1. No category

ACQUIRED VITIUMS
Diagnostic and medical therapy of vitiums
JUDIT VEGH MD PhD
VALVULAR HEART DISEASE
CONGENITAL
ACQUIRED
– AORTIC STENOSIS
– AORTIC REGURGITATION
–
–
–
MITRAL STENOSIS
MITRAL REGURGITATION
MITRAL PROLAPSE
– TRICUSPID STENOSIS
– TRICUSPID REGURGITATION
– PULMONARY STENOSIS
– PULMONARY REGURGITATION
AORTIC STENOSIS
Supravalvular
(connective tissue
membrane)
Valvular (rheumatic,
cong. bicuspid aortic
valve)
Subvalvular
(connective tissue,
muscular type)
AORTIC STENOSIS
Ethyology
– 71 % calcificated (degenerativ)
– 28 % bicuspid aortic valve
– 1 % rheumatic
PATHOPHYSIOLOGY
Tight aortic orifice
Increased demand of left ventricule
(systolic pressure gradient between
the left ventricule and aorta)
Left ventricular hypertrophy
relative myocardial ischaemia
Symptoms
– Mainly in male persons (80%)
– 40-50 year-olds
– Blood pressure is low
– Low pulse amplitude (tardus et parvus)
– Nervous system symptoms – losing
consciousness
(decreased brain perfusion)
– insufficient coronary flow
– Left ventricule insufficiency, angina
Progression – mainly 7 mmHg/yr
AORTIC STENOSIS
PHYSICAL FINDINGS
– Ejection type systolic murmur (2R2)
(transmitted to the jugular notch, carotid arteries –
NOT to the axillar region)
– protosystolic rasping murmur
(high pressure blood stream turnes over the aortic
cuspids)
doesn’t change with breathing
– Erb point
– Tardus et parvus (low and slight)
AORTIC STENOSIS
ECG:
– Left ventricular hypertrophy, left ventricule strain signs
Carotid pulse: delayed peak, with coarse systolic vibrations
Echocardiography:
Chest X-Ray: aortic configuration, left ventricule hypertrophy hardly
increases heart size
– Characterisation of severity of the stenosis: size of orifice- area of the
aortic valve
mild
1.5-4 cm2
gradient below 30 mmHg
moderate
0.75-1.5 cm2
gradient 30-50 mmHg
severe
< 0.75 cm2
gradient more than 50 Hgmm
CW- flow velocity
P: 4xV2 - pressure gradient – highest actual gradient
(Bernoulli-formula)
– monitoring left ventricular function
– when is an operation required?
-> symptoms, decreased left ventricular function
Haemodynamic investigation – condition of coronary arteries
AORTIC
STENOSIS
AORTIC STENOSIS
AORTIC STENOSIS
DISEASE HISTORY - TREATMENT
– asymptomatic for a long time
– When to operate? - When left ventricular function is still sufficient
- below 0,75 cm2 alatt – operation indication
Arteficial valve:
plastic: more permanent, anticoagulation
biological: lasts for 10-12 years, when anticoagulation therapy is
contraindicated
Balloondilation: old patient, transient effect
Medication:
– In case of atrial fibrillation: digitalis glycosides
– Cardioversion: with amiodarone
– ACE inhibitors, nitrate, beta blocker, diuretic (carefully)
AORTIC REGURGITATION
AORTIC VALVE CLOSURE IS
INSUFFICIENT
PART OF THE BLOOD STREAM IS
REGURGITATING BACK INTO
THE LEFT VENTRICULE
DIASTOLIC OVERLOAD OF LEFT
VENTRICULE
SYSTOLIC OVERLOAD OF THE LEFT
VENTRICULE
LEFT VENTRICULE DILATION,
HYPERTROPHY
CARDIAC HEART FAILURE
CAUSES
– CUSPIDS contract
(2/3-rheumatic)
– come off, perforate
(bacterial endocarditis)
– Aortic root is expanding
(Marfan syndrome)
– Lues, Bechterew
AORTIC REGURGITATION
ACUTE
CAUSES:
Infectiv endocarditis
Trauma
Aortic dissection
No LV hypertrophy
Significant increase in
loading volume of left
ventricule during a short
time
Therapy: operation
CHRONIC
CAUSES:
Degenerativ
Bicuspid aortic valve
Rheumatic fever
Infectiv endocarditis
Chronic aortic dissection
Marfan’s syndrome
Permanent volume
overload leads to
dilatation, LV hypertrophy
AORTIC REGURGITATION
SYMPTOMS
Physical examination: decrescendo
type proto-/mesodiastolic murmur 3M-4L1
Austin –Flint murmur
(functional mitral stenosis)
Corrigan pulse (high pulse
amplitude)
Musset sign: inclination of head due
to pulse
Quincke symptome: pulsation
when pressing nail-bed
Duroziez murmur: systolic and
diastolic murmur over the femoral
arteries
ECG: diastolic, then systolic
Continous chest X-ray: enlarged
Echocardiography:
overload
left ventricule pulses visible
X-ray: enlarged heart
– Grade of regurgitation I-IV
(Color Doppler)
– Left ventricular function
– Left ventricular size
Haemodynamic examinations:
– Condition of coronary
arteries
AORTIC REGURGITATION
Treatment of heart failure
-digitalis glycosides, diuretics, ACE inhibitors,
beta blockers
Operation
–
–
–
Plastic valve is preferated because of longer lasting
Exeption: contraindication of anticoagulation
At Grade III-IV: operation is necessary already at
NYHA II-III
AORTIC STENOSIS AND REGURGITATION
TOGETHER
Both
physical examination findings
Is
the aortic stenosis relativ or organic ?
