© continuing medical implementation …...bridging the care gap valvular heart disease tulika jain,...
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© Continuing Medical Implementation …...bridging the care gap
Valvular Heart Valvular Heart DiseaseDisease
Tulika Jain, MDTulika Jain, MDResident Teaching Resident Teaching ConferenceConferenceDecember 5, 2008December 5, 2008
AuscultationAuscultation Use the diaphragm for high pitched sounds and Use the diaphragm for high pitched sounds and
murmursmurmurs Use the bell for low pitched sounds and Use the bell for low pitched sounds and
murmurs (diastolic rumble)murmurs (diastolic rumble) Sequence of auscultation Sequence of auscultation
– upper right sternal border (URSB)upper right sternal border (URSB)– upper left sternal border (ULSB) upper left sternal border (ULSB) – lower left sternal border (LLSB)lower left sternal border (LLSB)– apexapex– apex - left lateral decubitus positionapex - left lateral decubitus position– lower left sternal border (LLSB)- sitting, leaning lower left sternal border (LLSB)- sitting, leaning
forward, held expirationforward, held expiration
Innocent MurmursInnocent MurmursCommon in asymptomatic Common in asymptomatic adultsadults
Characterized byCharacterized by– Grade I – II @ LSBGrade I – II @ LSB– Systolic ejection pattern - no Systolic ejection pattern - no with Valsalva with Valsalva
– Normal precordium, apex, S1
– Normal intensity & splitting of second sound (S2)
– No other abnormal sounds or murmurs
– No evidence of LVH
S1 S2
Characteristic of the Characteristic of the NOT NOT Innocent MurmurInnocent Murmur Diastolic murmurDiastolic murmur Loud murmur - grade III or aboveLoud murmur - grade III or above Regurgitant murmurRegurgitant murmur Murmurs associated with a clickMurmurs associated with a click Murmurs associated with other Murmurs associated with other
signs or symptoms e.g. cyanosissigns or symptoms e.g. cyanosis Abnormal 2Abnormal 2ndnd heart sound – fixed heart sound – fixed
split, paradoxical split or singlesplit, paradoxical split or single
Heart Sounds PearlsHeart Sounds Pearls
Right sided valves open earlier and Right sided valves open earlier and close last due to lower pressure close last due to lower pressure gradient gradient
All right sided murmur and sounds All right sided murmur and sounds tend to augment with inspiration: tend to augment with inspiration: EXCEPTION: PULMONIC STENOSIS EXCEPTION: PULMONIC STENOSIS click DECREASES WITH INSPIRATIONclick DECREASES WITH INSPIRATION
Valsalva releases increases murmur Valsalva releases increases murmur of HOCM and MVPof HOCM and MVP
Heart Sounds: ClicksHeart Sounds: Clicks
Valve DisordersValve Disorders
EtiologyEtiology SymptomsSymptoms Physical ExamPhysical Exam TestingTesting SeveritySeverity Indications for SurgeryIndications for Surgery
Common Clinical Common Clinical ScenariosScenarios Younger Younger
peoplepeople– Functional Functional
murmur vs murmur vs MVP vs MVP vs bicuspid AVbicuspid AV
Older peopleOlder people– Aortic sclerosis Aortic sclerosis
vs aortic vs aortic stenosisstenosis
Aortic Stenosis - Aortic Stenosis - EtiologyEtiology Young patient think Young patient think
congenitalcongenital– Bicuspid AVDBicuspid AVD
2% population2% population 3:1 3:1
male:female male:female distributiondistribution
Co-existing Co-existing coarctation 6% coarctation 6% of patientsof patients
RarelyRarely– Unicuspid valveUnicuspid valve– Sub-aortic stenosisSub-aortic stenosis
DiscreteDiscrete Diffuse (Tunnel)Diffuse (Tunnel)
Middle aged Middle aged patient(4&5patient(4&5thth decades) decades) think bicuspid or think bicuspid or rheumatic diseaserheumatic disease
Old patient think Old patient think degenerative (6,7,8degenerative (6,7,8thth decades)decades)
Aortic Stenosis: Aortic Stenosis: EtiologyEtiology Valvular Valvular SubvalvularSubvalvular SupravalvularSupravalvular
