1. Valvular heart disease Dr. Rehab F. Gwada

2. Normal Valve Function Maintain forward flow and prevent backward of blood flow. Valves open and close in response to pressure differences (gradients) between cardiac chambers.

3. What Is Valvular Heart Disease? Heart valve disease occurs when your heart's valves do not work the way they should. The disease can affect the valve and derange its function in two ways: Reduction in the orifice of the valve called stenosis which limits the forward blood flow Backward leak of blood due to inefficient closing of the valve called regurgitation or insufficiency.

4. What Are the Types of Valve Disease? I-Valvular stenosis II_ Valvular insufficiency, regurgitation or incompetence

6. The valves affected most commonly by the disease are aortic and mitral valves. The pulmonary and tricuspid valves are affected less often.

7. What Causes Valvular Heart Disease? idiopathic valvular degeneration, unknown cause. Congenital valve disease. Most often affects the aortic or pulmonary valve. Congenital valve disease Rheumatic fever Endocarditis Other causes of valve disease include :Other causes of valve disease include coronary artery disease, heart attack, cardomyopathy, syphilis, hypertension, and connective tissue diseases.

8. Rheumatic fever Is an inflammatory disease that can develop as a complication of inadequately treated strep throat or scarlet fever. Which are caused by a streptococcus bacterium infection. Develop in younger children and adults. The cardiac manifestation of rheumatic fever is focal inflammatory involvement of the interstitial tissue in all 3 layers of the heart(pan-carditis) The pathognomonic feature of pancarditis is the presence of Aschoff nodules.

9. Aortic Regurgitation Aortic regurgitation is incompetency of the aortic valve causing blood flow from the aorta into the left ventricle during diastole..

10. Signs systolic BP increases while diastolic BP decreases, creating a widened pulse pressure the LV impulse displaced downward and laterally normal 1st heart sound (S1) loud, sharp or slapping 2nd heart sound (S2) The murmur of AR is blowing, high-pitched, diastolic.

11. Symptoms AR may be acute or chronic. In chronic AR, left ventricular (LV) volume and stroke volume gradually increase because the LV receives aortic blood regurgitated in diastole in addition to blood from the pulmonary veins and left atrium leading to LV hypertrophy this is asymptomatic for years. These changes may ultimately cause arrhythmias, heart failure (HF), or cardiogenic shock. Progressive exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitations develop.

12. signs (Musset's sign) Visible signs include head bobbing (slapping, water-hammer, or collapsing pulse) Palpable signs include a large-volume pulse with rapid rise and fall. (Corrigan's sign)pulsation of the carotid arteries (Mayne's sign) BP findings may be a fall in diastolic BP of > 15 mm Hg with arm elevation (pistol-shot sound, or Traube's sign) Auscultatory signs include a sharp sound heard over the femoral pulse

13. Aortic Stenosis Aortic stenosis (AS) is narrowing of the aortic valve obstructing blood flow from the left ventricle to the ascending aorta during systole. A valve area of 0.5 to 1.0 cm2 represents severe stenosis; an area < 0.5 cm2 represent critical stenosis

14. Symptoms The left ventricle (LV) gradually hypertrophies in response to AS. Significant LV hypertrophy and, with progression, may lead to decreased contractility, ischemia, or fibrosis, any of which may cause heart failure (HF). AS produces low cardic output ultimately results in syncope, angina, and exertional dyspnea; heart failure and arrhythmias {ventricular fibrillation } may develop

15. Signs A decreased carotid and peripheral pulsation. Systolic ejection murmur.. A palpable 4th heart sound (S4), felt best at the apex Systolic BP may be high with mild or moderate AS and fall as AS becomes more severe.

16. Mitral Regurgitation Mitral regurgitation (MR) is incompetency of the mitral valve causing blood flow from the left ventricle (LV) into the left atrium during systole

17. Mitral Regurgitation Regurge of blood into LA during systole LA dilation and hypertrophy Pulmonary congestion RV failure LV dilation and hypertrophy-to accommodate increased preload and decreased CO

18. Symptoms Most patients with chronic MR are initially asymptomatic and develop symptoms insidiously as the LA enlarges, pulmonary BP increases, and LV remodeling occurs. dyspnea, fatigue (due to heart failure), palpitations (often due to AF); rarely, patients present with endocarditis (eg, fever, weight loss,….). Signs develop only when MR becomes moderate to severe affected.

19. Signs sustained left parasternal movement due to expansion of an enlarged LA. LV impulse is displaced downward and to the left suggests LV hypertrophy and dilation. (S1) may be soft or absent if valve leaflets are rigid but is usually present if the leaflets are not rigid. (S3), loud at the apex in proportion to the degree of MR, reflects a greatly dilated LV. (S4) is characteristic of recent ruptured chordae, when the LV has not had enough time to dilate. Apansystolic murmur, heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position

21. Mitral Valve Stenosis the narrowing of the orifice of the mitral valve of the heart ]mitral valveheart ]

22. Mitral Stenosis  The normal area of the mitral valve orifice is 4 to 6 cm2.  An area of 2 to 1 cm2 reflects moderate to severe MS and often causes exertional symptoms.  An area < 1 cm2 represents critical stenosis and may cause symptoms during rest.  Left atrial (LA) size and pressure increase progressively to compensate for MS;  pulmonary venous and capillary pressures also increase and may cause secondary pulmonary hypertension, leading to right ventricular (RV) heart failure and tricuspid and pulmonic regurgitation.  Valvular change with LA enlargement predisposes to atrial fibrillation (AF), a risk factor for thromboembolism.

