4. Causes of valve disease Valve regurgitation * Congenital *Acute rheumatic carditis *Chronic rhe. Carditis * I E *Syphlitic aortitis *Dilated Valve ring *Senile degeneration e.g. dilated CMP *Traumatic valve rupture *Damage to chordae and papillary muscles e.g. M I Valve stenosis * Congenital * Senile degeneration *Rheumatic carditis

7. Aetiology and pathophysiology * Almost rheumatic in origin. 2/3 are Females * Almost rheumatic in origin. 2/3 are Females Pure or predominant MS 40% of all RVD Pure or predominant MS 40% of all RVD * Heavy calcification in elderly may produce * Heavy calcification in elderly may produce a form of mitral stenosis. a form of mitral stenosis. * Congenital MS { rare }. * Congenital MS { rare }. _ Mitral vave orifice progressively diminish by _ Mitral vave orifice progressively diminish by fibrosis, calcification of leaflets and fusion 0f cusps and subvalvular apparatus. fibrosis, calcification of leaflets and fusion 0f cusps and subvalvular apparatus. _LA dilate … LA pressure rises … pulmonary congestion occurs … later pulmonary hypertension ….RVF _LA dilate … LA pressure rises … pulmonary congestion occurs … later pulmonary hypertension ….RVF _Atrial fibrillation occurs in most patients with risk of _Atrial fibrillation occurs in most patients with risk of thromboembolism. thromboembolism. _> 20% remain in sinus rhythm with small fibrotic LA and _> 20% remain in sinus rhythm with small fibrotic LA and severe PH severe PH

8. * Normal valve area : 4-6 cm 2 * Normal valve area : 4-6 cm 2 * Mild. mitral stenosis * Mild. mitral stenosis _ MVA 1.5-2.5 cm 2 _ MVA 1.5-2.5 cm 2 _ Minimal symptoms _ Minimal symptoms * Mod. mitral stenosis * Mod. mitral stenosis _ MVA 1.0-1.5 cm 2 usually does not produce _ Symptoms at rest _ MVA 1.0-1.5 cm 2 usually does not produce _ Symptoms at rest * Severe mitral stenosis * Severe mitral stenosis _ MVA < 1.0 cm2 _ MVA < 1.0 cm2 Pathophysiology of MV :

9. JVP

10. * Dyspnia {pulmonary congestion } * Fatigue { low COP } * Oedema, ascitis {RVF } * Palpitation { AF } * Haemoptysis {pulmonary congestion, PE } * Cough {pulmonary congestion } * Chest pain {PH } * Symptoms of thromboembolic complication { e.g. stroke, ischaemic limb} Clinical features Symptoms * Dyspnia {pulmonary congestion } * Fatigue { low COP } * Oedema, ascitis {RVF } * Palpitation { AF } * Haemoptysis {pulmonary congestion, PE } * Cough {pulmonary congestion } * Chest pain {PH } * Symptoms of thromboembolic complication { e.g. stroke, ischaemic limb} Clinical features Symptoms

11. Signs : * Atrial fibrillation * Mitral facies, tapping apex {Palpable 1 st HS} * Auscultation : Loud first HS, Opening snap Mid-diastolic murmer, presyst. Accentuation * Signs of raised pulmonary capillary pressure : _Crepitations, _Pulmonary oedema, Effusion * Signs of pulmonary hypertension: RV heave, Loud P2 Clinical features cont.

12. Physical examination Physical examination Auscultation

13. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Aortic stenosis Mitral insufficiency Mitral insufficiency Mitral valve prolapse Mitral valve prolapse Tricuspid insufficiency Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Aortic insufficiency Mitral stenosis Mitral stenosis S1 S2 S1

14. Investigations * ECG : * ECG : LA hypertrophy, RVH, AF LA hypertrophy, RVH, AF * Chest X-ray : * Chest X-ray : Enlarged LA Enlarged LA Pulmonary venous congestion Pulmonary venous congestion * ECHO : * ECHO : Thick immobile cusps Thick immobile cusps Reduced valve area Reduced valve area Reduced rate of LV diastolic filling Reduced rate of LV diastolic filling * Doppler : * Doppler : _ PG across MV _ Pulmonary artery pressure _ PG across MV _ Pulmonary artery pressure * Cardiac catheterization : * Cardiac catheterization : _ Pulmonary wedge pressure _ Pulmonary wedge pressure _ PG between LA and LV _ PG between LA and LV

15. ECG MS+ AF

16. Chest X-ray PA view

17. Chest X-ray lat. View +Barium swallow

19. . AO LA MV

20. 2-D mode Active ECHO.

21. Pw Dopler

22. Color dopler

23. *Progressive, lifelong disease, *Progressive, lifelong disease, *usually slow & stable in the early years. *usually slow & stable in the early years. *Progressive acceleration in the later years *Progressive acceleration in the later years *20-40 year latency from rheumatic fever to symptom onset. *20-40 year latency from rheumatic fever to symptom onset. *Additional 10 years before disabling symptoms *Additional 10 years before disabling symptoms Natural history

24. Management : * Medical management : * Medical management : _Digoxin for AF +beta blocker or calcium antagonist _Digoxin for AF +beta blocker or calcium antagonist _Diuretics for pulmonary congestion _Diuretics for pulmonary congestion _Anticoagulant to reduce risk of systemic emboli _Anticoagulant to reduce risk of systemic emboli _Antibiotic prophylaxis against IE _Antibiotic prophylaxis against IE *Mitral balloon valvoplasty : *Mitral balloon valvoplasty : _ Significant symptoms _ Significant symptoms _Isolated MS _Isolated MS _ No or trivial MR _ No or trivial MR _Mobile noncalcific valve /subvalvular apparatus on ECHO _Mobile noncalcific valve /subvalvular apparatus on ECHO _ LA free of thrombus _ LA free of thrombus * Mitral valve surgery : * Mitral valve surgery : _Closed mitral valvotomy _Closed mitral valvotomy _ Open mitral valvotomy _ Open mitral valvotomy _Mitral valve replacement _Mitral valve replacement * Mechanical * Mechanical * Bioprosthesis * Bioprosthesis

25. Mechanical valves