2. RJS Valvular heart disease Richard Schilling St Mary’s Hospital London

3. RJS Valve disease Aetiology Clinical findings Investigations Management

4. RJS Heart Valve lesions Mitral stenosis Aortic stenosis Pulmonary stenosis Tricuspid stenosis Prosthetic stenosis Mitral regurgitation Aortic regurgitation Pulmonary regurgitation Tricuspid regurgitation Prosthetic regurgitation Mitral valve prolapse

5. RJS Mitral regurgitation - Aetiology Valve –Rheumatic fever –Endocarditis Mitral valve annulus –Dilation –Calcification Chordae tendinae –Rupture –Lengthening Papillary muscle –ischaemia –dilation

6. RJS Mitral regurgitation – pathophysiology  LV emptying  LA pressure (if acute, pulmonary odema)  LV filling  LVedd LV stretch  failure 

7. RJS Mitral regurgitation – Clinical Symptoms appear late –SOB –Fatigue –Right heart failure Signs –Full volume pulse –Pan systolic murmur radiating to apex –Right heart failure –Pulmonary hypertension

8. RJS Mitral Regurgitation Investigations –ECG p mitrale –Xray large heart, calcified mv annulus, pulmonary odema –Echocardiogram large LA, abnormal valve, MR –LV angio MR, large LA

9. RJS

11. Mitral Regurgitation Heart Failure Decrease afterload Replacement Anticoagulation Antibiotic prophylaxis

12. RJS Mitral Stenosis - Aetiology Rheumatic fever Congenital

13. RJS Mitral Stenosis - pathophysiology  LA pressure  Pulmonary pressure R Heart failure  LV function

14. RJS Mitral Stenosis – Symptoms/Signs SOB Haemoptysis Embolisation Mitral Facies AF, thready pulse  JVP RV heave

15. RJS Mitral Stenosis – Symptoms/Signs Opening snap Rumbling diastolic murmur Presystolic murmur

16. RJS

17. Mitral stenosis - Investigations ECG – AF Xray – Pulmonary congestion, large LA and R heart Echo – tight valve, high inflow large LA

18. RJS MS ECG

19. RJS MS x-ray

20. RJS MS echo

21. RJS MS Treatment Antibiotic prophylaxis Anticoagulation (AF) Digoxin (AF) Mitral Valvuloplasty Surgical Replacement

22. RJS Mitral Valvuloplasty

23. RJS Aortic Stenosis - aetiology Congenital – bicuspid valve Acquired –Rheumatic –Senile/degenerative

24. RJS Aortic Stenosis – pathophysiology LVH  Cardiac output on exercise LV dilatation and failure

25. RJS Aortic stenosis – symptoms/ signs Asymptomatic Angina Heart Failure Syncope Sudden Death

26. RJS Aortic stenosis – symptoms/ signs Slow rising pulse LV heave Ejection systolic murmur radiating to carotids

27. RJS Aortic Stenosis - investigations ECG – LVH Echo – LVH, calcified valve, high doppler velocity Angio – Ao valve gradient

28. RJS AS ECG

29. RJS Congenital AS

30. RJS Echo AS

31. RJS Doppler/Pressure Aortic stenosis

32. RJS Aortic stenosis - treatment Antibiotic prophylaxis Surgical replacement before heart failure

33. RJS Aortic valve replacement

34. RJS Aortic Regurgitaiton- aetiology Aortic valve –Rheumatic fever –Infective endocarditis –Bicuspid vlave Aortic dilation –Age related –Marfans –Dissection

35. RJS Aortic regurg - pathophysiology Increased Lved volume Increased stroke volume LV dilatation LV failure

36. RJS AR – symptoms/signs Often asymptomatic Chest pounding Prominent pulse Heart failure

37. RJS AR – symptoms/signs deMusset’s sign Collapsing pulse Displaced apex beat Early diastolic murmur

38. RJS Auscultation AR

39. RJS AR investigations ECG – LVH X-ray – abnormal aorta, large heart Echo – AR, LV dilation, dissection Angiogram – AR, LV dilation

40. RJS AR - xray

41. RJS AR - Echo

42. RJS AR - treatment Antibiotics Vasodilators Replacement – when LV begins to dilate or fail

43. RJS When to replace the aortic valve?

44. RJS When to replace the mitral valve When symptoms significant Before LV failure Before significant pulmonary hypertension

45. RJS Right heart valves Low pressure Tricuspid regurg (drug addicts) Pulmonary stenosis (congenital)