Valvular Heart Disease

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By: syrasen (47 month(s) ago)

Symptoms of aortic insufficiency is bounding pulse, chest pain which is called angina type and under the chest bone, pain may move to other areas of the body, crushing, pressing, pressure, density . pain increases with exercise and goes away with rest, fainting, fatigue, excessive tiredness, irregular, rapid, racing, pounding, or fluttering heartbeat, palpitations, shortness of breath with exertion or when lying down, weakness, especially with
activity. http://www.insideheart.com/aortic-valve-insufficiency.html

Presentation Transcript

Valvular Heart Disease Mitral Stenosis : 

© Continuing Medical Implementation …...bridging the care gap Valvular Heart Disease Mitral Stenosis

A 75 year old woman with loud first heart sound and mid-diastolic murmur : 

© Continuing Medical Implementation …...bridging the care gap A 75 year old woman with loud first heart sound and mid-diastolic murmur Chronic dyspnea Class 2/4 Fatigue Recent orthopnea/pnd Nocturnal palpitation Pedal edema

Mitral Stenosis : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery

Mitral Stenosis: Etiology : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Etiology Primarily a result of rheumatic fever (~ 99% of MV’s @ surgery show rheumatic damage ) Scarring & fusion of valve apparatus Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.

Mitral Stenosis:Pathophysiology : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis:Pathophysiology Normal valve area: 4-6 cm2 Mild mitral stenosis: MVA 1.5-2.5 cm2 Minimal symptoms Mod mitral stenosis MVA 1.0-1.5 cm2 usually does not produce symptoms at rest Severe mitral stenosis MVA < 1.0 cm2

Mitral Stenosis:Pathophysiology : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis:Pathophysiology

Mitral Stenosis: Symptoms : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Symptoms Fatigue Palpitations Cough SOB Left sided failure Orthopnea PND Palpitation Afib Systemic embolism Pulmonary infection Hemoptysis Right sided failure Hepatic Congestion Edema Worsened by conditions that  cardiac output. Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy, thyrotoxicosis

Recognizing Mitral Stenosis : 

© Continuing Medical Implementation …...bridging the care gap Recognizing Mitral Stenosis Palpation: Small volume pulse Tapping apex-palpable S1 +/- palpable opening snap (OS) RV lift Palpable S2 ECG: LAE, AFIB, RVH, RAD Auscultation: Loud S1- as loud as S2 in aortic area A2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS & rumble may be inaudible

Mitral Stenosis: Physical Exam : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Physical Exam First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm) S1 S2 OS S1

Common Murmurs and Timing (click on murmur to play) : 

© Continuing Medical Implementation …...bridging the care gap Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

Auscultation-Timing of A2 to OS Interval : 

© Continuing Medical Implementation …...bridging the care gap Auscultation-Timing of A2 to OS Interval Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlirthe LV pressure falls below LAP and the MV opens

Mitral Stenosis: Natural History : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Natural History Progressive, lifelong disease, Usually slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. Additional 10 years before disabling symptoms

Mitral Stenosis: Complications : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Complications Atrial dysrrhythmias Systemic embolization (10-25%) Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Massive: 20 to ruptured bronchial veins (pulm HTN) Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections

Mitral Stenosis: EKG : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: EKG LAE RVH Premature contractions Atrial flutter and/or fibrillation  freq. in pts with mod-severe MS for several years A fib develops in  30% to 40% of pts w/symptoms

A 75 year old woman with loud first heart sound and mid-diastolic murmer : 

© Continuing Medical Implementation …...bridging the care gap A 75 year old woman with loud first heart sound and mid-diastolic murmer

Mitral Stenosis: Role of Echocardiography : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis: Role of Echocardiography Diagnosis of Mitral Stenosis Assessment of hemodynamic severity mean gradient, mitral valve area, pulmonary artery pressure Assessment of right ventricular size and function. Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty Diagnosis and assessment of concomitant valvular lesions Reevaluation of patients with known MS with changing symptoms or signs. F/U of asymptomatic patients with mod-severe MS

Slide 18: 

© Continuing Medical Implementation …...bridging the care gap

Slide 19: 

© Continuing Medical Implementation …...bridging the care gap

Mitral Stenosis:Therapy : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis:Therapy Medical Diuretics for LHF/RHF Digitalis/Beta blockers/CCB: Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis Balloon valvuloplasty Effective long term improvement

Mitral Stenosis:Therapy : 

© Continuing Medical Implementation …...bridging the care gap Mitral Stenosis:Therapy Surgical Mitral commissurotomy Mitral Valve Replacement Mechanical Bioprosthetic

Recommendations for Mitral Valve Repair for Mitral Stenosis : 

© Continuing Medical Implementation …...bridging the care gap Recommendations for Mitral Valve Repair for Mitral Stenosis ACC/AHA Class I Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if percutaneous mitral balloon valvotomy is not available Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with the decision to proceed with either repair or replacement made at the time of the operation.

Recommendations for Mitral Valve Repair for Mitral Stenosis : 

© Continuing Medical Implementation …...bridging the care gap Recommendations for Mitral Valve Repair for Mitral Stenosis ACC/AHA Class IIB Patients in NYHA functional Class I, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation. ACC/AHA Class III Patients with NYHA functional Class I-IV symptoms and mild MS. *The committee recognizes that there may be a variability in the measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.