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Valvular Heart Disease

Dr. Nigussie Berihun

Assistant Prof. of Pediatrics
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Valvular Heart Disease

MITRAL STENOSIS (ms)

Almost all mitral stenosis is due to rheumatic heart disease.

It is much more common in female.?

Other causes include: Lutembacher's syndrome, which is the

combination of acquired mitral stenosis and an atrial septal
defect, carcinoid tumours and SLE.
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Valvular Heart Disease

PATHOPHYSIOLOGY
When the normal valve orifice area is reduced to 1 cm2, severe
mitral stenosis is present.
To maintain cardiac output, the left atrial pressure increases and
left atrial hypertrophy and dilatation occur.

Consequently, pulmonary venous, pulmonary arterial and right

heart pressures also increase, followed by pulmonary oedema.

Pulmonary hypertension leads to right ventricular hypertrophy,

dilatation and failure resulting in tricuspid regurgitation.
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Valvular Heart Disease

COMPLICATIONS OF MITRAL STENOSIS

Atrial fibrillation
Systemic embolization
Pulmonary hypertension
Pulmonary infarction
Chest infections
Infective endocarditis (rare)
Tricuspid regurgitation
Right ventricular failure
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Valvular Heart Disease

SYMPTOMS
Usually there are no symptoms until the valve orifice is moderately
stenosed (i.e. has an area of 2 cm2).
Because of pulmonary venous hypertension and recurrent
bronchitis, progressively severe dyspnoea develops.
A cough productive of blood-tinged, frothy sputum and
occasionally frank haemoptysis may occur.
Right heart failure and its symptoms of weakness, fatigue and
abdominal or lower limb oedema.
Atrial fibrillation, giving rise to palpitations.
Atrial fibrillation may result in systemic emboli.
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Valvular Heart Disease

SIGNS
Face: mitral facies or malar flush.
Pulse: a small-volume pulse, may be an irregularly irregular pulse.
Jugular veins: Distension of jugular veins in right heart failure.
Palpation: There is a tapping impulse felt parasternally on the left
side (palpable first heart sound). A sustained parasternal impulse due
to right ventricular hypertrophy may also be felt.
Auscultation: loud first heart sound, and 'opening snap'. This is
followed by a low-pitched 'rumbling' mid-diastolic murmur at the
apex with presystolic accentuation.
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Valvular Heart Disease

INVESTIGATIONS
Chest X-ray:
small heart with an enlarged left atrium, Pulmonary venous hypertension, a
calcified mitral valve, signs of pulmonary oedema or pulmonary hypertension.
ECG:
shows a bifid P wave or AF, features of right ventricular hypertrophy
(right axis deviation and perhaps tall R waves in V1)
Echocardiogram:
assessment of the mitral valve apparatus and calculation of mitral valve area, also
determines left atrial and right ventricular size and function. Estimate of
pulmonary artery pressure

Cardiac catheterization
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Valvular Heart Disease
TREATMENT
Mild mitral stenosis may need no treatment other than prompt
therapy of attacks of bronchitis.
Antibiotic prophylaxis for infective endocarditis.
Mild dyspnoea is treated with low doses of diuretics.
Atrial fibrillation requires treatment with digoxin and
anticoagulation to prevent atrial thrombus and systemic
embolization.
If pulmonary hypertension develops, surgical relief of the mitral
stenosis is advised.
Surgical treatment includes; Trans-septal balloon valvotomy,
valvotomy
Closed valvotomy, Open valvotomy or Mitral valve replacement.
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MITRAL REGURGITATION
CAUSES

The most common cause is rheumatic heart disease

(50%) and a prolapsing mitral valve.

Other causes include; aortic valve disease, acute

rheumatic fever, myocarditis, dilated cardiomyopathy,
hypertensive heart disease, ischemic heart disease, infective
endocarditis, hypertrophic cardiomyopathy, SLE, Marfan's
syndrome, Ehlers-Danlos syndrome, rupture of the chordae
tendineae (e.g.due to myocardial infarction).
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MITRAL REGURGITATION

