Valvular Heart Disease

MEFRI YANNI, MD
 Normal Valve Function

■ Maintain forward flow and

prevent reversal of flow.
■ Valves open and close in
response to pressure differences
(gradients) between cardiac
chambers.
 Abnormal Valve Function
■ Valve Stenosis
■ Obstruction to valve flow during that phase of the cardiac cycle when
the valve is normally open.
■ Hemodynamic hallmark -“pressure gradient” ~ flow// VA
■ Valve Regurgitation, Insufficiency, Incompetence
■ Inadequate valve closure--- back leakage
■ A single valve can be both stenotic and regurgitant; but both
lesions cannot be severe!!
■ Combinations of valve lesions can coexist
■ Single disease process
■ Different disease processes
■ One valve lesion may cause another
■ Certain combinations are particularly burdensome (AS & MR)
 Mitral Valve Competence

■ Integrated function of
several anatomic elements :
■ Posterior LA wall
■ Anterior & Posterior valve
leaflets
■ Chordae tendineae
■ Papillary muscles
■ Left ventricular wall where
the papillary muscles attach
Mitral Valve Disease : Etiology
❖ Mitral Stenosis ❖ Chronic Mitral Regurgitation
❖ Rheumatic - 99.9%!!! ❖ Ischemic Heart disease
❖ Congenital ❖ Papillary ms dysfunction
❖ Prosthetic valve stenosis
❖ Inferior & posterior MI
❖ Mitral Annular Calcification
❖ Left Atrial Myxoma
❖ Mitral Valve prolapse
❖ Infective endocarditis
❖ Rheumatic
❖ Acute Mitral Regurgitation
❖ Infective endocarditis
❖ Prosthetic
❖ Ischemic Heart disease
❖ Mitral annular calcification
❖ Papillary ms rupture ❖ Cardiomyopathy
❖ Mitral valve prolapse ❖ LV dilatation
❖ Chordal rupture ❖ IHSS
❖ Chest trauma
Mitral Regurgitation : Pathophysiology

■ MR: Leakage of blood into

LA during systole
■ 10 Abnormality -Loss of
forward SV into LA
■ Compensatory Mechanisms
■ Increase in SV (& EF)
■ Forward SV + regurgitant

volume
■ LV (LA) dilatation
■ Left Ventricular Volume

Overload (LVVO)
Chronic Mitral Regurgitation -
LV Volume Overload

■ LVVO
■ LV dilatation
■ Eccentric hypertrophy

■ Increased LA pressure
■ Pulmonary HTN
■ Dyspnea
■ Atrial arrhythmias
■ Low output state
 Pathophysiology –
Acute vs Chronic Mitral Regurgitation
■ Acute MR
■ Normal (noncompliant) LA
■ Increase LA pressure
■ large “V” waves
■ Acute Pulmonary Edema

■ Chronic MR
■ Dilated, compliant LA
■ LA pressure normal or

slightly increased
■ Fatigue, low output state
■ Atrial arrhythmias- a. fib.

■ Most patients fall between

these two extremes!!
 Mitral Regurgitation : Physical Findings

■ Auscultatory Findings
■ S1 – soft or normal
■ P2 – increased (if PH)
■ Pansystolic blowing murmur at apex
■ MVP – mid-systolic click
■ IHSS – murmur increases with Valsalva
■ Acute MR – descrescendo systolic murmur
■ S3 gallop & diastolic flow rumble
■ Hyperdynamic Left Ventricle
■ Brisk carotid upstrokes
■ Hyperdynamic LV apical impulse
■ LA lift; RV tap
 Mitral Stenosis - Pathophysiology
■ Restriction of blood flow from
LA➔LV during diastole.
■ Normal MVA 4-6cm2.
■ Mild MS 2-4cm2.
■ Severe MS < 1.0cm2.

■ MV Pressure gradient –
■ MV grad ~ MV flow//MVA.
■ Flow = CO/DFP (diastolic filling

period).
■ As HR increases, diastole shortens
disproportionately and MV gradient
increases.
 Relationship between MV gradient
and Flow for different Valve Areas

■ Cross hatched area indicates range

of normal resting flow.
■ The vertical line represents the
threshold for developing pulmonary
edema.
■ Pressure gradient increases as flow
increases:
■ to a small degree with normal

valve area(4-6cm2).
■ to greater degrees with

smaller valve areas.

■ in severe stenosis, a significant

gradient is present at rest.