Supravalvular Aortic Supravalvular Aortic StenosisStenosis
Aortic Stenosis: Aortic Stenosis: SymptomsSymptoms Cardinal SymptomsCardinal Symptoms
– Chest pain (angina)Chest pain (angina) Reduced coronary flow reserveReduced coronary flow reserve Increased demand-high afterloadIncreased demand-high afterload
– Syncope (exertional pre-syncope)Syncope (exertional pre-syncope) Fixed cardiac outputFixed cardiac output Vasodepressor responseVasodepressor response
– Dyspnea on exertion & restDyspnea on exertion & rest Other signs of LV failure Other signs of LV failure
– Diastolic & systolic dysfunctionDiastolic & systolic dysfunction
Severity of StenosisSeverity of Stenosis
Normal aortic valve area 2.5-3.5 Normal aortic valve area 2.5-3.5 cmcm22
Mild stenosis 1.5-2.5 cmMild stenosis 1.5-2.5 cm22
Moderate stenosis 1.0-1.5 cmModerate stenosis 1.0-1.5 cm22
Severe stenosis < 1.0 cmSevere stenosis < 1.0 cm22
Onset of symptomsOnset of symptoms~0.9 cm0.9 cm22 with CAD with CAD~0.7 cm0.7 cm22 without CAD without CAD
Aortic Stenosis: Aortic Stenosis: Physical FindingsPhysical Findings
Intensity DOES NOT predict severityIntensity DOES NOT predict severity Presence of thrill DOES NOT predict Presence of thrill DOES NOT predict
severityseverity ““DiamondDiamond” shaped, systolic crescendo-” shaped, systolic crescendo-
decrescendo decrescendo Decreased, delay & prolongation of pulse Decreased, delay & prolongation of pulse
amplitude: “pulsus parvus and tardus”amplitude: “pulsus parvus and tardus” Paradoxical S2 Paradoxical S2 S4 (with left ventricular hypertrophy)S4 (with left ventricular hypertrophy) S3 (with left ventricular failure)S3 (with left ventricular failure)
Aortic Stenosis: Aortic Stenosis: Physical FindingsPhysical Findings
S1 S2 S1 S2
Mild-Moderate Severe
Wave Sound
Heart Sounds: Heart Sounds: SplittingSplitting
AS
Aortic Stenosis : Lab Aortic Stenosis : Lab
EKG: LVHEKG: LVH CXR: Intially have concentric LVH CXR: Intially have concentric LVH
so unremarkable; Critical AS may so unremarkable; Critical AS may show post stenotic dilation of the show post stenotic dilation of the aorta, hypertrophy, congestionaorta, hypertrophy, congestion
CXR: AS with Post CXR: AS with Post Stenotic Dilatation of Stenotic Dilatation of AortaAorta
Aortic Stenosis: Aortic Stenosis: TreatmentTreatment
Indications for surgery:Indications for surgery: Symptomatic Symptomatic Asymptomatic but EF < 50%Asymptomatic but EF < 50% Poor performance on ETTPoor performance on ETT Reasonable if asymptomatic true Reasonable if asymptomatic true
AS and operative mortality is lowAS and operative mortality is low If low output, low gradient AS then If low output, low gradient AS then
need dobutamine stress echoneed dobutamine stress echo
Aortic Stenosis: Aortic Stenosis: TreatmentTreatment Aortic stenosis is a surgical Aortic stenosis is a surgical
diseasedisease Treatment is valve replacementTreatment is valve replacement Aortic valve balloon valvuloplasty Aortic valve balloon valvuloplasty
rarely done due to stroke risk and rarely done due to stroke risk and other complicationsother complications
Current trials using catheter based Current trials using catheter based aortic valve replacementaortic valve replacement
Aortic Regurgitation:Aortic Regurgitation:EtiologyEtiology Any conditions Any conditions
resulting in resulting in incompetent aortic incompetent aortic leafletsleaflets
CongenitalCongenital– Bicuspid valveBicuspid valve
AortopathyAortopathy– Cystic medial necrosisCystic medial necrosis– Collagen disorders (e.g. Collagen disorders (e.g.
Marfan’s)Marfan’s)– Ehler-DanlosEhler-Danlos– Osteogenesis imperfectaOsteogenesis imperfecta– Pseudoxanthoma Pseudoxanthoma
elasticumelasticum
AcquiredAcquired– Rheumatic heart diseaseRheumatic heart disease– Dilated aorta (e.g. Dilated aorta (e.g.
