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Valvular Heart Disease
Dr.Suhaemi,SpPD, Finasim
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Types
Mitral Stenosis Mitral Regurgitation Mitral Valve Prolapse
Aortic Stenosis Aortic regurgitation Tricuspid valve
• Tricuspid stenosis
• Tricuspid regurgitation
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Tricuspid Valve
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Mitral Valvehoc!ey stic!
appearanceindicatingRheumatic Valve
DiseaseValve area varied"et#een $.% to
$.&'(ercise 'cho #asdone
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Rheumatic Heart Disease
)n*ammatory process that may a+ectthe myocardium, pericardium and orendocardium
sually results in distortion andscarring o- the valves
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Rheumatic Heart Disease
Su"ectivesymptoms• Prior history o-
rheumatic -ever• /eneral malaise
• Pain 0 may or maynot "e present
1"ectivesymptoms• Temperature
• Murmurs• Dyspnea
• Polyarthritis
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Rheumatic Heart Disease
Diagnosis• H2P
• 345 and 'SR
• 56reactive protein• 5ardiac en7ymes
• '8/
• 5hest (6ray
• 'cho• 5ardiac cath
• 5ardiac output
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Rheumatic Heart Disease
9ursing 5are• Vital signs
• Rest and :uiet environment
• /ive anti"iotics, digitalis, and diuretics• Provide ade:uate nutrition
• Monitor )21
•
'(plain treatment and home care
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Mitral Stenosis sually results -rom rheumatic carditis )s a thic!ening "y ;"rosis or calci;cation 5an "e caused "y tumors, calcium and throm"us Valve lea*ets -use and "ecome sti+ and the
cordae tendineae contract These narro#s the opening and prevents normal"lood *o# -rom the
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Mitral Stenosis, cont.
Mild 0 asymptomatic 3ith progression 0 dyspnea, orthopneas,
dry cough, hemoptysis, and pulmonary
edema may appear as hypertension andcongestion progresses Right sided heart -ailure symptoms occur
later S2S
• Pulse may "e normal to A6Fi"• Apical diastolic murmur is heard
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=6D 'cho sho#ing heavily calci;ed
Mitral valve lea*ets and Mitral stenosis
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3-D Echo of Mitral Stenosis
LA view LV view
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LALA
A B C
D E F G
Real Time TT' o- MS
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MitralStenosis
MitralStenosisManagement PrinciplesManagement Principles
evere MS
is usually symptomatic
Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
PMC in silled centers has a mortality of ! "%
Success of PMC depends on the pre#PMC valve anatomy
Commissural calci$cation is a predictor of suoptimal outcom
Complications& severe M' emoliation and cardiac perforati
evere MS
is usually symptomatic
Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
PMC in silled centers has a mortality of ! "%
Success of PMC depends on the pre#PMC valve anatomy
Commissural calci$cation is a predictor of suoptimal outcom
Complications& severe M' emoliation and cardiac perforati
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• Surgical treatment
- commissurotomy (only occasionally indicated
usually PMC)
- valve replacement
MitralStenosis
MitralStenosisManagement PrinciplesManagement Principles
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Mitral Regurgitation Primarily caused "y rheumatic heart disease, "ut
may "e caused "y papillary muscle rupture -ormcongenital, in-ective endocarditis or ischemicheart disease
A"normality prevents the valve -rom closing 4lood *o#s "ac! into the right atrium during
systole During diastole the regurg output *o#s into the
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Mitral Valve Anatomy
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Pathophysiology
Hemodynamic changes much morepronounced than in chronic MR dueto lac! o- time -or adaptation
The a"rupt increase in le-t atrialpressure is transmitted to thepulmonary circulation
5ardiac output -alls and systemicvascular resistance increases
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'cho per-ormed>
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Mitral Valve Prolapse
5ause is varia"le and may "e associated#ith congenital de-ects
More common in #omen Valvular lea*ets enlarge and prolapse into
the
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Mitral Valve ProlapseMitral Valve Prolapse
• *omen +, to 5, years
• -o. /P orthostatic hypotension palpitations chest pain
• Mid systolic clic maye mid systolic murmur
• 0cho&
- thicened redundant lea1ets
- lea1et e2cursion (prolapse) into -3 in systole
- redundant chordae tendinae trivial or mild M'
• -ittle progression of M' 32 prophyla2is