(organic if the carotid pulses with coarse
systolic vibrations)
Echocardiography:
grade of regurgitation
seems larger then it is
MITRAL STENOSIS
Cuspids become fibrotic, unite, contract, scar over
Mitral orifice contracts
Blood is collected to the left atrium
Left atrium streches, dilates
pressure symptoms -> disturbancies of rate and rhythm
Increased pressure in pulmonary circulation, congestion
(pulmonary edema, effort dyspnoe)
Accelerates the development of right ventricular hypertrophy and failure
Increased pressure in main circulation
(edema, nycturia – patient must sleep on a high pillow)
Permanent edema, liver congestion
MITRAL STENOSIS
female predominance
rheumatic origin - rarely a development disorder (cor triatrum)
SYMPTOMS
– Depend on the stage (develop early)
mitral rose – small vessel configuration on the face
– Physical examination: loud snapping 1st sound
opening snap – valve is turned over by the blood stream
praesystolic increasing diastolic murmur
(in case of atrial fibrillation there is a silent, hardly recognizable murmur)
ECG: P mitrale - left atrial overload
CHEST XRAY: mitral configuration-enlarged left atrium, heart border
passes the sternum on the right side, impresses the esophagus, pulmonary
veins are wide
KERLEY LINES – interlobular fluid
MITRAL STENOSIS
ECHOCARDIOGRAPHY:
– Continous Wave: estimating transvalvular (main and maximal) blood flow
velocity and gradient
Pulsatile Doppler: Diastolic pressure gradient (E, A wave)
Area of mitral valve: GORLIN FORMULA:
MVA = 220/PHT
normally 2,5-4 CM2,
mild stenosis: above 1,5 cm2
moderate stenosis: 1-1,5cm2,
severe stenosis: 0,6-1 cm2
– Size: dilated LA, normal LV
– Intracardial thrombus
CATHETERIZATION
– Exact gradient can only calculated by transseptal catheterization - dangerous
MITRAL STENOSIS
TREATMENT
Medical treatment
–
–
–
–
anticoagulation (wide atrium, atrial fibrillation)
Digitalis glycosides, beta blockers (AF)
diuretics
ACE inhibitors
Operation: comissurotomy
valve replacement (NYHA III)-plastic
MITRAL REGURGITATION
Male predominance
CAUSES
–
–
–
–
–
–
–
Rheumatic fever
Endocarditis
Papillar dysfunction (AMI, IHD)
Mitral prolapse
Functional enlargment of the mitral anulus (DCM)
HOCM
Congenital broken mitral cuspids
MITRAL REGURGITATION
closure of the cuspids is insuffitient
LV
LA overload
Pulmonary pressure is increasing
pulmonary congestion
LA regurgitation
LV diastolic overload
LV hypertrophy
MITRAL REGURGITATION
SYMPTOMS
– Depend of the stage, mainly dyspnoe
Physical findings
– holosystolic murmur , pm on the apex, transmitted to the
axillar region
ECG:
– LV-, biventricular hypertrophy
– Mitrale P
CHEST X-ray
– Mitral configuration, left ventricular enlargement,
postcapillary pressure increasement
ECHOCARDIOGRAPHY
– Color Doppler: Grade I-IV
– Monitoring left ventricular function
– Size of the left atrium, thrombus
CORONAROGRAPHY -
MITRAL REGURGITATION
TREATMENT
When condition requires treatment operation is necessary
( NYHA II )
Operation: valve replacement
Medical therapy:
ACE inhibitors
digitalis glycosides
diuretics
MITRAL PROLAPSE
(special case of mitral regurgitation)
Cause: congenital connective tissue-weakness of the
mitral apparate
Wide severity scale
Symptoms: neurotic complains, palpitation
Physical finding: mesosystolic click
Diagnosis: echocardiography
Therapy: beta blockers, sedative drugs, (valve
replacement)
Significance: makes susceptible to endocarditis
DUPLICATE MITRAL VITIUM
Both physical examination findings
Differential diagnosis: tricuspidal regurgitation
(gets louder at breathing in, while mitral vitium gets more silent!)
atrial septal defect
Diagnosis: ECHOCARDIOGRAPHY
NOTA BENE! : stenosis is overestimated
Important to know wheather the stenosis or the regurgitation
dominates!
– Stenosis: treatment of the mitral stenosis
– Regurgitaiton: early operation, NYHA II
TRICUSPID VALVULAR DISEASES
rarely alone, usually develop together with other valvulopathies
REGURGITATION
usually relativ (wide RV)
Isolated regurg.: endocarditis, carcinoid
Special case: EBSTEIN anomaly
Holosystolic murmur getting louder
while breathing in (4L)(Rivero-Carvallo sign)
Transmitted to the liver
ECG: pulmonal P
XRay: wide right side
ECHOCARD.: Grade I-IV
RV pressure can be measured
Therapy: elimination of the cause
results in disappearing
-if organic and significant:
valvular plastic surgery
biological arteficial valve
STENOSIS
Proto-meso diastolic and praesystolic
murmur
ECG: pulmonal P
X-ray: wide RA
Therapy: if significant: valve
replacement
ARTEFICIAL VALVES
biograft
human
pork aortic valve
other pericardial tissue
permanent
high risk of thrombosis not so long lasting
not strong enough
plastic
made of carbon
anticoagulation
(INR:2,5-3,5)
low risk of thrombosis
Danger: Endocarditis!
Any surgical procedure must be done in antibiotical protection!