hypertension..)hypertension..)– DegenerativeDegenerative– Connective tissue Connective tissue
disorders disorders E.g. ankylosing E.g. ankylosing
spondylitis, rheumatoid spondylitis, rheumatoid arthritis, Reiter’s arthritis, Reiter’s syndrome, Giant-cell syndrome, Giant-cell arteritis )arteritis )
– Syphilis (chronic aortitis)Syphilis (chronic aortitis) Acute AI: aortic Acute AI: aortic
dissection, infective dissection, infective endocarditis, traumaendocarditis, trauma
Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND With extreme reductions in diastolic With extreme reductions in diastolic
pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina
Aortic Regurgitation:Aortic Regurgitation: Physical Exam Physical Exam Widened pulse pressureWidened pulse pressure
– Systolic – diastolic Systolic – diastolic = pulse pressure= pulse pressure
High pitched, High pitched, blowing, blowing, decrescendo diastolic decrescendo diastolic murmurmurmur at LSB at LSB
Best heard at Best heard at end-end-expiration & leaning expiration & leaning forwardforward
Hands & Knee positionHands & Knee positionS1 S2 S1
Wave Sound
Peripheral Signs of Peripheral Signs of Severe Severe Aortic RegurgitationAortic Regurgitation Quincke’s sign: Quincke’s sign:
capillary pulsationcapillary pulsation Corrigan’s sign: water Corrigan’s sign: water
hammer pulsehammer pulse Bisferiens pulse Bisferiens pulse
(AS/AR > AR) (AS/AR > AR) De Musset’s sign: De Musset’s sign:
systolic head bobbing systolic head bobbing Mueller’s sign: systolic Mueller’s sign: systolic
pulsation of uvulapulsation of uvula
Durosier’s sign: Durosier’s sign: femoral retrograde femoral retrograde bruits (bell)bruits (bell)
Traube’s sign: pistol Traube’s sign: pistol shot femoralsshot femorals
Hill’s sign:BP Lower Hill’s sign:BP Lower extremity >BP Upper extremity >BP Upper extremity by extremity by – > 20 mm Hg - mild AR> 20 mm Hg - mild AR– > 40 mm Hg – mod AR> 40 mm Hg – mod AR– > 60 mm Hg – severe > 60 mm Hg – severe
ARAR
Wave Sound
Central Signs of Central Signs of Severe Severe Aortic RegurgitationAortic Regurgitation Apex:Apex:
– EnlargedEnlarged– DisplacedDisplaced– Hyper-dynamicHyper-dynamic– Palpable S3 Palpable S3 – Austin-Flint Austin-Flint
murmurmurmur
Aortic diastolic Aortic diastolic murmurmurmur– length correlates length correlates
with severity with severity (chronic AR)(chronic AR)
– in acute AR in acute AR murmur shortens murmur shortens as Aortic as Aortic DP=LVEDPDP=LVEDP
– in acute AR - mitral in acute AR - mitral pre-closurepre-closure
Assessing Severity Assessing Severity of ARof AR
Assess severity by impact on Assess severity by impact on peripheral signs and LVperipheral signs and LV peripheral signs = peripheral signs = severity severity LV = LV = severity severity– S3S3– Austin -FlintAustin -Flint– LVHLVH– radiological cardiomegalyradiological cardiomegaly
Aortic RegurgitationAortic Regurgitation
Aortic Regurgitation:Aortic Regurgitation: Natural History Natural History
AsymptomaticAsymptomatic %/Y %/Y Normal LV function (~good prognosis)Normal LV function (~good prognosis)
– Progression to symptoms or LV dysfunction < 6Progression to symptoms or LV dysfunction < 6– Progression to asymptomatic LV dysfunction < 3.5Progression to asymptomatic LV dysfunction < 3.5– 75% 5-year survival75% 5-year survival– Sudden deathSudden death < 0.2 < 0.2
Abnormal LV functionAbnormal LV function– Progression to cardiac symptomsProgression to cardiac symptoms 25 25
Symptomatic (Poor prognosis)Symptomatic (Poor prognosis)– Mortality Mortality > 10 > 10
Bonow RO, et al, JACC. 1998;32:1486.
Aortic Regurgitation:Aortic Regurgitation: Treatment Treatment
Before development of heart failure, AI can be treated with vasodilators (ACE Inhibitors), diuretics, salt restriction
Goal: Surgery BEFORE LV dysfunction !!!!
“Rule of 55”
Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic AorticAortic & Mitral Regurgitation & Mitral Regurgitation
Type of Type of RegurgitationRegurgitation
LVESD mmLVESD mm EF %EF %
Aortic Aortic > 55> 55 < 55< 55
MitralMitral > 40> 40 < 60< 60
A 75 year old woman A 75 year old woman with Recent with Recent orthopnea/PNDorthopnea/PND
Chronic dyspnea Chronic dyspnea Class 2/4Class 2/4
FatigueFatigue Recent Recent
orthopnea/PNDorthopnea/PND Nocturnal Nocturnal
palpitationpalpitation Pedal edemaPedal edema
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
#2 ?#2 ?