• *omen +, to 5, years
• -o. /P orthostatic hypotension palpitations chest pain
• Mid systolic clic maye mid systolic murmur
• 0cho&
- thicened redundant lea1ets
- lea1et e2cursion (prolapse) into -3 in systole
- redundant chordae tendinae trivial or mild M'
• -ittle progression of M' 32 prophyla2is
Types Types
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Mitral Valve ProlapseMitral Valve Prolapse
• Men 4, to 7, years
• My2omatous and thicened M
• Signi$cant lea1elt prolapse
• Signi$cant M' progressive M'
• Complications& Chordal rupture 3$
• 0ndocarditis prophyla2is
• Surgery for M' often re6uired
• Men 4, to 7, years
• My2omatous and thicened M
• Signi$cant lea1elt prolapse
• Signi$cant M' progressive M'
• Complications& Chordal rupture 3$
• 0ndocarditis prophyla2is
• Surgery for M' often re6uired
Types Types
Classic or non#classic comined MP e6ual in male andfemales More complications in M08
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ransthoracic echocardiographic image in parasternallong#a2is vie. sho.ing posterior mitral lea1et o.ingac.ard and prolapsing into left atrium during systole-:left ventricle -3:left atrium PM-:posterior mitralvalve lea1et
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Aortic Stenosis Valve "ecomes sti+ and ;"rotic, impeding "lood *o# #ith
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AorticStenosis
AorticStenosis;iagnosis;iagnosis
Clinical
# pulsus parvus et tardus (asent in hypertensives and elderl
- systolic thrill and typical heaving apical impulse
- S4 and late peaing ejection systolic murmur
- parado2ical split of +nd '
- dilated ascending aorta (post#stenotic dilatation)
- alve calci$cation
Clinical
# pulsus parvus et tardus (asent in hypertensives and elderl
- systolic thrill and typical heaving apical impulse
- S4 and late peaing ejection systolic murmur
- parado2ical split of +nd '
- dilated ascending aorta (post#stenotic dilatation)
- alve calci$cation
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AorticStenosis
AorticStenosisManagement PrinciplesManagement Principles
• 3symptomatic
- no speci$c therapy
- endocarditis prophyla2is
- if appropriate rheumatic fever prophyla2is
• Mild and Mod 3S ( 33 ? "5 s6 cm and ", to "4 s6 cm)
- 8ormal physical activity
- 8o speci$c therapy restoration of 8S' in case of 3@i
- appro2 progression is a decrease y ," s6 cm per year
- annual echo follo.#up
• 3symptomatic
- no speci$c therapy
- endocarditis prophyla2is
- if appropriate rheumatic fever prophyla2is
• Mild and Mod 3S ( 33 ? "5 s6 cm and ", to "4 s6 cm)
- 8ormal physical activity
-
8o speci$c therapy restoration of 8S' in case of 3@i- appro2 progression is a decrease y ," s6 cm per year
- annual echo follo.#up
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• 8onsurgical (/alloon vavuloplasty)
- only a palliative treatment
- high ris elderly patients or as an emergent
procedure
AorticStenosis
AorticStenosisManagement PrinciplesManagement Principles
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5ardiac MR) and 5T
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)ndications -or Surgery
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)ndications -or Surgery
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Aortic Regurgitation Aortic valve lea*ets do not close properly during diastole The valve ring that attaches to the lea*ets may "e dilated,
loose, or de-ormed The ventricle dilates to accommodate the ? "lood volume
and hypertrophies 5auses in-ective endocarditis, congenital, hypertension,
Mar-an@s May remain asymptomatic -or years Develop dyspnea, orthopnea, palpitations, ,and angina May have ? systolic pressure #ith "ounding pulse Have a high pitch, "lo#ing, decrescendo diastolic murmur
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Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154
E!a"#le o$ a Jet o$ %orti& 'egurgitation, a( S)o*n + olor-lo* /"aging
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Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154
E!a"#le o$ uantitation o$ %orti& 'egurgitation + t)e onergen&e o$ t)e ro!i"al lo*
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Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154
la((i$i&ation o$ t)e Seerit o$ %orti& 'egurgitation
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Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-154
uideline( $or /ndi&ation( $or Surger in atient( *it) Seere %orti& 'egurgitation
Assessment -or Valve
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Assessment -or ValveDys-unction
Su"ective symptoms• Fatigue• 3ea!ness•
/eneral malaise• Dyspnea on e(ertion• Di77iness• 5hest pain or discom-ort
• 3eight gain• Prior history o- rheumatic heart disease
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Assessment, cont.
