1. CV 3: Valvular Heart Disease Lab September 19, 2011

2. Case 1

3. A 75 year-old man presents with exertional angina, syncope, and dyspnea. The patient also admits to having occasional spells of lightheadedness and fainting on exercise On physical examination: – Systolic ejection murmur to right of sternum radiating to the neck – Weak and delayed carotid pulses

4. A chest x-ray shows calcifications of aortic valve leaflets and an enlarged cardiac shadow The patient does not have any evidence of significant coronary artery disease on angiogram.

5. What do you think is the most likely diagnosis?

6. In a 75 year-old man, what is the most likely etiology of the valvular disease

7. The patient underwent surgery for aortic valve replacement The excised valve is shown in image 1B Image 1A shows a normal aortic valve.

8. 1A 1B Image 1A, 1B

9. In a 50 year-old man with similar symptoms and with no evidence of significant coronary artery disease, what would the most likely diagnosis be?

10. Image 1C

11. Image 1D

12. In a 25 year old-man with similar symptoms, what would be the most likely cause of the disease?

13. Image 1E

14. Image 1F

15. Case 2 A 25 year old white-male presents to his cardiologist with complaints of pounding of the heart and angina. There is no family history of coronary artery disease The patient denies smoking or drinking and claims to have had no major illnesses in the past On physical examination the patient has a bounding pulse, large in volume and a wide pulse pressure and a diastolic murmur. His systolic blood pressure is high and diastolic blood pressure low Chest X-ray shows an enlarged left ventricle and dilated ascending aorta.

16. Why would this patient have a bounding pulse? What is the most likely diagnosis?

17. On additional questioning the patient mentioned that his older brother died of aortic dissection at the age of 30 years. Why is this relevant? A CT angiogram of this patient is shown in image 2A and 2B

18. 2A 2B

19. The next two slides(2C, 2D) demonstrate the pathology in this patient.

20. Image 2C

21. Image 2D

22. Case 3 A 34-year-old white female is admitted to the hospital with progressively increasing dyspnea and orthopnea The patient denies any prior cardiovascular disease, but on additional questioning she reveals that she had rheumatic fever as a child

23. On physical examination, the patient has elevated JVP, mid-diastolic murmur ECG: Left atrial hypertrophy and atrial fibrillation Chest X-ray (Image 3A) shows interstitial and alveolar densities

24. Image 3A

25. The patient underwent mitral valve replacement Excised valve is shown in image 3B

26. Image 3B

27. Image 3C is from another patient with similar history who underwent aortic valve replacement. Please describe the gross features.

28. Image 3C

29. Images 3D, 3E, 3F & 3G are autopsy images from another patient with similar clinical history

30. Image 3D

31. Thrombus Image 3E

32. Image 3F Image 3G

33. Case 4

34. A 50 year-old with a history of rheumatic fever in childhood presents to the emergency with fever for 10 days She has had dyspnea on exertion for the past two years, but says that the dyspnea has become worse since the onset of fever On physical examination splinter hemorrhages were seen in his finger nails as shown in image 4A CASE 4

35. Image 4A

36. Blood cultures were positive for staphylococcus aureus What is the most likely etiology of this patient’s fever and dyspnea? A mitral valve replacement was performed. The next image is from the mitral valve from an autopsy patient with similar findings

37. Image 4B

38. Image 4C

39. Image 4D

40. Case 5

41. A 50 year-old-man died of bleeding complications following surgery for adenocarcinoma of the pancreas He was diagnosed with disseminated intravascular coagulation shortly before his death An autopsy was performed – The heart showed vegetations on his mitral valve and aortic valve – Blood cultures were negative for microorganisms

42. Image 5A

44. Libman-Sacks Disease -- Seen in patients with SLE – No predilection for lines of closure – Circulating antiphospholipid antibodies

45. Libman-Sacks Disease

46. Rheumatic valvulitis

47. LSE NBTEInfective endocarditis

48. Case 6

49. A 50 year-old man with known mitral regurgitation due to myxomatous degeneration presents in the ER with acute shortness of breath There is no fever. A coronary angiogram performed 2 months prior did not show any evidence of coronary artery disease. Prior echo showed normal left ventricle and an enlarged left atrium

50. What are the diagnostic possibilities in this patient?

51. The patient underwent emergent mitral valve replacement.

52. The gross and microscopic features of the excised mitral valve are shown in kodachrome 6A and 6B. What is your diagnosis?

53. Image 6A

54. Image 6B

55. In a patient with history of coronary artery disease the probable cause of acute mitral regurgitation is shown in the next kodachrome (6C) What is your diagnosis?

56. Image 6C

57. Case 7

58. A 35 year-old-man presents with complaints of flushing, cramps, nausea, vomiting, diarrhea and wheezing. On physical examination: patient has increased jugular venous pressure, hepatomegaly, ascites and bilateral lower leg edema.

59. The patient underwent right tricuspid valve replacement. Image 7B is from an autopsy heart of another patient with similar history.

60. Image 7B

61. Case 8

62. A 40 year old man underwent mitral valve replacement for mitral stenosis. A year later the patient presented to the emergency department with an acute surgical abdomen. On examination the patient had generalized peritonitis. On urgent laparotomy a ruptured spleen was found. The spleen was infarcted at the site of rupture. An echo was performed.

63. The patient subsequently underwent a redo heart valve replacement The pathologic abnormality of the valve is shown in image 8A which is from an autopsy heart

64. Image 8A

65. Another 40 year-old-man underwent mitral valve replacement for mitral stenosis. Four years later he developed mitral regurgitation.

66. The valve was excised and is shown in image 8B. What is the possible etiology?

67. Image 8B