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
#2 Rheumatic#2 Rheumatic
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
#2 Rheumatic#2 Rheumatic
#3 Rheumatic#3 Rheumatic
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
#2 Rheumatic#2 Rheumatic
#3 Rheumatic . . .#3 Rheumatic . . .
#99 ?#99 ?
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic
#2 Rheumatic#2 Rheumatic
#3 Rheumatic#3 Rheumatic
#99 Rheumatic#99 Rheumatic
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic#2 Rheumatic#2 Rheumatic#3 Rheumatic#3 Rheumatic#99 Rheumatic#99 Rheumatic#100 ?#100 ?
Mitral Stenosis: Mitral Stenosis: EtiologyEtiology
#1 Rheumatic#1 Rheumatic#2 Rheumatic#2 Rheumatic#3 Rheumatic#3 Rheumatic#99 Rheumatic#99 Rheumatic#100 Congenital, #100 Congenital,
endocarditis, Carcinoid, endocarditis, Carcinoid, Fabray, Hurler, Whipple, Fabray, Hurler, Whipple, Atrial MyxomaAtrial Myxoma
Mitral Stenosis Mitral Stenosis EtiologyEtiology Primarily a result of rheumatic feverPrimarily a result of rheumatic fever
– ~ 99% of MV’s @ surgery show ~ 99% of MV’s @ surgery show rheumatic damage)rheumatic damage)
Scarring & fusion of valve apparatusScarring & fusion of valve apparatus Rarely congenitalRarely congenital Pure or predominant MS occurs in Pure or predominant MS occurs in
approximately 40% of all patients with approximately 40% of all patients with rheumatic heart diseaserheumatic heart disease
Two-thirds of all patients with MS are Two-thirds of all patients with MS are female.female.
Mitral Stenosis Mitral Stenosis PathophysiologyPathophysiology
Normal valve area: 4-6 cmNormal valve area: 4-6 cm22
Mild mitral stenosis: Mild mitral stenosis: – MVA 1.5-2.5 cmMVA 1.5-2.5 cm22
– Minimal symptomsMinimal symptoms Mod mitral stenosisMod mitral stenosis
– MVA 1.0-1.5 cmMVA 1.0-1.5 cm2 2 usually does not produce usually does not produce symptoms at restsymptoms at rest
Severe mitral stenosisSevere mitral stenosis– MVA < 1.0 cm2MVA < 1.0 cm2
Right Heart Right Heart Failure:Failure:
Hepatic Hepatic CongestionCongestion
JVDJVD
Tricuspid Tricuspid RegurgitationRegurgitation
RA EnlargementRA Enlargement
Pulmonary HTNPulmonary HTN
Pulmonary Pulmonary CongestionCongestion
LA EnlargementLA Enlargement
Atrial FibAtrial Fib
LA ThrombiLA Thrombi
LA PressureLA Pressure
RV Pressure RV Pressure OverloadOverload
RVHRVH
RV FailureRV Failure LV FillingLV Filling
Mitral Valve Stenosis Mitral Valve Stenosis PathophysiologyPathophysiology
Mitral Stenosis: Mitral Stenosis: SymptomsSymptoms Dyspnea, PND, orthopneaDyspnea, PND, orthopnea
– Slow progressive courseSlow progressive course– May not admit to symptomsMay not admit to symptoms
HemoptysisHemoptysis PalpitationsPalpitations EmboliEmboli
Mitral Stenosis Mitral Stenosis ExaminationExamination
Mitral Stenosis Mitral Stenosis Physical ExamPhysical Exam
First heart sound (S1) is accentuated and snappingFirst heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closureOpening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apexLow pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm)Pre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S1
Auscultation-Timing of Auscultation-Timing of A2 to OS IntervalA2 to OS Interval
Width of A2-OS Width of A2-OS inversely correlates inversely correlates with severitywith severity
The more severe the The more severe the MS the higher the LAP MS the higher the LAP the earlier the LV the earlier the LV pressure falls below pressure falls below LAP and the MV LAP and the MV opensopens
Shorter A2-OS=more Shorter A2-OS=more severe mitral stenosissevere mitral stenosis
Mitral Stenosis: ECGMitral Stenosis: ECG
LAELAE With pulm HTN: RAD, RVHWith pulm HTN: RAD, RVH AFIBAFIB
Mitral Stenosis: CXRMitral Stenosis: CXR
Mitral Stenosis: CXRMitral Stenosis: CXR
Mitral Stenosis: Mitral Stenosis: TreatmentTreatment
