valvular heart disease jagdish butany mbbs,ms,frcpc. prof.,dept lab med & pathobiol....

Valvular Heart Disease

Jagdish Butany MBBS,MS,FRCPC.

Prof.,Dept Lab Med & Pathobiol.

Pathologist,UHN/TGH.

Physical Therapy

5 Nov 2007.

Valvular Disease-Objectives

Understanding of:

• Normal Heart Valve Structure

• Normal Heart valve Function

• Diseases of Heart Valves

• Complications of Heart Valve Dysfunction

• Treatment

Valvular Disease

• A.V. Valves:

–Tricuspid

–Mitral

• Semilunar:

–Pulmonic

–Aortic

Valvular Disease

• Principles:

– Valves are living structures with blood flow and endothelial covering

– Complex apparatus (MV + TV)

– Complex structural attachments (AV)


Understanding of:





• Treatment

Valvular Disease

• Dysfunction:

–Stenosis

–Incompetence

–Combination

Valvular Disease - Dysfunction

• Etiology:

– Congenital

• Acquired:

– Inflammatory

– Degenerative

– Neoplastic

– Iatrogenic

Valve Disease - Inflammatory

• Rheumatic

• Infective Endocarditis

Valve Disease

• Rheumatic Heart Disease• Damage:

–Myocardial-acute effects –Valvular-chronic and

substantive effects

Valve Disease - Rheumatic Fever (1)

• Acute immune mediated inflammatory disease

• Involves multiple organs

• Follows Group A Hemolytic Streptococcal

Pharyngitis (Approximately 3%)

• Acute: Rheumatic Carditis

Valve Disease - Rheumatic Fever (2)

• Clinical Symptoms;General or Systemic

• Other:

– Multiorgan

– See Jones Criteria for Diagnosis

• Sequelae: Chronic Rheumatic Valvular Disease

Valve Disease - Rheumatic Carditis

• Pathology: Myocardium

Acute:

– Focal lesions (Aaschoff Bodies)

– Mononuclear Cells (mainly lymphocytic)

– Macrophages

– Anitchkov cells

– Multinucleated giant cells

Valve Disease - Rheumatic

• Acute:

– Pericarditis with Aaschoff bodies

• Valves:

– Verrucae - Rough Zone

– Fibrin deposits

Valve Disease - Rheumatic• Chronic:

– Myocardium: Focal scars– Valves

• Leaflet fibrosis• Leaflet retraction• Commissural fusion• Calcification• Chordal fusion/calcification

– Orifice

Aortic Valve - Stenosis• Acquired: Rheumatic• Congenital:

– Bicuspid Valve– Unicommissural Valve– Unicuspid - “Dome” valve– Subvalvular (HOCM)– Supravalvular (Atresia)– Subaortic RingDegenerative

Mitral Valve - Stenosis

• Acquired: Rheumatic

• Congenital: Cortriatriatum

Endocardial Bands

Aortic Valve - Stenosis• Acquired: Rheumatic• Congenital:

– Bicuspid Valve– Unicommissural Valve– Unicuspid - “Dome” valve– Subvalvular (HOCM)– Supravalvular (Atresia)– Subaortic RingDegenerative

Mitral Valve - Incompetence

• Rheumatic (with “fixed” stenosis)

• Myxomatous change (“floppy”)

• Annular dilatation

• Annular calcification

• Infective endocarditis

Aortic Valve - Incompetence

• Fixed stenosis

• Myxomatous change

• “Annular” dilatation

• Sinotubular dilatation

[Ascending aortic dilatation]


Understanding of:





• Treatment

Valve Lesions

• Sequelae:– Turbulent Blood Flow

• Effects ?• Infection • Heart Failure

Valve Disease: Infective Endocarditis

• Microbial colonization or infection (also endocardium)

• “Vegetations” on valve tissue:

– Thrombus

– Dead Cells

– Inflammatory cells

– Bacteria

• Tissue destruction

Pathology of SBE• Early:

– Vegetation, friable, bulky– Tissue damage +/-

• Pathogenesis:– Bacterial colonies in blood– Site of entry ?– Endothelial damage– Thrombi– Infection

Valve Disease - Infective Endocarditis

• Virulent Bug:

– Rapid or acute infective endocarditis

– Death: days to weeks

• Low Virulence Bug:

– Subacute bacterial endocarditis

Valve Disease - SBE• Infection:

– Previously Normal Valve– Previously Abnormal Valve– Rheumatic– Congenital– Myxomatous– Calcified / Degenerative– Prosthetic Valves


Understanding of:





• Treatment

Valve Disease - Infective Endocarditis

• Treatment:

– General /supportive

– Antibiotics

– Valve replacement

Valve Disease - Surgery

AValve Repair

B Valve Replacement

– Mechanical

– Biological

– Porcine

– Pericardial

Valve Replacement

• Bioprostheses or Tissue Valves

• Porcine

• Homograft

• Pericardial

• [Duramater]

• Autografts

Valve Replacement

• Mechanical valves

– Ball in cage

– Disc (single leaflet)

– Bileaflet

• N.B. All need lifelong anticoagulation


Understanding of:





• Treatment

Heart Disease

• Regardless of Cause:

The End Result is Heart Failure!!!

valvular heart disease jagdish butany mbbs,ms,frcpc. prof.,dept lab med & pathobiol....

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