Mitral Stenosis : Pathophysiology
■ MV gradient ➔ Increased LA
pressure
■ Pulmonary HT
■ Passive
■ Reactive- 2nd stenosis

■ RV Pressure Overload
■ RVH
■ RV failure
■ Tricuspid regurgitation
■ Systemic Congestion

■ Paradoxes of MS
■ Disease of Pulm Arts & RV
■ LV unaffected (protected)
■ As RV fails, pulmonary symptoms

diminish
Mitral Stenosis : Clinical Symptoms

■ Symptoms related to severity

of MVA reduction
■ Symptoms unrelated to
severity of MS :
■ Atrial fibrillation
■ Systemic thromboembolism

■ Symptoms due to Pulmonary

HTN and RV failure :
■ Fatigue, low output state
■ Peripheral edema and hepato-

splenomegaly
■ Hoarseness –recurrent

laryngeal nerve palsy

Mitral Stenosis : Physical Findings

■ Auscultatory findings
■ S1 – variable intensity; increased early, progressively decreases
■ OS –opening snap, variable intensity
■ A2-OS interval – varies inversely with severity of MS; shortens as MVA
diminishes
■ Low-pitched diastolic murmur rumble at apex
■ Duration of murmur correlates with severity of MS
■ Pre-systolic accentuation
■ Increased P2 (if PH)
■ Body habitus – thin, asthenic, female
■ Low BP
■ LA lift & RV tap
Mitral Valve Disease : Echo findings

■ Mitral Stenosis
■ Thickened, deformed MV leaflets
■ 2D MVA
■ Doppler Gradient
■ Associated LAE, RVH, PHTN,
TR,MR, LV function
■ Mitral Regurgitation
■ Determine etiology – leaflets,
chordae, MVP, MR
■ Doppler severity of MR jet
■ LV function
 Mitral Valve Disease : Treatment

■ Mitral Stenosis ■ Chronic Mitral Regurgitation

■ Medical Rx (for Class I & II) ■ Medical Rx for mild to mod MR
■ HR control – Dig & BB ■ Vasodilators

■ Anticoagulation ■ Diuretics
■ Diuretic ■ Anticoagulation —> if AF

■ Surgical Rx (for Class III &IV) ■ Surgical Rx –ideally before LV

Balloon Mitral Valvuloplasty systolic function declines.
■ Commissural fusion ■ MV replacement
■ pliable, noncalcified leaflets ■ MV ring & CABG
■ No MR of LA thrombus
■ MV repair – associated with
improved long-term LV funvtion
Mitral Valve Surgery ■ MVP, ruptured chords, infective
■ Open commissurotomy endocadritis, pap ms rupture.
■ MV replacement
Balloon Mitral Commissurotomy
 Aortic Valve Disease: Etiology
■ Aortic Stenosis ■ Chronic Aortic Insufficiency
■ Degenerative calcific (senile) ■ Aortic leaflet disease
■ Infective endocarditis
■ Congenital – Uni or bicuspid
■ Rheumatic
■ Rheumatic
■ Bicuspid Aortic valve
■ Prosthetic ■ Prolapse & congenital VSD
■ Prosthetic

■ Aortic root disease

■ Acute Aortic Insufficiency ■ Aortic aneurysm/dissection
■ Infective endocarditis ■ Marfan’s syndrome
■ Acute Aortic Dissection ■ Connective tissue disorders
■ Marfan’s Syndrome ■ Syphilis
■ Chest trauma ■ HTN
■ Annulo-aortic ectasia
 Aortic Stenosis - Pathophysiology

■ Normal AVA 2.5-3.0cm2

■ Severe AS <1.0cm2
■ Critical AS <0.7cm2; <0.5cm2/m2
■ Hemodynamic Hallmark
■ Systolic pressure gradient
■ AV grad ~ AV flow//AVA
■ AV flow = CO/SEP (systolic ejection period)
■ 50-100mmHg gradients are
common in severe AS
 Relationship between AV gradient and
Flow for different Aortic valve areas.

■ Like Mitral Stenosis –

as flow increases so does the gradient.
■ Unlike Mitral Stenosis –
■ Resting flows are higher

■ smaller AV area

■ shorter SEP

■ Larger gradients

■ Significant (>50mmHg) gradient

can be present at rest in

asymptomatic individuals.
Aortic Stenosis : Patophysiology
LV Pressure Overload

■ Chronic LV Pressure Overload➔

Concentric LVH
■ “Stiff” noncompliant LV
■ Increased LVEDP
■ Increased LV mass➔ Increased MVO2
■ Well tolerated for decades
■ LV fails➔CHF
■ Atrial fibrillation
■ Poorly tolerated
■ Loss of atrial “kick”
■ Rapid HR
■ Acute pulmonary edema and hypotension.
 Aortic Stenosis :
Natural History & Clinical Symptoms
■ Asymptomatic for many ■ Natural History Studies-
years ■ Pts grad 25mmHg –20%
■ Symptoms develop when chance of intervention in 15
years
valve is critically narrowed ■ Pts with asymptomatic severe
and LV function AS require close f/u
deteriorates ■ Gradient progression
■ Bicuspid AV 5th - 6th decade ■ 6-10mmHg/yr
■ Senile AS 7th-8th decades ■ Risk Factors
■ Classic Symptom Triad ■ Age > 70
■ Angina pectoris – 5 years
■ CAD, hyperlipidemia
■ Chronic renal failure
■ CHF 1-2 years
■ Syncope 2-3 years
Aortic Stenosis: Physical Findings
Severity of AS Mild Moderate
Severe