Mitral Stenosis: Mitral Stenosis: TreatmentTreatment
Mitral Stenosis: Mitral Stenosis: TreatmentTreatment
Mitral Stenosis: Mitral Stenosis: TreatmentTreatment
An 80 year old woman An 80 year old woman with increasing with increasing dyspneadyspnea Longstanding Longstanding
heart murmurheart murmur Increasing Increasing
dyspnea & dyspnea & fatiguefatigue
Recent ER visit Recent ER visit Dx CHFDx CHF
Mitral Regurgitation:Mitral Regurgitation:EtiologyEtiology
Valvular-leafletsValvular-leaflets– Myxomatous MV Myxomatous MV
DiseaseDisease– RheumaticRheumatic– EndocarditisEndocarditis– Congenital-cleftsCongenital-clefts
ChordaeChordae– Fused/inflammatoryFused/inflammatory– Torn/tTorn/traumarauma– DegenerativeDegenerative– IEIE
AnnulusAnnulus– Calcification, Calcification, IE (abcess)IE (abcess)
Papillary MusclesPapillary Muscles– CAD (Ischemia, CAD (Ischemia,
Infarction, Rupture)Infarction, Rupture)– HCMHCM– Infiltrative disordersInfiltrative disorders
LV dilatation & LV dilatation & functional functional regurgitationregurgitation
TraumaTrauma
MR Etiology:Surgical MR Etiology:Surgical series series MVP(20-70%)MVP(20-70%) Ischemia (13-40%)Ischemia (13-40%) RHD (3-40%)RHD (3-40%) Infectious endocarditis(10-12%)Infectious endocarditis(10-12%)
MR PathophysiologyMR Pathophysiology
Chronic LV volume overload -» Chronic LV volume overload -» compensatory LVE initially compensatory LVE initially maintaining cardiac outputmaintaining cardiac output
Decompensation (increased LV wall Decompensation (increased LV wall tension) -»CHFtension) -»CHF
LVE – » annulus dilation – » increased LVE – » annulus dilation – » increased MRMR
Backflow – » LAE, Afib, Pulmonary HTNBackflow – » LAE, Afib, Pulmonary HTN
MRMR SymptomsSymptoms
Similar to MSSimilar to MS Dyspnea, Orthopnea, PNDDyspnea, Orthopnea, PND FatigueFatigue Pulmonary HTN, right sided Pulmonary HTN, right sided
failurefailure HemoptysisHemoptysis Systemic embolization in A FibSystemic embolization in A Fib
Recognizing ChronicRecognizing ChronicMitral RegurgitationMitral Regurgitation
Pulse:Pulse:– brisk, low volumebrisk, low volume
Apex:Apex:– hyperdynamichyperdynamic– laterally displacedlaterally displaced– palpable S3 +/- thrillpalpable S3 +/- thrill– late parasternal lift 2late parasternal lift 2
to LA fillingto LA filling S 1 soft or normalS 1 soft or normal S 2 wide split (early S 2 wide split (early
A2) unless LBBBA2) unless LBBB
Murmur-Fixed MR:Murmur-Fixed MR:– pansystolicpansystolic– loudest apex to axillaloudest apex to axilla– no post extra-systolic no post extra-systolic
accentuationaccentuation Murmur-Dynamic Murmur-Dynamic
MR(MVP)MR(MVP)– mid systolicmid systolic– +/- click+/- click uprightupright
S 3 / flow rumble if S 3 / flow rumble if severesevere
Wave Sound
Recognizing Acute Recognizing Acute SevereSevereMitral RegurgitationMitral Regurgitation Acute severe dyspnea, Acute severe dyspnea,
CHF & hypotensionCHF & hypotension LV size normalLV size normal LV may/may not be LV may/may not be
hyperdynamichyperdynamic Loud S1Loud S1 Systolic murmur Systolic murmur
may/may not be pan-may/may not be pan-systolicsystolic
Inflow/rumbleInflow/rumble S3 present-may be S3 present-may be
only abnormalityonly abnormality
RV liftRV lift TTE/TEE for diagnosisTTE/TEE for diagnosis
– Chordal or papilllary Chordal or papilllary muscle rupture/tearmuscle rupture/tear
– Infarction with Infarction with papillary muscle papillary muscle ischaemia or tearischaemia or tear
– Infectious Infectious endocarditis with endocarditis with leaflet perforation or leaflet perforation or disruption or chordal disruption or chordal teartear
– Flail MV segmentFlail MV segment
Recognizing Mitral Recognizing Mitral RegurgitationRegurgitation
ECG:ECG:– LA enlargementLA enlargement– AfibAfib– LVH (50% pts. LVH (50% pts.
