late systolic murmurs

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Aortic stenosis

• Aetiology
• Aortic stenosis may be congenital or acquired.
• Congenital malformations may be tricuspid,
  bicuspid or unicuspid.
• Acquired causes include the following
• - Degenerative disease
• - Rheumatic disease
• - Calcific e.g. end-stage renal failure, Pagets
  disease
• - Miscellaneous e.g. rheumatoid involvement

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Aetiology of aortic stenosis
A Normal aortic valve B Congenital aortic
stenosis C Rheumatic aortic stenosis D
Calcific aortic stenosis E Degenerative aortic
stenosis
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Aortic stenosis

• Grading and severity
• Aortic valve area must be reduced to 25 of
  normal before significant circulatory changes
  occur.
• Grading of stenosis severity is as follows
• - Normal valve area 3-4cm2
• - Mild stenosis 1.5-3cm2
• - Moderate stenosis 1.0-1.5cm2
• - Severe stenosis 1.0cm2
• When stenosis is severe, the peak gradient across
  the aortic valve is usually gt 60mmHg.

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Pathophysiology of aortic stenosis

• Aortic stenosis
• LV outflow obstruction
• LV systolic pressure Aortic
  pressure
• LV hypertrophy
• LV dysfunction
  Myocardial ischaemia
• 
  LV failure

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Aortic stenosis
Natural history of aortic stenosis without
operative treatment
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Aortic stenosis

• Physical findings
• Slow rising pulse
• Reduced systolic and pulse pressure
• Systolic thrill over the aortic area
• Ejection systolic, crescendo-decrescendo murmur
• Soft or inaudible second heart sound
• ECG LVH, AV node conduction defects

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Aortic stenosis

• Medical therapy
• Conservative treatment should be offered for mild
  to moderate aortic stenosis and to asymptomatic
  patients with severe aortic stenosis as follows
• - Advise to report symptoms
• - Avoid vigorous exercise
• - Antibiotic prophylaxis for endocarditis
• - Regular follow-up echocardiography

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Aortic stenosis

• Surgical therapy
• Aortic valve replacement should be offered to the
  following
• - Symptomatic pts with severe AS
• - Pts with severe AS undergoing CABG surgery
• - Pts with moderate AS undergoing CABG surgery
• - Asymptomatic pts with severe AS and LV
  dysfunction
• Balloon valvuloplasty can play a temporary role
  as a bridge to surgery in haemodynamically
  unstable patients, or as palliation for patients
  with serious comorbid conditions

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Aortic stenosis

• Aortic valve replacement
• In the absence of LV dysfunction, operative risk
  is
• 2-8.
• Indicators of higher mortality are NYHA class, LV
  dysfunction, age, concomitant coronary artery
  disease, and aortic regurgitation.
• Valve replacement usually results in reduced LV
  volumes, improved LV performance and regression
  of LV hypertrophy.

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Aortic regurgitation

• Aetiology
• Either due to primary disease of the aortic valve
  or wall of the aortic root or both.
• Causes of primary aortic valve disease include
• - Congenital eg. bicuspid aortic valve
• - Acquired rheumatic valve disease, infective
  endocarditis, trauma, connective tissue
  disease.
• Causes of primary aortic root disease include
• - Degenerative, cystic medial necrosis (eg.
  Marfans), aortic dissection, syphilis,
  connective tissue disease, hypertension.

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Pathophysiology of aortic regurgitation

• Aortic regurgitation
• LV volume stroke volume diastolic
  BP
• LV mass systolic BP
• LV dysfunction myocardial ischaemia
• LV failure

40
Aortic regurgitation

• Clinical history
• In chronic severe AR, the left ventricle
  gradually enlarges while the patient remains
  asymptomatic. Symptoms usually develop after
  cardiomegaly and LV dysfunction have occurred.
  Dyspnoea is the principal complaint. Syncope is
  rare and angina is less frequent than in aortic
  stenosis.
• In acute severe AR, LV decompensation occurs
  readily with fatigue , severe dyspnoea and
  hypotension.