PATHOPHYSIOLOGY
Regurgitation into the left atrium produces left atrial
dilatation but little increase in left atrial pressure.
With acute mitral regurgitation the left atrial v wave is
greatly increased and pulmonary venous pressure rises to
produce pulmonary oedema.
Since a proportion of the stroke volume is regurgitated,
the stroke volume increases to maintain the forward
cardiac output and the left ventricle therefore enlarges.
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MITRAL
REGURGITATION(MR)
SYMPTOMS
Mitral regurgitation can be present for many years before any
symptoms occur.
The increased stroke volume is sensed as a 'palpitation'.
Dyspnoea & orthopnoea develop owing to left ventricular failure.
Fatigue & lethargy develop because of the reduced cardiac output.
In the late stages of the disease the symptoms of right heart failure
also occur and eventually lead to congestive cardiac failure.
Cardiac cachexia may develop.
Thromboembolism is less common than in mitral stenosis, but
subacute infective endocarditis is much more common.
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MITRAL REGURGITATION

SIGNS

Laterally displaced (forceful) diffuse apex beat and a

systolic thrill (if severe).
Soft 1st heart sound.
Pansystolic murmur, radiating widely over the precordium
and into the axilla.
Prominent 3rd heart sound.
The signs related to atrial fibrillation, pulmonary HTN,
and left & right heart failure develop later in the disease.
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MITRAL REGURGITATION

INVESTIGATIONS
Chest X-ray: left atrial and left ventricular enlargement. There is an
increase in the CTR(cardiothorasic ratio), and valve calcification is seen.
ECG shows the features of left atrial delay (bifid P waves) and left
ventricular hypertrophy as manifested by tall R waves in leads I and V6
and deep S waves in the right-sided precordial leads V1 &V2.
Atrial fibrillation may be present.
Echocardiogram: dilated left atrium and left ventricle. There may be
specific features of chordal or papillary muscle rupture.
Cardiac catheterization.
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MITRAL REGURGITATION

TREATMENT
Mild mitral regurgitation in the absence of symptoms can be managed
conservatively by following the patient with serial echocardiograms.

Any evidence of progressive cardiac enlargement generally warrants

early surgical intervention by either mitral valve repair or replacement.
In patients who are not considered appropriate for surgical intervention,
management usually involves treatment with
1.ACE inhibitors.
2.Diuretics.
3.Anticoagulants.
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AORTIC STENOSIS(AS)

CAUSES
Congenital aortic valve stenosis.
Rheumatic fever; In rheumatic heart disease the
aortic valve is affected in about 40% of cases and
there is usually associated mitral valve disease.
Calcific valvular disease is the commonest cause
of aortic stenosis and mainly occurs in the elderly.
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AORTIC STENOSIS

PATHOPHYSIOLOGY
Obstructed left ventricular emptying leads to increased lt.
ventricular pressure and compensatory lt. ventricular
hypertrophy.
In turn, this results in relative
1.Ischemia of the lt. ventricular myocardium.
2.Consequent angina.
3.Arrhythmias.
4.lt. ventricular failure.
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AORTIC STENOSIS

SYMPTOMS
There are usually no symptoms until aortic stenosis is moderately
severe (when the aortic orifice is reduced to one-third of its normal
size).
At this stage, exercise-induced syncope, angina and dyspnoea develop.

When symptoms occur, the prognosis is poor - on average, death

occurs within 2-3 years if there has been no surgical intervention.
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AORTIC STENOSIS

SIGNS
Pulse: small volume and is slow-rising or plateau in nature.
Precordial palpation: The apex beat is not usually displaced because
hypertrophy (as opposed to dilatation) does not produce noticeable
cardiomegaly.
However, the pulsation is sustained and obvious. A double impulse is
sometimes felt because the 4th heart sound or atrial contraction ('kick')
may be palpable.
A systolic thrill may be felt in the aortic area.
Auscultation:
an ejection systolic murmur that is usually 'diamond-shaped' (crescendo-
decrescendo).
The murmur is usually rough in quality and best heard in the aortic area.
It radiates into the carotid arteries and also the precordium.
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AORTIC STENOSIS
INVESTIGATIONS
Chest X-ray: reveals a relatively small heart with a prominent &
dilated ascending aorta. This occurs because turbulent blood flow above
the stenosed aortic valve produces so-called 'post-stenotic dilatation'.
The aortic valve may be calcified. The CTR increases in heart failure.
ECG shows left ventricular 'strain' pattern due to 'pressure overload'
(depressed ST segments & T wave inversion in leads I, AVL, V5, V6).
Echocardiogram:
readily demonstrates the thickened, calcified & immobile aortic valve
cusps.
Left ventricular hypertrophy may be seen.
Cardiac catheterization.
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AORTIC STENOSIS