With severe MR)With severe MR)– RVH (15%)RVH (15%)– Combined Combined
hypertrophy hypertrophy (5%)(5%)
CXR:CXR: LVLV LALA pulmonary pulmonary
vascularityvascularity– CHFCHF– Ca++ MV/MACCa++ MV/MAC
Mitral RegurgitationMitral Regurgitation
CXR: MS vs MRCXR: MS vs MR
CXR: Mitral stenosis CXR: Mitral stenosis with MR and TRwith MR and TR
Chronic MR Chronic MR EchocardiographyEchocardiography Baseline evaluation to identify Baseline evaluation to identify
etiology, quantify severity of MRetiology, quantify severity of MR Assess and quantify LV function and Assess and quantify LV function and
dimensionsdimensions Annual or semi-annual surveillance of Annual or semi-annual surveillance of
LV function, estimated EF and LVESD LV function, estimated EF and LVESD in asymptomatic severe MRin asymptomatic severe MR
To establish cardiac status after To establish cardiac status after change in symptomschange in symptoms
Baseline study post MVR or repair Baseline study post MVR or repair
Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic AorticAortic & & Mitral RegurgitationMitral Regurgitation
Type of Type of RegurgitationRegurgitation
LVESD mmLVESD mm EF %EF %
Aortic Aortic > 55> 55 < 55< 55
MitralMitral > 40> 40 < 60< 60
Mitral Valve Prolapse: Mitral Valve Prolapse: EpidemiologyEpidemiology Affects 5-10% of population Affects 5-10% of population Most common cause of isolated severe MR Most common cause of isolated severe MR Females >> males; Ages of 14 and 30years Females >> males; Ages of 14 and 30years Strong hereditary component (? autosomal Strong hereditary component (? autosomal
dominant)dominant) 22ºº to failure of apposition/coaptation of the to failure of apposition/coaptation of the
anterior and posterior mitral valve leaflets.anterior and posterior mitral valve leaflets. Results form diverse pathologic conditions, Results form diverse pathologic conditions,
but cause is unknown in a majority of ptsbut cause is unknown in a majority of pts
Mitral Valve Prolapse: Mitral Valve Prolapse: SymptomsSymptoms Majority are asymptomatic for Majority are asymptomatic for
entire lifeentire life PalpitationsPalpitations Chest pain (atypical).Chest pain (atypical).
– Often substernal, prolonged, poorly Often substernal, prolonged, poorly related to exertion, and rarely related to exertion, and rarely resembles typical anginaresembles typical angina
SyncopeSyncope
Fixed mitral regurgitationFixed mitral regurgitation
Mitral valve prolapseMitral valve prolapse
Mitral Insufficiency:Mitral Insufficiency: Physical Exam Physical Exam
S1 S2 S1
S1 C S2
Wave Sound
Wave Sound
MVP Physical Exam:MVP Physical Exam:Click MurmurClick Murmur
Standing broadens murmur
Squatting squishes murmur
Mitral Valve Prolapse: Mitral Valve Prolapse: ComplicationsComplications Arrhythmias (Usually PVC, Arrhythmias (Usually PVC,
PSVT>>VT)PSVT>>VT) Transient cerebral ischemic Transient cerebral ischemic
(embolic – rare)(embolic – rare) Infective endocarditis (if assoc w/ Infective endocarditis (if assoc w/
MR)MR) Sudden death (rare)Sudden death (rare)
MVP TreatmentMVP Treatment
Watch for mitral regurgitationWatch for mitral regurgitation As with MR, surgery when As with MR, surgery when
LVESD>40 mm or EF <60%.LVESD>40 mm or EF <60%.
© Continuing Medical Implementation …...bridging the care gap
Thanks!Thanks!