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Aortic regurgitation

• Physical findings
• Collapsing pulse.
• Wide pulse pressure due to both raised systolic
  blood pressure and reduced diastolic blood
  pressure.
• Displaced, diffuse and hyperdynamic apex beat.
• Early blowing diastolic murmur.
• ECG Left axis deviation, LV hypertrophy.
• CXR Cardiomegaly, aortic calcification, aortic
  root dilatation.

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Aortic regurgitation

• Management
• Medical treatment includes
• - Diuretics, digoxin, salt restriction
• - Vasodilators
• - Endocarditis prophylaxis
• Indications for surgical treatment depend on
  symptoms,
• and LV size and function.
• Without surgery, death usually occurs within 4
  years of developing angina and within 2 years
  after onset of heart failure.

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Aortic regurgitation

• Surgical therapy
• Severe acute AR requires prompt surgical
  intervention.
• Indications for valve replacement in pure,
  severe, chronic AR include
• - Symptomatic patients with normal LV function
• - Symptomatic patients with LV dysfunction or
  dilatation
• - Asymptomatic patients with LV dysfunction or
  dilatation (EFlt50 or end-systolic diameter gt
  55mm)
• Aortic valve and root replacement are indicated
  in patients with disease of the proximal aorta
  and AR of any severity when the aortic root
  diameter is 50mm.

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Aortic valve replacement and prognosis
Relation of preoperative LV function to
postoperative survival
45
Mitral stenosis

• Aetiology
• Rheumatic fever is the predominant cause.
• Rarely, mitral stenosis is congenital and
  observed almost exclusively in infants and young
  children.
• Miscellaneous rare causes include carcinoid, SLE,
  rheumatoid arthritis and mucopolysaccharidoses.
• Causes of left atrial outflow obstruction that
  may simulate mitral stenosis include left atrial
  myxoma, ball-valve thrombus, infective
  endocarditis with large vegetation and cor
  triatriatum.

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Rheumatic mitral stenosis

• Rheumatic mitral stenosis is due to four forms of
  fusion commissural (30), cuspal (15), chordal
  (10) or combined (45).
• The stenotic mitral valve is typically
  funnel-shaped the orifice is frequently shaped
  like a fish mouth.
• Symptoms usuually occur in the 3rd or 4th decade,
  but mild MS in the aged is becoming more common.
• 25 of patients with rheumatic mitral valve
  disease have pure mitral stenosis and two-thirds
  are female.
• May be associated with an atrial septal defect
  Lutembachers syndrome.

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Mitral stenosis

• Pathophysiology
• Normal mitral valve area 4-6cm2.
• Usually, a mitral valve area 2.5cm2 must occur
  before the development of symptoms.
• A mitral valve area gt1.5cm2 usually does not
  produce symptoms at rest.
• The first symptoms in mild mitral stenosis are
  usually precipitated by exercise, emotional
  stress, infection, pregnancy or fast atrial
  fibrillation.
• A mitral valve area 1cm2 equates to severe
  mitral stenosis.
• Pulmonary hypertension results from backward
  pressure, pulmonary arteriolar constriction and
  organic obliterative changes in the pulmonary
  vascular bed.

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Mitral stenosis

• Natural history
• Long latent period of 20 to 40 years from the
  occurrence of rheumatic fever to onset of
  symptoms.
• Once symptoms develop, there is a further 10
  years before symptoms become disabling.
• Once significant limiting symptoms occur, the
  10-year survival rate is 5-15.
• When there is severe pulmonary hypertension, mean
  survival falls to lt 3 years.
• Mortality from untreated mitral stenosis is due
  to progressive heart failure (60-70), systemic
  embolism (20-30) and pulmonary embolism (10).

