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Valvular Heart Disease Vincent E. Friedewald, M.D.
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Classification of Heart Disease Congenital Coronary Electrical Endomyocardial Pericardial Valvular
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The Cardiac Valves
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Cardiac Valve Anatomy
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Valvular Heart Disease Acute and Chronic are Different Diseases
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Aortic Stenosis
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Aortic Stenosis Types Valvular Subvalvular Supravalvular
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Aortic Valve Stenosis
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Bicuspid Rheumatic Degenerative
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Aortic Valve Stenosis Age Relationship
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Bicuspid Aortic Stenosis
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Rheumatic Aortic Stenosis
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Degenerative Aortic Stenosis
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Risk Factors Elevated LDL-cholesterol Diabetes mellitus Systemic arterial hypertension Cigarette smoking
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Aortic Valve Stenosis Symptoms Often Asymptomatic Angina pectoris Dyspnea Fatigue Syncope
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Aortic Valve Stenosis Signs ARTERIAL PULSE, GEN – RISE, SLOW ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN – DOWNSLOPE GRADUAL ARTERIAL PULSE, GEN – PULSE PRESSURE, NARROW ARTERIAL PULSE, GEN – SHUDDER ARTERY, CAROTID – THRILL HEART, LV APEX – IMPULSE, PRESYSTOLIC HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – MURMUR, SYSTOLIC
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Aortic Valve Stenosis Signs (cont) HEART, LV APEX – CLICK, SYSTOLIC HEART, LV APEX – IMPULSE, SUSTAINED HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – CLICK, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SINGLE HEART, SOUND S2 – SPLIT REVERSED (PARADOXICAL) NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC
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Aortic Valve Stenosis Symptoms FATIGUE BREATHING – DIFFICULT WITH EFFORT (DYSPNEA) CHEST, ANT – PAIN, NONPLEURITIC (ANGINA PECTORIS) CHEST, ANT – PALPITATIONS CONSCIOUSNESS – LOSS, SUDDEN (SYNCOPE) CONSCIOUSNESS – LOSS, SUDDEN EFFORT (EFFORT SYNCOPE) DIZZINESS – EFFORT
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Aortic Valve Stenosis Untreated Prognosis
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Aortic Valve Stenosis Chest X-Ray
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Aortic Valve Stenosis ECG
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Aortic Valve Stenosis Echo
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Aortic Valve Stenosis AV Pressure Gradient
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Aortic Valve Stenosis Medical RX No drugs alter course – only valve repair/replacement Antibiotic Prophylaxis ? Statins For symptoms (if not candidate for valve replacement) – after-load reduction, i.e., nitroglycerine, used with caution to avoid BP fall
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Aortic Valve Stenosis Surgical Rx Valvotomy Replacement Artificial Bioprosthesis Minimally-invasive transfemoral
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Aortic Valve Replacement Transfemoral
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Aortic Valve Stenosis Complications Atrial fibrillation Aortic Dissection Heart failure Infective endocarditis Myocardial infarction Sudden death
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Aortic Regurgitation (Insufficiency)
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Aortic Regurgitation Etiologies Primary aortic valve disease Aortic root abnormalities (Dissection, Syphilis) Connective tissue disorders (Marfan’s) Infective endocarditis Inflammatory disorders (SLE) Tumors
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Aortic Regurgitation Symptoms BREATHING – DIFFICULT, NOCTURNAL BREATHING – DIFFICULT WITH EFFORT CHEST, ANT – PAIN, NONPLEURITIC (ANGINA) CHEST, ANT – PALPITATIONS HEAD, GEN – PAIN SWEATING – NOCTURNAL
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Aortic Regurgitation Signs ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, ELEVATED ARTERIAL PULSE, GEN – DOUBLE ARTERIAL PULSE, GEN – FALL, RAPID ARTERIAL PULSE, GEN – PULSE PRESSURE, WIDE ARTERIAL PULSE, GEN – RISE, RAPID ARTERY, CAROTID – THRILL ARTERY, FEMORAL – SOUND, DIASTOLIC BOOMING
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HEAD – BOBBING HEART, LSB MID – MURMUR, DIASTOLIC HEART, LSB MID – THRILL, DIASTOLIC HEART, LV APEX – IMPULSE, INF DISPLACEMENT HEART, LV APEX – IMPULSE, LAT DISPLACEMENT HEART, LV APEX – IMPULSE, DIFFUSE HEART, LV APEX – MURMUR, DIASTOLIC HEART, RSB UPPER – MURMUR, SYSTOLIC HEART, RSB UPPER – MURMUR, DIASTOLIC Aortic Regurgitation Signs (cont)
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HEART, RSB UPPER – THRILL, SYSTOLIC HEART, SOUND A2 – ABSENT OR REDUCED HEART, SOUND S1 – SOFT HEART, SOUND S2 – SPLIT REVERSED HEART, SOUND S3 LV MOUTH, UVULA – PULSATIONS NAILS – PULSATIONS NECK, SUPRATERNAL NOTCH – THRILL, SYSTOLIC
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Aortic Regurgitation – Chronic Chest X-Ray