PSPS
Recognizing AorticRecognizing Aortic Stenosis Stenosis
Sign Correlation with Severity
JVP-prominent A wave No Carotid-delayed, anacrotic Yes A2 audible over carotids Mean AV gradient 50 mm Hg and stenosis not
severe i.e. AVA > 1.0 cm2 Apex- sustained, atrial kick - enlarged, displaced
Yes Yes
Thrill No Cardiomegaly- Clinical/CXR Yes Soft S1 Yes Paradoxical S2 Yes S3, S4 Yes SEM- intensity - late peak
No Yes
ECG- LAE, LVH Yes
Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic Aortic & Mitral RegurgitationAortic & Mitral Regurgitation
Type of Type of RegurgitatioRegurgitatio
nn
LVESD LVESD mmmm
EF EF %%
FSFS
Aortic Aortic > 55> 55 < 55< 55 < 0.27< 0.27
MitralMitral > 45> 45 < 60< 60 < 0.32< 0.32
Auscultation-Timing of Auscultation-Timing of A2 to OS IntervalA2 to OS Interval
Width of A2-OS Width of A2-OS inversely inversely correlates with correlates with severityseverity
The more severe The more severe the MS the higher the MS the higher the LAP the earlier the LAP the earlier the LV pressure the LV pressure falls below LAP and falls below LAP and the MV opensthe MV opens
Say Timing seconds
Severity of MS
Other HS’s
Prrr 0.06 Severe
Pada .07-.08 Mod-severe
Pata .08-.09 Mod
Papa 0.10 Mild PK 0.1-0.110
Tu-huh
.12 A2-S3 0.12-0.18
Echo Indicators for Valve Echo Indicators for Valve Replacement in Asymptomatic Replacement in Asymptomatic Aortic & Mitral RegurgitationAortic & Mitral Regurgitation
Type of Type of RegurgitatiRegurgitati
onon
LVESD LVESD mmmm
EF EF %%
FSFS
Aortic Aortic > 55> 55 < 55< 55 < 0.27< 0.27
MitralMitral > 45> 45 < 60< 60 < 0.32< 0.32
Recognizing Mitral Recognizing Mitral StenosisStenosis
Palpation:Palpation: Small volume pulseSmall volume pulse Tapping apex-Tapping apex-
palpable S1palpable S1 +/- palpable opening +/- palpable opening
snap (OS)snap (OS) RV liftRV lift Palpable S2Palpable S2
ECG:ECG: LAE, AFIB, RVH, RADLAE, AFIB, RVH, RAD
Auscultation:Auscultation: Loud S1- as loud as S2 in Loud S1- as loud as S2 in
aortic areaaortic area A2 to OS interval inversely A2 to OS interval inversely
proportional to severityproportional to severity Diastolic rumble: length Diastolic rumble: length
proportional to severityproportional to severity In severe MS with low In severe MS with low
flow- S1, OS & rumble flow- S1, OS & rumble may be inaudiblemay be inaudible
Wave Sound
Mitral Stenosis: Mitral Stenosis: SymptomsSymptoms
Heart Sounds: Heart Sounds: MurmurMurmur Systolic murmurSystolic murmur
– Right sided vs left sided:Right sided vs left sided: Effect of respiration (RIGHT SIDED INCREASE WITH Effect of respiration (RIGHT SIDED INCREASE WITH
INSPIRATION)!!!!!!!! Except PS decreasesINSPIRATION)!!!!!!!! Except PS decreases Valsalva release– two systolic murmurs that increase are Valsalva release– two systolic murmurs that increase are
HOCM and MVPHOCM and MVP Diastolic murmur: Diastolic murmur:
– Early diastolic (Great vessel origin): Semilunar: AI or PREarly diastolic (Great vessel origin): Semilunar: AI or PR– Mid diastolic: AV valve flow, MS, TS, increased cardiac Mid diastolic: AV valve flow, MS, TS, increased cardiac
output, severe MR/TR with rumble from increased flowoutput, severe MR/TR with rumble from increased flow Continuous MurmurContinuous Murmur
– PDA – infraclavicular and peaks at S2PDA – infraclavicular and peaks at S2– AV fistulaAV fistula– Venous HumVenous Hum– To and Fro is AS and AITo and Fro is AS and AI
Mitral Stenosis Mitral Stenosis SymptomsSymptoms Fatigue Fatigue PalpitationsPalpitations CoughCough SOBSOB Left sided failureLeft sided failure
– OrthopneaOrthopnea– PNDPND
PalpitationPalpitation
AFibAFib Systemic embolismSystemic embolism Pulmonary infectionPulmonary infection HemoptysisHemoptysis Right sided failureRight sided failure
– Hepatic CongestionHepatic Congestion– EdemaEdema
Worsened by conditions Worsened by conditions that that cardiac output. cardiac output.– Exertion,fever, anemia, Exertion,fever, anemia,
tachycardia, Afib, tachycardia, Afib, intercourse, pregnancy, intercourse, pregnancy, thyrotoxicosisthyrotoxicosis
Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND With extreme reductions in diastolic With extreme reductions in diastolic
pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina
Percutaneous AVRPercutaneous AVR
Aortic Regurgitation:Aortic Regurgitation:SymptomsSymptoms Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND Chest pain.Chest pain.