23. Symptoms many patients are asymptomatic until they become pregnant or AF develops. Initial symptoms are usually those of heart failure (eg, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue). They typically do not appear until 15 to 40 yr after an episode of rheumatic fever Palpitation Chest pain Hemoptysis Thromboembolism in later stages when the left atrial volume is increased (i.e., dilation). leads to increase risk of atrial fibrillation, which increases the risk of blood stasis.This increases the risk of coagulation.atrial fibrillation Ascites and edema and hepatomegaly (if right-side heart failure develops)heart failure Fatigue and weakness increase with exercise and pregnancy. Less common symptoms include: – hoarseness due to compression of the left recurrent laryngeal nerve by a dilated LA or pulmonary artery

24. Mitral Valve Prolapse (MVP) It is a very common condition, affecting 1 to 2 % of the population. MVP causes the leaflets of the mitral valve to flop back into the left atrium during the heart's contraction. MVP also causes the tissues of the valve to become abnormal and stretchy, causing the valve to leak. The condition rarely causes symptoms and usually doesn't require treatment.

26. symptoms MVP is usually asymptomatic, although chest pain, dyspnea, and symptoms of sympathetic excess (eg, palpitations, dizziness, syncope, migraines, anxiety) may develop.

27. Pulmonary regurge Pulmonic (pulmonary) regurgitation (PR) is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole The most common cause is pulmonary hypertension.

28. Symptoms PR may contribute to development of right ventricular (RV) hypertrophy and eventually RV dysfunction – induced heart failure (HF), but in most cases, pulmonary hypertension contributes to this complication much more significantly PR is usually asymptomatic. A few patients develop symptoms and signs of RV dysfunction – induced HF

29. Pulmonic stenosis is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole. Pulmonic stenosis (PS) is most often congenital and affects predominantly children;

30. Symptoms When symptoms develop, they resemble those of aortic stenosis (syncope, angina, dyspnea).

31. Tricusped regurge is insufficiency of the tricuspid valve causing blood flow from the right ventricle to the right atrium during systole. The most common cause is dilation of the right ventricle

32. Symptoms and signs are usually absent, but severe TR can cause neck pulsations, a holosystolic murmur, right ventricular – induced heart failure or atrial fibrillation. TR is usually benign and does not require treatment, but some patients require valve repair or replacement.

33. How Are Valve Diseases Diagnosed? symptoms physical exam the doctor may order diagnostic tests. These may include: – Echocardiography Echocardiography – Transesophageal echocardiography recent advances is the development of probes which can be advanced into the esophagus and take the images from the close proximity of the heart Transesophageal echocardiography – Cardiac catheterization (also called an angiogram) Cardiac catheterization – Radionuclide scans – Magnetic resonance imaging (MRI) Magnetic resonance imaging

34. Goals of treatment There are three goals of treatment for heart valve disease: protecting the valve from further damage lessening symptoms repairing or replacing valves.

35. Protecting the valve from further damage. Patient is still at risk for endocarditis, even if his valve is repaired or replaced through surgery. To protect himself, give him the following advices: Know the type and extent of your valve disease. Tell all your doctors and dentist you have valve disease. Call your doctor if you have symptoms of an infection. Take good care of your teeth and gums. Take antibiotics before you undergo any procedure that may cause bleeding. Take your medications. Follow your doctor's instructions. See your heart doctor for regular visits, even if you have no symptoms.

36. Strategies for treatment MedicationSurgeryCardiac rehabilitation

37. How Is Heart Valve Disease Treated? Common Types of Medications Diuretics Antiarrhythmic Vasodilators ACE inhibitorsA type of vasodilator used to treat high blood pressureand heart failure ACE inhibitorshigh blood pressure Beta blockersTreat high blood pressure and lessen the heart's work by helping the heart beat slower and less forcefully. Used to decrease palpitations in some patients. Beta blockers Anticoagulants

38. Surgery and Other Procedures Surgical options include heart valve repair or replacement. Heart valves may also be repaired by other procedures such as percutaneous balloon valvotomy.

39. Treatment Valve Surgery (repair): Various technique can be used: (eg: Leaflet repair, Use of prosthetic rings and etc). to optimize the valve orifice making sure that the valve is no longer stenotic or regurgitant. Generally, repairs are preferred over replacements.

40. Valve replacement: It occur,When the valve is severely damaged and it is not possible to repair. The artificial valves are of three types – a mechanical (metallic) valve – a valve made from animal tissue – or a human valve removed from the human cadaver and frozen to preserve its integrity (cryopreservation). The mechanical valve is the most durable but it has the disadvantage of the risk of blood clot formation. Valve repair or replacement with tissue valves have the advantage that blood clot formation is not a risk. The decision about the type of the artificial heart valve is made by the cardiologist and surgeon.

41. Indications for MV Replacement in Severe MR ANY Symptoms at rest or exercise with (repair if feasible) Asymptomatic: – If EF <60% – If new onset atrial fibrillation

42. Indications for Surgical Treatment of AR ANY Symptoms at rest or exercise Asymptomatic treatment if: – EF drops below 50% or LV becomes dilated

43. Indications for Mitral valve MS))replacement ANY SYMPTOMATIC Patient with NYHA Class III or IV Symptoms Asymptomatic moderate or Severe MS

44. Indications for Surgery in Aortic Stenosis Any SYMPTOMATIC patient with severe AS (includes symptoms with exercise) Any patient with decreasing EF Any patient undergoing CABG with moderate or severe AS

45. Question?