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Aortic Regurgitation Echo
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Aortic Regurgitation Medical Rx Vasodilators to reduce systolic BP Antibiotic prophylaxis
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Aortic Regurgitation Surgical Rx Aortic valve replacement
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Mitral Regurgitation (Insufficiency)
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Mitral Regurgitation Etiologies Congenital deformities Degenerative, i.e., myxomatous Endomyocardial fibroelastosis Mitral annular calcification Papillary muscle dysfunction – ischemic heart disease Rheumatic
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Mitral Regurgitation Etiologies (cont) Ergotamine toxicity Carcinoid syndrome Radiation Rx SLE Diet-drug therapy
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Mitral Regurgitation Papillary Muscles
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Mitral Regurgitation Leaflet Prolapse (MVP Syndrome)
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Mitral Regurgitation Calcified Annulus
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Mitral Regurgitation Symptoms BREATHING – DIFF, EFFORT FATIGUE SKIN, GEN – TEMPERATURE, COOL SWEATING – EXCESSIVE
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Mitral Regurgitation Signs ARTERIAL PULSE, GEN - AMP, ABSENT OR REDUCED ARTERIAL PULSE, GEN - FALL, RAPID ARTERIAL PULSE, GEN - RISE, RAPID CHEST, ANT LEFT - BULGE HEART, LV APEX - IMPULSE, FORCEFUL HEART, LV APEX - IMPULSE, DIFFUSE
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Mitral Regurgitation Signs (cont) HEART, LV APEX - IMPULSE, SUSTAINED HEART, LV APEX - MURMUR, DIASTOLIC HEART, LV APEX - MURMUR, SYSTOLIC HEART, SOUND P2 - LOUD HEART, SOUND S3 LV SKIN, GEN - TEMPERATURE, COOL
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Mitral Regurgitation 2-D Echo
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Mitral Regurgitation Doppler Echo
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Mitral Regurgitation Complications Atrial fibrillation Pulmonary hypertension LV dysfunction Infective endocarditis
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Mitral Regurgitation Medical Rx Antibiotic prophylaxis ACEIs (functional form of MR) Beta-blockers (functional form of MR)
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Mitral Regurgitation Surgical Rx Mitral repair Mitral valve replacement
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Mitral Stenosis
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Mitral Stenosis Increased LA Pressure
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Mitral Stenosis Etiologies Rheumatic Rare: Congenital Chest radiation Left atrial myxoma Mucopolysaccharidosis Severe mitral annular calcification
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Mitral Stenosis Symptoms ABDOMEN, GEN – PAIN BREATHING – DIFF, NOCTURNAL BREATHING – DIFF, EFFORT BREATHING – DIFF, RECLINING FLAT BREATHING – DIFF, RESTING BREATHING – RAPID CHEST, ANT – PAIN, NONPLEURITIC CHEST, ANT – PALPITATIONS COUGH – CHRONIC, NONSPECIFIC FATIGUE SPUTUM – BLOODY
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Mitral Stenosis Signs ARTERIAL PRESSURE, GEN – DIASTOLIC, LOW ARTERIAL PRESSURE, GEN – LOW ARTERIAL PRESSURE, GEN – SYSTOLIC, LOW ARTERIAL PULSE, GEN – AMP, ABSENT OR REDUCED BREATH SOUNDS, GEN – WHEEZES EXTREMITIES, LOWER BILATERAL - EDEMA HEART RATE – RAPID HEART, LSB LOWER – IMPULSE, SYSTOLIC
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Mitral Stenosis Signs (cont) HEART, LSB LOWER – MURMUR, DIASTOLIC HEART, LSB MID – PERCUSSION, DULLNESS HEART, LV APEX – MURMUR, DIASTOLIC HEART, LV APEX – OPENING SNAP, MITRAL HEART, LV APEX – THRILL, DIASTOLIC HEART, RSB – SOUND, SYSTOLIC EJECTION HEART, RSB UPPER – MURMUR, DIASTOLIC HEART, SOUND P2 – LOUD
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Mitral Stenosis Signs (cont) HEART, SOUND P2 – PALPABLE HEART, SOUND S1 – SOFT HEART, SOUND S1 – LOUD LIVER – ENLARGED SKIN, CHEEKS – COLOR, PINK PURPLE SKIN, GEN – COLOR, BLUE VENOUS PULSE, JUGULAR - A WAVE, LARGE VENOUS PULSE, JUGULAR – ELEVATED
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Mitral Stenosis Chest X-ray
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Mitral Stenosis Echo
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Mitral Stenosis LA Thrombus
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Mitral Stenosis ECG
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Mitral Stenosis Complications Atrial fibrillation Infective Endocarditis Peripheral embolism Pulmonary hypertension
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Mitral Stenosis Medical RX Antibiotic prophylaxis Anticoagulation for Atrial fibrillation Prior embolic event Documented LA thrombus Arrhythmia control
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Mitral Stenosis Surgical RX Invasive valvuloplasty Percutaneous valvotomy Valve replacement
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Mitral Stenosis Invasive Valvuloplasty
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Mitral Stenosis Surgical RX – Valvuloplasty with Balloon Catheter
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Valvular Heart Disease Follow up Antibiotic prophylaxis New symptoms Change in symptoms Change in physical findings Echocardiography/other imaging
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Thank you!
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