1. Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and treatment of valve pathology.

2. Valvular Heart Disease Hakan Karpuz, MD Dept. of Cardiology Cerrahpasa Medical School

4. Valvular Heart Disease (part I) Hakan Karpuz, MD Dept. of Cardiology Cerrahpasa Medical School

5. Aortic Valve Aortic Stenosis Aortic Regurgitation

6. Aortic Valve Aortic Stenosis Aortic Regurgitation

7. Learning Objectives Describe the pathophysiology, etiology, signs and symptoms, natural history, and treatment of aortic stenosis.

8. Aortic Stenosis Pathophysiology Related to pressure changes, Valve obstructed, LV > pressure, LV hypertrophy, LA enlarges, Decreased cardiac output

10. Etiology Sub-valvular Supra-valvular Valvular (most common) Aortic Stenosis

11. Etiology Rheumatic Heart Disease Congenital AV Disease Bicuspid Aortic Valve Idiopathic Calcific Aortic Stenosis Aortic Stenosis “Valvular”

13. Symptoms Fatigue Dyspnea on exertion Angina Exertional Syncope Heart Failure Sudden Cardiac Death Aortic Stenosis “Valvular”

14. Vital Signs Narrow pulse pressure PMI Displaced Ascultation S2 Murmur Aortic Stenosis “Valvular”

15. ECG Hypertrophy CXR Cardiomegaly 50% of the time ECHO Confirm, Severity LHC Severity, Coronary Artery Disease Aortic Stenosis “Valvular”

17. Aortic Valve Area…formula

18. don’t forget! the best method is…

19. Natural History Asymptomatic For many years Duration of symptoms (until death) Angina - 3 years Syncope - 2 years CHF - 18 months Aortic Stenosis “Valvular”

20. Treated Aortic Stenosis 40% survived for 5 years 20% survived for 10 years Sudden Cardiac Death Decreased cerebral blood flow Arrhythmias Natural History Aortic Stenosis “Valvular”

21. Treatment Strenous Activity Limit for symptomatic Medical treatment of HF ACC/AHA guidelines for preload/afterload reduction& fluid management Aortic Stenosis “Valvular”

22. Treatment Surgical treatment indications, techniques, outcome depend on age/cause Adults: valve replacement Aortic Stenosis “Valvular”

24. Aortic Valve Aortic Stenosis Aortic Regurgitation

25. Learning Objectives Describe the etiology, signs and symptoms, findings and treatment for aortic insufficiency.

27. Etiology Valvular Disease Rheumatic Heart Disease Infective Endocarditis Trauma (tear of the ascending aorta) Bicuspid valve Aortic Insufficiency

28. Etiology Aortic root disease (1/3 of patients) Marfan’s syndrome Cystic medial necrosis Syphilitic aortitis Ankylosing spondylitis Behcets syndrome Reiter’s syndrome Systemic Hypertension Aortic Insufficiency

29. Symptoms Angina, Palpitations, CHF symptoms Vital Signs Wide pulse pressure Pulses Abrupt distension/quick collapse: Corrigan’s pulse Bisferiens pulse Aortic Insufficiency

30. Palpation PMI, Thrill Auscultation S2 variable, A2 absent Murmur Diastolic: patient sitting, leaning forward, on expiration, diaphragm at Erb’s point Austin Flint Murmur, De Musset’s Aortic Insufficiency

31. Findings EKG LVH CXR Marked enlargement if AI is chronic ECHO Confirms/severity LHC Severity/CAD Aortic Insufficiency

32. remember! the best method is…

33. Natural History Aortic Insufficiency

34. Treatment Follow clinically (q 6 mos) Asymptomatic with normal LV Use IE prophylaxis Treated Symptomatic with LV function decrease Medications AVR Aortic Insufficiency

35. Valvular Heart Disease (part II) Hakan Karpuz, MD Dept. of Cardiology Cerrahpasa Medical School

37. Mitral Valve Mitral Stenosis Mitral Regurgitation

38. Mitral Valve Mitral Stenosis Mitral Regurgitation

39. Learning Objectives Describe the etiology, pathophysiology, signs and symptoms, physical exam, and treatment of mitral stenosis.

