1. Valvular Heart Disease Dr. Raid Jastania

2. Valvular Heart Disease Congenital or Acquired Part of congenital heart diseases May involve any valve: Aortic, Mitral, Pulmonary, Tricuspid

3. Valvular Heart Disease Types of Diseases: –Stenosis –Regurgitation –Endocarditis

4. Pathological Mechanisms of valve diseases Primary –Congenital/Developmental defect –Acquired Pathological process Infection: endocarditis Immune disorder: Rheumatic heart disease Degenerative (Aging) changes Secondary –LV dilatation –Abnormality of papillary muscle

5. Case

6. A ten-year-old child was brought to a pediatrician because of a mild sore throat. The pediatrician noticed some redness, swabbed her throat, tested for group A streptococci in the office, sent blood for antistreptolysin O titer, and prescribed treatment. Three weeks later, the child returned with fever and painful swelling of the knee joints, followed by pain and swelling of elbow joints.

7. Physical examination revealed a pericardial friction rub and a murmur suggestive of mitral regurgitation. The antistreptolysin O titer was elevated over the previous value. The child was hospitalized and treated with antibiotics and anti-inflammatory drugs. The patient recovered and did well over the next several decades.

8. In her thirties, the patient began to have dyspnea on exertion, which slowly increased in severity in her forties. In the months prior to her hospital admission for this and related symptoms, she had awakened at night feeling short of breath. She had one fainting spell, followed by an episode of temporary loss of vision in one eye. On admission to the hospital, she was very short of breath and had coughed up some blood-tinged sputum.

9. Physical examination and laboratory tests suggested narrowing of the mitral valve orifice. X-ray of her chest showed an enlarged left atrium and pulmonary edema. Cardiac surgery was offered, but she refused. She was treated medically for several days and discharged, feeling better but with some residual limitation of cardiac function.

10. The week before her next admission, she went to a dentist because of tooth pain, and underwent a dental extraction. She returned to the hospital with high spiking fevers and overt signs and symptoms of heart failure.

11. Rheumatic Fever and Heart disease Acute inflammatory disease Affecting different tissues and systems: Heart, joints, serosal surfaces, skin… Immune mediated Follow pharyngitis with GroupA streptococcal infection Few weeks after resolution of infection Antibody against M-protein of GroupA strep Cross-reaction with self antigen

13. Rheumatic Fever and Heart disease <3% of GroupA strep phayngitis Genetic susceptibility Age affected 5-15 years Positive anti streptolysinO, or DNAse B Fever Arthritis: migratory, large joints Carditis: pericarditis, pericardial effusion, myocarditis CHF

14. Rheumatic Fever and Heart disease Recurrence of acute illness Progress to chronic Rheumatic heart disease –Years after the acute illness –Valve disease: commonly mitral stenosis and aortic stenosis Complications: –CHF –Arrhythmia (atrial fibrillation) –Infective endocarditis –Thromboembolism

15. Rheumatic Fever and Heart disease Morphology: –Carditis, arthritis, skin lesions –Central fibrinoid necrosis surrounded by inflammatory cells (Aschoff body) –Followed by fibrosis –Valves: Mitral stenosis Aortic and mitral stenosis Vegetation of valves endocarditis

18. Degenerative Valve Disease Calcific Aortic Stenosis Degeneration is aging process End by fibrosis and calcification Common cause of isolated aortic stenosis Affect mitral valve as well, but usually does not result in functional abnormality Fatigue, syncope, systolic murmur L.V hypertrophy, ischemia, angina CHF

20. Mitral Valve Prolapse 3-5% of the general population Discovered between 20-40 years Accumulation of loose ground substance in the leaflets and cordae of mitral valve Floppy valve Ballooning of the valve to the left atrium during systole

21. Mitral Valve Prolapse Usually asymptomatic Midsystolic click Fatigue, chest pain 3% develop complications –Mitral regurgitation –CHF –Infective endocarditis –Thromboembolism