– Nocturnal angina >> exertional angina Nocturnal angina >> exertional angina – (( diastolic aortic pressure and increased diastolic aortic pressure and increased
LVEDP thus LVEDP thus coronary artery diastolic coronary artery diastolic flow)flow)
With extreme reductions in diastolic With extreme reductions in diastolic pressures (e.g. < 40) may see anginapressures (e.g. < 40) may see angina
Common Murmurs and Common Murmurs and TimingTiming
Systolic MurmursSystolic Murmurs Aortic stenosisAortic stenosis Mitral insufficiencyMitral insufficiency Mitral valve prolapseMitral valve prolapse Tricuspid insufficiency Tricuspid insufficiency
Diastolic MurmursDiastolic Murmurs Aortic insufficiencyAortic insufficiency Mitral stenosisMitral stenosis
S1 S2 S1
Assessing Severity of Assessing Severity of Chronic Chronic Mitral RegurgitationMitral Regurgitation
Measure the Impact on the LV:Measure the Impact on the LV: Apical displacement and sizeApical displacement and size Palpable S3Palpable S3 Longer/louder MR murmer (chronic MR)Longer/louder MR murmer (chronic MR) S3 intensity/ length of diastolic flow S3 intensity/ length of diastolic flow
rumblerumble Wider split S2 (earlier A2) unless HPT Wider split S2 (earlier A2) unless HPT
narrows the splitnarrows the split
Mitral Valve Prolapse: Mitral Valve Prolapse: Physical ExamPhysical Exam
Most important finding: mid Most important finding: mid late systolic late systolic clickclick..– Acute tensing of the mitral valve chordaeAcute tensing of the mitral valve chordae
Variable murmurs:Variable murmurs:– high pitched late high pitched late systolicsystolic crescendo-crescendo-
decrescendo murmurdecrescendo murmur, , – Occasionally “whooping” or “honking” at the Occasionally “whooping” or “honking” at the
apexapex
S1 C S2
MR EchocardiographyMR Echocardiography
Etiology: Etiology: – flail leaflets (chord/pap rupture)flail leaflets (chord/pap rupture)– thick (RHD)thick (RHD)– post mvt of leaflets (MVP)post mvt of leaflets (MVP)– vegetations(IE)vegetations(IE)
Severity: Severity: – regurgitant volume/fraction/orifice arearegurgitant volume/fraction/orifice area– LV systolic functionLV systolic function– increased LV/LA size, EFincreased LV/LA size, EF
MR StagesMR StagesMR StagesMR Stages
LV size and function defined by echoLV size and function defined by echo Stage 1-compensated: Stage 1-compensated:
– End-diastolic dimension less 63mm, ESD End-diastolic dimension less 63mm, ESD less 42mmless 42mm
– EF more than 60EF more than 60 Stage 2-transitionalStage 2-transitional
– EDD 65-68mm, ESD 44-45mm, EF 53-57EDD 65-68mm, ESD 44-45mm, EF 53-57 Stage 3-decompensatedStage 3-decompensated
– EDD more than 70mm, ESD more than EDD more than 70mm, ESD more than 45mm, EF less than 5045mm, EF less than 50
RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYRECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYIN PATIENTS WITH CHRONIC MITRAL REGURGITATIONIN PATIENTS WITH CHRONIC MITRAL REGURGITATIONAND PRIMARY MITRAL-VALVE DISEASE. AND PRIMARY MITRAL-VALVE DISEASE.
SEVERITY OFSEVERITY OF
MITRALMITRAL
REGURGITATIONREGURGITATION
LEFT LEFT VENTRICULAR VENTRICULAR
FUNCTION*FUNCTION*
FREQUENCY OFFREQUENCY OF
ECHOCARDIOGRA-ECHOCARDIOGRA-PHIC FOLLOW-UPPHIC FOLLOW-UP
MildMild Normal ESD and EFNormal ESD and EF Every 5 yrEvery 5 yr
ModerateModerate Normal ESD and EFNormal ESD and EF Every 1 –2 yrEvery 1 –2 yr
ModerateModerate ESD >40 mm or EF ESD >40 mm or EF <0.65<0.65
AnnuallyAnnually
SevereSevere Normal ESD and EFNormal ESD and EF AnnuallyAnnually
SevereSevere ESD >40 mm or EF ESD >40 mm or EF <0.65<0.65
Every 6 moEvery 6 mo
*ESD denotes end-systolic dimension and EF ejection fraction. Otto C.M. NEJM 345:10.
Mitral Valve Prolapse: Mitral Valve Prolapse: Physical ExamPhysical Exam
Most important finding: mid Most important finding: mid late systolic late systolic clickclick..– Acute tensing of the mitral valve chordaeAcute tensing of the mitral valve chordae
Variable murmurs:Variable murmurs:– high pitched late high pitched late systolicsystolic crescendo-crescendo-
decrescendo murmurdecrescendo murmur, , – Occasionally “whooping” or “honking” at the Occasionally “whooping” or “honking” at the
apexapex
S1 C S2
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