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Mitral stenosis

• Clinical features
• The main symptom is dyspnoea due to reduced lung
  compliance.
• Haemoptysis may also occur.
• Approximately 15 of patients experience angina
  due to either coincidental coronary artery
  disease, right ventricular hypertension or
  coronary embolisation.
• Embolic events may occur and 80 of such patients
  are in atrial fibrillation.

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Mitral stenosis

• Physical findings
• Mitral facies pinkish-purple patches on the
  cheeks.
• Tapping apex beat palpable first heart sound.
• Right ventricular heave, loud P2 indicating
  pulmonary hypertension.
• Loud first heart sound.
• Opening snap.
• Rumbling, mid-diastolic murmur with
  presystolic accentuation in sinus rhythm.

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Mitral stenosis

• Echo evaluation
• Assessment of valve morphology degree of leaflet
  thickness, mobility and calcification and extent
  of subvalvular fusion.
• Estimation of left atrial size.
• Doppler echo estimation of mitral valve area,
  transvalvular gradient and PA pressure.

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Mitral stenosis

• Medical treatment
• The asymptomatic patient with mild mitral
  stenosis should be managed medically. Medical
  therapy includes
• - Avoidance of unusual physical stress.
• - Salt restriction.
• - Diuretics if needed.
• - Control of heart rate ß-blocker or digoxin.
• - Anticoagulation for AF or prior embolic
  event.
• - Annual follow-up.
• - Echocardiography if deterioration in clinical
  condition.

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Mitral stenosis

• Management of symptomatic mitral stenosis
• Patients with symptoms should undergo clinical
  re-evaluation with echocardiography.
• NYHA class II symptoms and mild mitral stenosis
  may be managed medically.
• NYHA class II symptoms and at least moderate
  stenosis (MVA1.5cm2 or mean gradient 5mmHg) may
  be considered for balloon valvuloplasty.
• NYHA class III or IV symptoms and severe mitral
  stenosis should be considered for balloon
  valvuloplasty or surgery.

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Mitral stenosis

• Balloon mitral valvuloplasty
• The technique involves passing a balloon
  flotation catheter across the interatrial septum
  after trans-septal puncture and dilating the
  balloon within the mitral valve orifice.
• Results of the procedure are highly dependent on
  the experience of the operator.
• 80-95 of patients have a successful procedure.
• Complications include severe MR, residual ASD,
  myocardial perforation, emboli, MI and death.
• Overall event-free survival is 50 to 65 over
  3-7 years.
• The underlying mitral valve morphology is the
  most important factor in determining outcome.
• Relative contraindications include the presence
  of a left atrial thrombus and significant mitral
  regurgitation.

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Mitral stenosis

• Mitral valve replacement
• Mitral valve replacement is indicated in patients
  with severe mitral stenosis and contraindications
  to surgical commisurotomy or balloon
  valvuloplasty
• - Restenosis following surgical commisurotomy
  or balloon valvuloplasty.
• - Significant mitral stenosis and
  regurgitation.
• - Extensive calcification of the subvalvular
  apparatus.
• Operative mortality ranges from 3-8 in most
  centres.
• Postponement of surgery until the patient reaches
  NYHA class IV symptoms should be avoided.

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Mitral regurgitation

• Aetiology
• Mitral regurgitation may be caused by
  abnormalities of the valve leaflets, chordae
  tendinae, papillary muscles or mitral annulus
• Valve leaflets
• - myxomatous degeneration causing mitral valve
  prolapse
• - shortening, rigidity, deformity and
  retraction due to rheumatic heart disease
• - vegetations due to infective endocarditis
• Chordae tendinae
• - congenital, infective endocarditis, trauma,
  rheumatic fever, myxomatous
• Papillary muscles
• - myocardial ischaemia, congenital
  abnormalities, infiltrative disease
• Mitral annulus
• - dilatation eg. ischaemic or dilated
  cardiomyopathy
• - calcification due to degeneration,
  hypertension, aortic stenosis, diabetes,
  chronic renal failure

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Mitral regurgitation

• Clinical features
• Symptoms usually occur with LV decompensation
  dyspnoea and fatigue.
• Physical findings include
• - Pulse sharp upstroke
• - Apex displaced, hyperdynamic
• - Heart sounds pansystolic murmur loudest at the
  apex, radiating to the axilla and accentuated by
  expiration.