1"ective symptoms• 1rthopnea
• Dyspnea, rales
•
Pin!6tinged sputum• Murmurs
• Palpitations
• 5yanosis, capillary re;ll
• 'dema• Dysrhythmias
• Restlessness
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Diagnosis
History and physical ;ndings '8/ 5hest (6ray 5ardiac cath 'chocardiogram
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Medical Treatment
9onsurgical management -ocuses ondrug therapy and rest
Diuretic, "eta "loc!ers, digo(in, 1=,
vasodilators, prophylactic anti"iotictherapy
Manage A6;", i- develops, #ith
conversion i- possi"le, and use o-anticoagulation
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)nterventions Assess vitals, heart sounds, adventitious "reath
sounds ? H14 1= as prescri"ed
'motional support /ive medications )21 3eight 5hec! -or edema
'(plain disease process, provide -or home care#ith 1=, medications
S i l M - V l
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Surgical Management o- ValveDisease
Mitral Valve• 5ommissurotomy
• Mitral Valve Replacement
• 4alloon Valvuloplasty Aortic Valve Replacement
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Mechanical Valve
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Mechanical Valve
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Porcine Valve
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Tissue Valve
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Tissue Valve
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)nitial studies
First report o- left sided percutaneous valve implants "y4onhoe+er
• se o- "ovine ugular vein containing a valve #hich #asdissected and sutured into a stent in lam"s
• Valve initially implanted in descending aorta -or acuteaortic insuciency model.
1rientation and orthotopic position optimi7ed in -urtheranimal models
)n vitro testing sho#ed a satis-actory dura"ility -or up to =
yrs.
'ur Heart B =CC= =E $C%G6$C%
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Schematic views of device
Left - 3 parts of device arerepresented separately (from
top: platinum stent, nitinol
stent, and valve). Middle - Fully epanded device
is shown lon!itudinally and
aially. "i!h - dia!rams demonstrate
where nitinol and platinum
stents are attached, which
allowed stepwise approach.
From: #oud$emline: %irculation, &olume '(*).Fe+ruary ', .-
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/ewly desi!ned stent crimped on outer +alloon of delivery system +efore
+ein! covered. /otice spontaneous epansion of nitinol stent.
#oud emline: %irculation, &olume ' * .Fe+ruar ', .-
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(') 0hole system advanced in left ventricle.
() 1evice then uncovered, deployin! nonsutured part of nitinol stent.
Free wires of nitinol stent positioned in +ottom of native leaflet.
(3) #alloons are inflated to epand platinum stent
(2) Finally deflated, and retrieved, leavin! device in position.
#oud$emline: %irculation, &olume '(*).Fe+ruary ', .-
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From: %ri+ier: %irculation, &olume '*(2).1ecem+er ', .3*-3
he percutaneous valve crimped
over the 3-mm-lon! +alloon +efore
implantation
Percutaneous
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BA55 =CC% %E$CI=6J BA55 =CC= E$&&%6$&&
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Summary Percutaneous alvuloplasty
• M valvuloplasty eAcacious in carefully selected patients• 3 valvuloplasty
Bnly transient improvement and high restnosis rate in adultpopulation
-ast resort or ridge to surgery in patients .ith severe calci$ed 3S• P valvuloplasty
mainly in pediatric population *ell#accdepted treatment for PS and good fu results
Percutaneous alve repair
• Currently investigational devices for M' only• Still early stage .ith no pulished results (that D no. of) in human
Percutaneous valve replacementimplantation• 0arly stages .ith very limited data on human• Promising results for P in pediatric population• -imited ut promising data in human for 3 implant in non#surgical
candidates
• -arger scale clinical trials and long term data needed• Enans.ered 6uestions regarding ideal material paravalvular leas
duraility complications and more
Bverall percutaneous valve intervention is an e2citing $eld ininterventional cardiology ut still at an infantile stage .ith potentiallyimmense clinical applicationF