40. Etiology Rheumatic heart disease (female) Congenital Rare: SLE Amyloid Carcinoid Rheumatoid Arthritis Mitral Valve Stenosis

41. Pathophysiology Minimum of 2 yrs for severe MS to develop after ARF Pressure elevates in: Left atrium Pulmonary tree Right heart Atrial contraction 30% of CO, Atrial fibrillation Mitral Valve Stenosis

42. Dyspnea on exertion Hemoptysis Chest pain CHF symptoms Hoarseness Pulmonary Embolism Infective Endocarditis Mitral Valve Stenosis

43. Physical Exam Inspection JVP Sternal lift Palpation Sternal heave Apex Auscultation Accentuated S1, Opening snap, Diastolic murmur Mitral Valve Stenosis

44. EKG LAE Pulmonary HTN CXR LAE ECHO Confirm/severity LHC Severity/CAD Mitral Valve Stenosis

45. Treatment Medical SBE prophylaxis Avoid strenuous exercise Diuretics Anticoagulants Rheumatic heart disease Atrial fibrillation Treatment AF Digoxin Mitral Valve Stenosis

46. Treatment Surgical Asymptomatic Follow Symptomatic Balloon Valvuloplasty Open commissurotomy Valve replacement Mechanical Bio-prosthetic Mitral Valve Stenosis

49. Mitral Valve Prolapse Other terms: Floppy valve, Barlow’s Etiology Congenital Marfan’s syndrome RHD Sequelae of CM or MI Pathophysiology Valve leaflet has redundant tissue Extra tissue balloons into LA, click sound

50. Mitral Valve Prolapse Incidence 10-20 % of population F > M Clinical Presentation Asymptomatic Symptomatic Palpitations Arrhythmias Atypical Chest Pain

51. Mitral Valve Prolapse MVP-Physical Exam/Diagnosis Thin, young females Abnormalities Skeletal Heart Auscultation Mid-systolic click

52. MVP-Physical Exam/Diagnosis EKG Normal Abnormal Arrhythmias: SVT NSST-T changes ECHO Confirm the diagnosis R/O other abnormalities

53. MVP-Treatment Reassurance SBE prophylaxis Beta blockers

55. Mitral Valve Mitral Stenosis Mitral Regurgitation

56. Etiology Valve leaflets: (Do not close properly/Do not stay closed) Chronic RHD SLE Trauma Endocarditis Mitral Valve Regurgitation

57. Etiology Mitral annulus: Dilation Calcification Chordae tendinae: Congenital, Rupture, Endocarditis Mitral Valve Regurgitation

58. Etiology Papillary muscles: Ischemia; Dysfunction Scarring Infarction: Necrosis Rupture Mitral Valve Regurgitation

59. Annular dilatation PerforationDegenerativ

60. Pathophysiology MV and AV are in parallel Amount of MR is dependent on LV outflow impedence, Increased by aortic stenosis Symptoms Chronic Acute Mitral Valve Regurgitation

62. Clinical Findings Auscultation S1: Diminished S2: Wide splitting Murmur: Holosystolic, Loudest at apex Mitral Valve Regurgitation

63. EKG LAE Atrial fibrillation LVH CXR Cardiomegaly: LVH/LAE ECHO Mitral Valve Regurgitation

66. Treatment Low sodium diet Preload reduction: Diuretics Afterload reduction: Vasodilators (Nitroprusside, ACE inhibitors, Hydralazine) Digoxin SBE prophylaxis Mitral Valve Regurgitation

67. Treatment Surgical Symptomatic: Class II, III, IV Asymptomatic: Monitor Symptoms Echo Mitral Valve Regurgitation

70. Tricuspid Stenosis

71. Etiology Rheumatic Pathophysiology Pressures elevate in RA Symptoms Fatigue Right sided symptoms Tricuspid Stenosis

72. Physical findings JVD Right sided failure sxs EKG RAE CXR ECHO Treatment Diet restriction, Diuretics, Surgery Tricuspid Stenosis

73. Tricuspid Regurgitation

74. Etiology Valvular: SBE, RHD, CHD Annular: Cor Pulmonale Ebstein’s anomaly Clinical features SOB/DOE Tricuspid Regurgitation

75. Physical exam Right sided failure Holosystolic murmur EKG RAE, RVH CXR ECHO Tricuspid Regurgitation

76. Pulmonary Valve

77. Pulmonary Valve Insufficiency PHTN Little clinical significance Treat PHTN

78. Pulmonary Valve Stenosis Congenital (common) Dyspnea Physical exam Systolic murmur Sternal heave EKG Treat symptoms, valvuloplasty, replacement