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Mitral regurgitation

• Natural history
• The natural history of chronic MR depends on the
  volume of regurgitation, the state of the
  myocardium and the underlying cause.
• Preoperative LV end-systolic diameter is a useful
  predictor of postoperative survival in chronic
  MR.
• The preoperative LV end-systolic diameter should
  be lt 45mm to ensure normal postoperative LV
  function.

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Mitral regurgitation

• Medical treatment
• Symptomatic patients may benefit from the
  following drug therapy whilst awaiting surgery
• Vasodilator therapy
• Diuretics
• Digoxin / Beta-blockers in presence of atrial
  fibrillation.
• Endocarditis prophylaxis

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Mitral regurgitation

• Surgical treatment
• Surgery is indicated in the presence of symptoms
  or left ventricular end systolic diameter 45mm.
• The surgical procedure consists of either mitral
  valve repair or replacement.
• Mitral valve repair better preserves LV function
  and avoids the need for chronic anticoagulation.
• However, mitral valve repair is technically more
  demanding and often not possible to perform in
  severely deformed valves.

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Mitral regurgitation
Relationship of preoperative ejection fraction
to postoperative survival
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Acute mitral regurgitation

• Aetiology
• Important causes of acute mitral regurgitation
  include
• Infective endocarditis causing disruption
• of valve leaflets or chordal rupture.
• Ischaemic dysfunction or rupture of papillary
  muscle.
• Malfunction of prosthetic valve.

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Chronic versus Acute MR

• Finding Chronic MR Acute MR
• Symptoms subtle onset obvious
• Appearance normal/mildly severely ill
• dyspnoeic
• Tachycardia not striking always present
• Apex beat displaced not displaced
• Systolic thrill common absent
• Murmur harsh pansystolic soft
  or absent early systolic component
• ECG-LVH usually present absent
• CXR severe cardiomegaly normal
  heart size

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Acute mitral regurgitation

• Medical therapy
• The following therapies may be beneficial in
  reducing the severity of MR
• - Vasodilator therapy
• - Inotropic therapy
• - Intra-aortic balloon counterpulsation
• Surgical therapy
• Indicated in patients with acute severe MR and
  heart failure.
• Higher mortality rates than for elective chronic
  MR, but unless treated aggressively, the
  outcome is usually fatal.

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Mitral valve prolapse

• General features
• Occurs in 2-6 of the general population
• Twice as common in women.
• Due to myxomatous proliferation of the mitral
  valve.
• Usually occurs as a primary condition, but may
  be a secondary
• finding in connective tissue diseases e.g.
  Marfans syndrome.
• Vast majority of patients are asymptomatic.
• Symptoms may include palpitations, dizziness,
  syncope, or chest
• discomfort.
• The principal physical finding is the
  mid-systolic click, followed
• by a late systolic murmur in the presence of
  regurgitation.

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Mitral valve prolapse

• Echocardiographic criteria
• M-mode criterion ? 2mm posterior displacement
  of one or both
• leaflets.
• 2-D echo findings Systolic displacement of one
  or both leaflets
• within the left atrium in the parasternal
  long-axis view leaflet
• thickening, redundancy, chordal elongation and
  annular dilatation.
• The diagnosis of mitral valve prolapse is even
  more certain
• when leaflet thickness is gt5mm.
• Echocardiography is useful in the risk
  stratification of patients
• with mitral valve prolapse.

