3 Hemodynamic effects:1. Increase LA pressure that leading to its dilatation2. Lung congestion.Reactive pulmonary arteriolar vasoconstriction:- Decrease pulmonary congestion.- Initiate pulmonary hypertension.LA dilatation produce AF & pressure symptoms
6 Clinical picture:Symptoms:Mild cases may be asymptomatic.Moderate to severe cases present with symptoms of pulmonary congestive symptomsPalpitation (irregular) AF.Manifestation of pulmonary hypertension- low cardiac output.- right hypochondrial pain & GIT upset.- bilateral edema of lower limb .5. Pressure symptoms: hoarseness of voice , dysphagia , and dyspnea
7 Signs :Apex is normal in position & slapping (hypokinitic ) in character.Palpable first heart soundAccentuated first heart sound.Opening snape after second heart soundDiastolic rumbling murmur at the apexSevere cases with pulmonary hypertension manifestation of low cardiac out put can be seen as peripheral cyanosis – malar flash at the cheeks
10 Investigations1. Chest X- ray :show straight left border of the heart due to LA dilatation(mitralization )& double contour.
11 2. Echocardiography :show thick leaflets dilated LA & can calculate mitral valve area
12 Complications : Atrial fibrillation LA thrombus & systemic embolizationsInfective endocarditis.Recurrence of rheumatic activityPulmonary hypertension
13 Management :A- Medical treatment in minimal symptomatic patients:Diuretic to relieve lung congestionControl rate of AF and give also oral anticoagulant.Prophylaxis against recurrence by LA penicillin.Prophylaxis against infective endocarditis.Follow up the patient by Echocardiography.
18 Etiology :Rheumatic fever causing :- fibrosis & deformity of valve leaflets.- shortening of chordae tendinae .Dilatation of the LV & mitral valve ring (functional)Dysfunction of papillary muscles: due to ischemia , infarction.Less common causes as:- congenital abnormalities.- endocarditis.- HOCM- Mitral valve prolapse (degenerative disease )
19 Heamodynamic effect :Regurgitated jet from LV to LA during systole leading to LA dilatation.Transmission of large volume from LA to LV produce hyperdynamic heart.LV dilated and ending by failure if the regurge is severe & prolonged.LV failure leading to pulmonary congestion and if this is prolonged , pulmonary hypertension occursAtrial fibrillation may occur due to LA dilatation
20 Clinical picture:symptoms:For many years , patients with mild or moderate mitral regurge are asymptomatic or complain only of palpitation.Symptoms of pulmonary congestion appear due to LV failure .Symptoms of low cardiac output may occur due to pulmonary hypertension
21 Signs :Hyperdynamic apex and may be displaced outward and downwards.Systolic thrill at the apex.Pansystolic murmur at the apex & propagated to the axillaFaint first heart sound.Third heart sound at the apex.Signs of LV failure as bilateral basal crepitation.
26 A - Medical treatment:Prophylaxis against endocarditis.Prophylaxis against rheumatic activityACE inhibitor .Diuretic in case of lung congestionPatient with AF :- digitalis to control rate.- oral anticoagulant
27 - Mitral valve repair :in case of wide annulus , rupture chordae. B- Surgical treatment : for symptomatic severe regurge- Mitral valve repair :in case of wide annulus , rupture chordae.- Mitral valve replacement : for destructive valve
28 Aortic regurge Etiology : The vast majority due to : rheumatic fever . Rare causes :- Congenital heart disease.- Infective endocarditis.- Trauma.- Dissecting aneurysm.- Ankylosing spondylitis.- Syphilis.- Marfan syndrome.
30 C/P:Symptoms:Mild & moderate case may be complaint from palpitation for a long time.Manifestations of LV failure as dyspnea , orthopenia ,PNDAngina in severe cases only
31 Signs :High systolic pressure & very low diastolic pressurePeripheral pulse has the following characters:- High volume.- marked arterial pulsations in the neck(corrigan´s)- water hummer pulse-pistol shot femoral.Hyperdynamic apex & is displaced outward and downwardLong early diastolic murmur immediately after second heart sound at second aortic area .
36 Treatments : A- Medical treatment : - long acting penicillin - prophylaxis against endocarditis.- on severe LV failure use digitalis . Diuretic , ACEIB- Surgery :aortic valve replacement on severe symptomatic cases before LV failure.
37 Aortic stenosis Causes : Rheumatic : it is more common in males Congenital : bicuspid aortic valve.Senile sclerosis : in old age.The valvular aortic stenosis should be differentiated from other causes of LV outflow obstructions as:Sub-aortic membrane.HOCM.Supra-valvular stenosis.