Valvular heart disease Richard Schilling St Marys Hospital

Valvular heart disease Richard Schilling St Mary’s Hospital London RJS

Valve disease • • Aetiology Clinical findings Investigations Management RJS

Heart Valve lesions • • • Mitral stenosis Aortic stenosis Pulmonary stenosis Tricuspid stenosis Prosthetic stenosis • • • Mitral regurgitation Aortic regurgitation Pulmonary regurgitation Tricuspid regurgitation Prosthetic regurgitation • Mitral valve prolapse RJS

Mitral regurgitation - Aetiology • Valve – Rheumatic fever – Endocarditis • Mitral valve annulus – Dilation – Calcification • Chordae tendinae – Rupture – Lengthening • Papillary muscle – ischaemia – dilation RJS

Mitral regurgitation – pathophysiology • • • LV emptying LA pressure (if acute, pulmonary odema) LV filling LVedd LV stretch failure RJS

Mitral regurgitation – Clinical • Symptoms appear late – SOB – Fatigue – Right heart failure • Signs – Full volume pulse – Pan systolic murmur radiating to apex – Right heart failure – Pulmonary hypertension RJS

Mitral Regurgitation • Investigations – ECG p mitrale – Xray large heart, calcified mv annulus, pulmonary odema – Echocardiogram large LA, abnormal valve, MR – LV angio MR, large LA RJS

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Mitral Regurgitation • • • Heart Failure Decrease afterload Replacement Anticoagulation Antibiotic prophylaxis RJS

Mitral Stenosis - Aetiology • Rheumatic fever • Congenital RJS

Mitral Stenosis - pathophysiology • • LA pressure Pulmonary pressure R Heart failure LV function RJS

Mitral Stenosis – Symptoms/Signs • • SOB Haemoptysis Embolisation Mitral Facies AF, thready pulse JVP RV heave RJS

Mitral Stenosis – Symptoms/Signs • Opening snap • Rumbling diastolic murmur • Presystolic murmur RJS

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Mitral stenosis - Investigations • ECG – AF • Xray – Pulmonary congestion, large LA and R heart • Echo – tight valve, high inflow large LA RJS

MS ECG RJS

MS x-ray RJS

MS echo RJS

MS Treatment • • • Antibiotic prophylaxis Anticoagulation (AF) Digoxin (AF) Mitral Valvuloplasty Surgical Replacement RJS

Mitral Valvuloplasty RJS

Aortic Stenosis - aetiology • Congenital – bicuspid valve • Acquired – Rheumatic – Senile/degenerative RJS

Aortic Stenosis – pathophysiology • LVH • Cardiac output on exercise • LV dilatation and failure RJS

Aortic stenosis – symptoms/ signs • • • Asymptomatic Angina Heart Failure Syncope Sudden Death RJS

Aortic stenosis – symptoms/ signs • Slow rising pulse • LV heave • Ejection systolic murmur radiating to carotids RJS

Aortic Stenosis - investigations • ECG – LVH • Echo – LVH, calcified valve, high doppler velocity • Angio – Ao valve gradient RJS

AS ECG RJS

Congenital AS RJS

Echo AS RJS

Doppler/Pressure Aortic stenosis RJS

Aortic stenosis - treatment • Antibiotic prophylaxis • Surgical replacement before heart failure RJS

Aortic valve replacement RJS

Aortic Regurgitaiton- aetiology • Aortic valve – Rheumatic fever – Infective endocarditis – Bicuspid vlave • Aortic dilation – Age related – Marfans – Dissection RJS

Aortic regurg - pathophysiology • • Increased Lved volume Increased stroke volume LV dilatation LV failure RJS

AR – symptoms/signs • • Often asymptomatic Chest pounding Prominent pulse Heart failure RJS

AR – symptoms/signs • • de. Musset’s sign Collapsing pulse Displaced apex beat Early diastolic murmur RJS

Auscultation AR RJS

AR investigations • • ECG – LVH X-ray – abnormal aorta, large heart Echo – AR, LV dilation, dissection Angiogram – AR, LV dilation RJS

AR - xray RJS

AR - Echo RJS

AR - treatment • Antibiotics • Vasodilators • Replacement – when LV begins to dilate or fail RJS

When to replace the aortic valve? RJS

When to replace the mitral valve • When symptoms significant • Before LV failure • Before significant pulmonary hypertension RJS

Right heart valves • Low pressure • Tricuspid regurg (drug addicts) • Pulmonary stenosis (congenital) RJS