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Mitral valve prolapse

• Natural history
• In most patients, mitral valve prolapse is
  associated with a benign
• prognosis.
• Complications may occur in patients with a
  systolic murmur,
• thickened leaflets an increased LV or LA size,
  especially in men
• gt 45 years old
• Complications include progressive mitral
  regurgitation, infective
• endocarditis, cerebral emboli, arrhythmias and
  rarely sudden death.

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Mitral valve prolapse

• Management
• Asymptomatic patients without MR or arrhythmias
  have an excellent prognosis follow-up every 3-5
  years.
• Patients with a typical systolic murmur should
  receive endocarditis prophylaxis.
• Patients with a long systolic murmur may show
  progression of MR and should be reviewed
  annually.
• Patients with previous embolic events should be
  given antiplatelet / anticoagulant therapy.
• Severe MR requires surgery, often mitral valve
  repair.

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Prosthetic valves

• Prosthetic valves may be divided into 2 broad
  categories
• Mechanical valves
• Very good durability.
• Require long-term anticoagulation.
• May cause mild haemolysis.
• Bioprosthetic (tissue) valves
• Porcine variety most commonly used.
• Limited durability.
• Anticoagulation for first 3 months only.

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Mechanical valves
Designs and flow patterns of different types of
mechanical valves
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Prosthetic valves

• Mechanical versus tissue valves
• No difference in survival, haemodynamics or in
  probability of
• developing endocarditis, valve thrombosis or
  systemic embolism.
• Valve-related failure is much more common with
  tissue valves.
• Anticoagulant-related bleeding occurs with
  mechanical valves.
• Elderly patients tend to receive tissue valves.

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Tricuspid stenosis

• Always rheumatic in origin and when present
  accompanies mitral valve involvement.
• The anatomical changes and physiological
  principles are similar to those of mitral
  stenosis.
• The low cardiac output state causes fatigue
  abdominal discomfort may occur due to
  hepatomegaly and ascites.
• The diastolic murmur of tricuspid stenosis is
  augmented by inspiration.
• Medical management includes salt restriction and
  diuretics.
• Surgical treatment should be carried out in
  patients with a valve area lt2.0cm2 and a mean
  pressure gradient gt5mmHg.

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Tricuspid reurgitation

• Most common cause is annular dilatation due to RV
  failure of any cause may also be caused by
  intrinsic valve involvement
• Well tolerated in the absence of pulmonary
  hypertension in the presence of pulmonary
  hypertension, cardiac output declines and RV
  failure may worsen.
• Symptoms and signs result from a reduced cardiac
  output, ascites, painful congestive hepatomegaly
  and oedema.
• The pansystolic murmur of TR is usually loudest
  at the left sternal edge and augmented by deep
  inspiration.
• Severe functional TR may be treated by
  annuloplasty or valve replacement. Severe TR due
  to intrinsic tricuspid valve disease requires
  valve replacement.

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Pulmonary stenosis

• Most commonly due to congenital malformation and
  usually an isolated anomaly.
• Survival into adulthood is the rule, infective
  endocarditis is a risk and right ventricular
  failure is the most common cause of death.
• Rheumatic involvement of the pulmonary valve is
  very uncommon and rarely leads to serious
  deformity.
• Carcinoid plaques may lead to constriction of the
  pulmonary valve ring.

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Pulmonary regurgitation

• Most common cause is ring dilatation due to
  pulmonary hypertension, or dilatation of the
  pulmonary artery secondary to a connective tissue
  disorder.
• May be tolerated for many years unless
  complicated by pulmonary hypertension.
• The clinical manifestations of the primary
  disease tend to overshadow the pulmonary
  regurgitation.
• Physical examination reveals a right ventricular
  heave and a high-pitched, blowing, early
  diastolic decrescendo murmur over the left
  sternal edge, augmented by deep inspiration.
• Pulmonary regurgitation is seldom severe enough
  to require specific treatment. Surgery may be
  required because of intractable RV failure.