Carotid pulse normal Slow rising Parvus et Tardus

Heaving &
LV apical impulse normal heaving
sustained
Auscultation
S4 gallop - +/- ++
Systolic ejection
Click + +/- -
Early mid-to-late
SEM, peaking midsystole
systole systole

S2 Normal or Single or
normal
single paradoxical
Aortic Insufficiency- Pathophysiology
■ 10 abnormality – LVVO
■ Severity of LVVO
■ Size of regurgitant orifice
■ Diastolic pressure gradient
between Ao & LV
■ HR or duration of diastole
■ Compensatory Mechanisms
■ LV dilatation & eccentric LVH
■ Increased LV diastolic
compliance
■ Peripheral vasodilation
LV Volume vs Pressure Overload
LV Pressure Overload LV Volume Overload
Feature
(AS) (MR,AR)

LV Volume normal Dilated**

Normal to slightly
Wall thickness Conc. LVH
increased

LV compliance “stiff” noncompliant Increased compliance

Normal to slightly
LV diastolic Pr increased
increased
Normal to slightly
LV systolic Pr Increased**
increased

LVEF normal increased

 Acute vs Chronic AR
Pathophysiology and Clinical Presentation

■ Acute Aortic Regurgitation

■ Sudden AoV incompetence
■ Noncompliant LV
■ Acute Pulmonary Edema
■ Emergency AVR
■ Chronic Aortic Regurgitation
■ Long asymptomatic phase
■ Progressive LV dilatation
■ DOE, orthopnea, PND
■ Frequent PVC’s
 Chronic Aortic Regurgitation:
Physical Findings
■ Widened Pulse Pressure > 70mmHg (170/60)
■ Low diastolic pressure < 60mmHg
■ Hyperdynamic LV –
■ DeMusset’s signs

■ Corrigan’s pulse

■ Quincke’s pulsations,

■ Durozier’s murmur

■ Auscultation:
■ Diminished A
2
■ Descrescendo diastolic blowing murmur at URSB
■ Austin-Flint murmur – diastolic flow rumble at apex
■ Due to interference with trans-mitral filling by impignement from aortic regurgitant jet.
■ DDx - mitral stenosis(increases intensity with amyl nitrite)
Aortic Valve Disease : Diagnostic Testing
Aortic Stenosis Aortic regurgitaiton
■ EKG : ■ EKG :
SR, LVH with strain, LVH without strain
LAE,LAD
■ Chest XRay – frequently
■ Chest XRay :
■ Chronic AI – “cor bovinum”
normal ■ Acute AI – pulmonary edema
■ 2D-ECHO
with nl heart size
■ Aortic cusps –thickened, calcified,
decreased mobility
■ 2D ECHO
■ Assessment of LVH & LV systolic ■ Assess Ao valve and root
function ■ Assess LV function/dilatation
■ Concomitant MR, AR ■ LVES dimension>55mm
■ Doppler assesment of AoV ■ Doppler severity of regurgitant
gradient jet
■ Planimetry of AV area
 Relationship between AV gradient and
Flow for different Aortic valve areas.
■ Like Mitral Stenosis –
as flow increases so does the gradient.
■ Unlike Mitral Stenosis –
■ Resting flows are higher
■ smaller AV area
■ shorter SEP
■ Larger gradients
■ Significant (>50mmHg) gradient
can be present at rest in
asymptomatic individuals.
 Balloon Aortic Valvuloplasty

■ Indications for BAV in critical Aortic Stenosis

■ Younger patients with congenital AS and predominant
commissural fusion
■ Bridge to eventual AVR
■ Moderate to severe heart failure/cardiogenic shock
■ Extremely high risk for AVR
■ Urgent/emergent need for noncardiac surgery
■ Patient with limited lifespan – cardiac or noncardiac
■ Patient refuses surgery
 Aortic Valve Disease : Treatment

■ Aortic Stenosis ■ Chronic Aortic Regurgitation

■ Medical Rx ■ Medical Rx for mild to mod MR
■ HR control – Dig & BB ■ Vasodilators
■ Diuretic ■ Diuretics

■ Surgical Rx (for Class III &IV) ■ Surgical Rx

Balloon Aorta Valvuloplasty ■ AV replacement
Aortic Valve Replacement ■ AV repair
The End