TREATMENT
In patients with aortic stenosis, symptoms are a good index of
severity and all symptomatic patients should have aortic valve
Replacement.
Asymptomatic patients should be under regular review for
assessment of symptoms and echocardiography.
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AORTIC
REGURGITATION(AR)

CAUSES
The most common
causes of aortic
regurgitation are
1.Rheumatic fever.
2.Infective
endocarditis.
complicating
a previously
damaged valves.
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AORTIC REGURGITATION

Pathophysiology
Aortic regurgitation is reflux of blood from the aorta
through the aortic valve into the left ventricle during diastole.
Consequently the left ventricular size must enlarge.
Because of the aortic run-off during diastole, diastolic blood
pressure falls and coronary perfusion is decreased.
Cardiac ischaemia develops.
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AORTIC REGURGITATION
SYMPTOMS
significant symptoms occur late and do not develop until
left ventricular failure occurs.

As with mitral regurgitation, a common symptom is

'pounding of the heart' because of the increased left ventricular
size and its vigorous pulsation.

Angina pectoris is a frequent complaint.

Varying grades of dyspnoea occur depending on the
extent of left ventricular dilatation and dysfunction.
Arrhythmias are relatively uncommon.
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AORTIC REGURGITATION

SIGNS
Pulse: bounding or collapsing,bisferiens pulse, wide pulse pressure.
Signs of hyperdynamic circulation: Quincke's sign (capillary pulsation
in the nail beds), De Musset's sign (head nodding with each heartbeat),
Duroziez's sign (a to-and-fro murmur heard when the femoral artery is
auscultated with pressure applied distally-it is a sign of severe aortic
regurgitation), pistol shot femorals (Traube sign) .
Müller sign consists of systolic pulsations of the uvula,
Becker's sign — Visible pulsations of the retinal arteries and pupils.
Hill's sign — Popliteal cuff systolic pressure exceeding brachial pressure
by more than 60 mmHg.
Mayne's sign — More than a 15 mmHg decrease in diastolic blood
pressure with arm elevation from the value obtained with the arm in the
standard position.
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Rosenbach's sign — Systolic pulsations of the liver.

Gerhard's sign — Systolic pulsations of the spleen.
Apical beat: is displaced laterally and downwards and is
forceful in quality.

Auscultation: a high-pitched early diastolic murmur best

heard at the left sternal edge in the fourth intercostal space
with the patient leaning forward and the breath held in
expiration.
 Commonly an ejection systolic flow murmur.
 The regurgitant jet can impinge on the anterior mitral valve
cusp, causing a mid-diastolic murmur (Austin Flint).
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AORTIC REGURGITATION

INVESTIGATIONS
Chest X-ray: left ventricular enlargement and possibly dilatation
of the ascending aorta.
The ascending aortic wall may be calcified in syphilis, and the
aortic valve may be calcified if valvular disease is responsible for
the regurgitation.
ECG: appearances are those of left ventricular hypertrophy due
to 'volume overload' - tall R waves and deeply inverted T waves in
the left-sided chest leads, and deep S waves in the right-sided leads.
Echocardiogram:
vigorous cardiac contraction and a dilated left ventricle.
The aortic root may also be enlarged.
Cardiac catheterization.
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AORTIC REGURGITATION

TREATMENT
The underlying cause of aortic regurgitation (e.g. syphilitic
aortitis or infective endocarditis) may require specific
treatment.
The treatment of aortic regurgitation usually requires aortic
valve replacement.
 Because symptoms do not develop until the myocardium
fails and because the myocardium does not recover fully after
surgery, operation is performed before significant symptoms
occur.
Antibiotic prophylaxis against infective endocarditis is
necessary.
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TRICUSPID STENOSIS

CAUSES
This uncommon valve lesion, which is seen much more
often in women than in men, is usually due to rheumatic
heart disease.
It is frequently associated with mitral and/or aortic valve
disease.
It is also seen in the carcinoid syndrome.
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TRICUSPID STENOSIS

PATHOPHYSIOLOGY
Tricuspid valve stenosis results in a reduced cardiac output,
which is restored towards normal when the right atrial
pressure increases.

The resulting systemic venous congestion produces

hepatomegaly, ascites & dependent oedema.
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TRICUSPID STENOSIS

SYMPTOMS
Usually, patients with tricuspid stenosis complain of
symptoms due to associated left-sided rheumatic valve lesions.

Abdominal pain (due to hepatomegaly), swelling (due to

ascites) & peripheral oedema.
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TRICUSPID STENOSIS

SIGNS
Prominent jugular venous a wave.
Presystolic pulsation may also be felt over the liver
Rumbling mid-diastolic murmur, heard best at the lower
left sternal edge & is louder on inspiration.

A tricuspid opening snap may occasionally be heard.

Hepatomegaly, abdominal ascites & dependent oedema
may be present.
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TRICUSPID
STENOSIS
INVESTIGATIONS
Chest X-ray: prominent right atrial bulge.
ECG: enlarged right atrium manifested by peaked, tall P
waves (> 3 mm) in lead II.
Echocardiogram: thickened & im-mobile tricuspid valve,
but this is not so clearly seen as an abnormal mitral valve.
Cardiac catheterization.
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TRICUSPID STENOSIS

TREATMENT
Medical management consists of diuretic therapy & salt
restriction.
Tricuspid valvotomy is occasionally possible, but tricuspid
valve replacement is often necessary.
Other valves usually also need replacement because
tricuspid valve stenosis is rarely an isolated lesion.
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TRICUSPID
REGURGITATION(TR)
CAUSES
Functional TR; may occur whenever the right ventricle
dilates, e.g. in cor pulmonale, myocardial infarction or
pulmonary hypertension. (CP,MI ,PH)

Organic TR; may occur with RHD, IE, carcinoid syndrome,

EBA (a congenitally malpositioned tricuspid valve) and other
congenital abnormalities of the atrioventricular valves.
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TRICUSPID
REGURGITATION
SYMPTOMS & SIGN
Symptoms of right heart failure.
Physical signs include a large jugular venous wave & a
palpable liver that pulsates in systole.
Usually a right ventricular impulse may be felt at the left
sternal edge, and there is a blowing pansystolic murmur, best
heard on inspiration at the lower left sternal edge.
Atrial fibrillation is common.
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TRICUSPID REGURGITATION

TREATMENT
Functional tricuspid regurgitation usually disappears with
medical management.

Severe organic tricuspid regurgitation may require

operative repair of the tricuspid valve or valve replacement.
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PULMONARY
STENOSIS(PS)
CAUSES
This is usually a congenital lesion, but it may rarely result
from rheumatic fever or from the carcinoid syndrome.

Congenital pulmonary stenosis may be associated with an

intact ventricular septum or with a ventricular septal defect
(Fallot's tetralogy).

Pulmonary stenosis may be valvular, subvalvular or

supravalvular.
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PULMONARY
STENOSIS
SYMPTOMS & SIGNS
Fatigue, syncope & the symptoms of right heart failure.
Physical signs: harsh mid-systolic ejection murmur, best
heard on inspiration, to the left of the sternum in the second
intercostal space.
This murmur is often associated with a thrill.
The pulmonary closure sound is usually delayed & soft.
There may be a pulmonary ejection sound if the obstruction is
valvular.
A right ventricular fourth sound & a prominent jugular venous
a wave are present when the stenosis is moderately severe.
A right ventricular heave (sustained impulse) may be felt.
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PULMONARY
STENOSIS
INVESTIGATIONS
Chest X-ray: prominent pulmonary artery owing to post-
stenotic dilatation.
ECG: both right atrial & right ventricular hypertrophy,
although it may sometimes be normal even in severe
pulmonary stenosis.
Echocardiogram Doppler is the investigation of choice.
Cardiac catheterization.
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PULMONARY
STENOSIS
TREATMENT
Treatment of severe pulmonary stenosis requires pulmonary
valvotomy (balloon valvotomy or direct surgery).
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PULMONARY
This isREGURGITATION
the most common acquired lesion of the pulmonary
valve.
It results from dilatation of the pulmonary valve ring, which
occurs with pulmonary hypertension.
It is characterized by a decrescendo diastolic murmur,
beginning with the pulmonary component of the second
sound, that is difficult to distinguish from the murmur of
aortic regurgitation.
Pulmonary regurgitation usually causes no symptoms and
treatment is rarely necessary.