VALVULAR HEART DISEASE

I B Rangga Wibhuti
Cardiovascular Dept
Udayana University - Sanglah Hospital
Spectrum of VHD
Aortic Valve

Mitral Valve Stenosis or

Regurgitation
Tricuspid Valve

Pulmonic Valve
Cardiac Physiology

Regurg/ Insuff – leaking (backflow) of blood across a closed valve

Stenosis – Obstruction of (forward) flow across an opened valve

Systole AV/PV – opens-------Aortic Stenosis

S1-S2 MV/TV – closes------Mitral Regurg
DiastoleAV/PV – closes------Aortic Regurg
S2-S1 MV/TV – opens-------Mitral Stenosis

These concepts are set in stone, it can’t occur any other way,
It would be anatomically impossible
Valvular Heart Disease
Aortic Stenosis
 Aortic Stenosis

• Etiology
• Physical Examination
• Assessing Severity
• Natural History
• Prognosis
• Timing of Surgery
 Common Clinical Scenarios

• Older
Younger
people
people
– Aortic
Rheumatic
sclerosis,
AS, bicuspid
aortic stenosis
AV
AORTA STENOSIS
Etiology :
 Valvular AS : congenital, rheumatic, bicuspid,
and age related calsific degeneration
 Subvalvular AS : congenital
 Supravalvular : uncommon, congenital
syndrome
 Aortic Stenosis - Etiology

•• Rarely
Young patient think congenital
– Unicuspid valve
–
– Bicuspid
Sub-aortic stenosis
•• Discrete
2% population
• Diffuse (Tunnel)
•
• Middle3:1 male:female th distribution
aged patient(4&5 decades) think bicuspid or
• Co-existing
rheumatic disease coarctation 6% of patients
• Old patient think degenerative (6,7,8th decades)

© Continuing Medical Implementation …...bridging the care gap

 Aortic Stenosis: Etiology
• Congenital bicuspid valve is the most common
abnormality (in young people in developed
countries)
• Rheumatic heart disease and degeneration with
calcification are found as well

Normal Bicuspid Ao V Geriatric calcific valve

Pathophysiology
Pressure overload
Diastolic dysfunction
Supply-demand mismatch
Gejala Klinis:
 Anamnesis : keluhan cepat lelah, nafas
pendek atau sesak nafas seperti dyspneu,
takipneu, sinkope, gangguan peredaran darah
sepintas, kadang” mengeluh sakit dada
seperti angina pektoris

 Pemeriksaan fisik : trill sistolik, bunyi jantung

dua lemah, bising ejeksi sistolik, bruit pd arteri
karotis (menjalar ke leher).
 Aortic Stenosis: Symptoms

• Cardinal Symptoms
– Chest pain (angina)
• Reduced coronary flow reserve
• Increased demand-high afterload
– Syncope/Dizziness (exertional pre-syncope)
• Fixed cardiac output
• Vasodepressor response
– Dyspnea on exertion & rest
– Impaired exercise tolerance
• Other signs of LV failure
– Diastolic & systolic dysfunction
 Aortic Stenosis: Physical
Findings
• Intensity DOES NOT predict severity
• Presence of thrill DOES NOT predict severity
• “Diamond” shaped, harsh, systolic crescendo-
decrescendo
• Decreased, delay & prolongation of pulse
amplitude
• Paradoxical S2
• S4 (with left ventricular hypertrophy)
• S3 (with left ventricular failure)
 Severity of Stenosis

• Normal aortic valve area 2.5-3.5 cm2

• Mild stenosis 1.5-2.5 cm2
• Moderate stenosis 1.0-1.5 cm2
• Severe stenosis < 1.0 cm2
• Onset of symptoms
~0.9 cm2 with CAD
~0.7 cm2 without CAD
 Echocardiogram

• Etiology
• Valve gradient and area
• LVH
• Systolic LV function
• Diastolic LV function
• LA size
• Concomitant regional wall
motion abnormalities
Pemeriksaan Penunjang
 EKG : deviasi aksis kiri, LVH
 Foto roentgen dada : segment aorta menonjol
 Laboratorium : tidak ada kelainan spesifik
 Echocardiography : hyperthrophy ventrikel
kiri, dooming sistolik katup aorta, kekakuan
dan ketebalan katup aorta
 Aortic Stenosis: Prognosis

Symptom/Sign Live expectancy

Angina 5 years
Syncope 2-3 years
Congestive Heart Failure 1-2 years
 Natural History of Aortic
Stenosis
• Heart failure reduces
life expectancy to less
than 2 years
• Angina and syncope
reduce life expectancy
between 2 and 5 years
• Rate of progression 
@ 0.1 cm2/year
Terapi
1. Pengelolaan Medik
-pemberian obat”an untuk mengatasi simptom
akibat obstruksi katup aorta
-penggunaan obat”an sbg pencegahan thd
infektif endokarditis

2. Pengelolaan Intervensi
-pengelolaan non bedah
-intervensi bedah
Aortic Stenosis
Treatment of Symptomatic Aortic Stenosis or
Decreased LV Function
Medical Therapy – treats the symptoms not the cause
Aortic Valve Replacement
Bioprosthetic vs Mechanical AVR
 Operative mortality of AVR
in the elderly
• ~–4-24%/year
Aortic regurgitation
• – Concomitant
Risk factors forsurgical procedures:CABG/MV
operative mortality
– surgery
Functional class
– Previous bypass
– Lack of sinus rhythm
– Emergency surgery
– HTN
– CAD
– Pre-existing LV dysfunction
– Female gender
AORTA REGURGITATION
Etiology :
1. Chronic AR : disease of the valve
leaflets can cause AR by inadequate
leaflet coaptation, leaflet perforation or
leaflet prolapse.
2. Acute AR : can result from
abnormalities in the valve leaflet or in
the aortic root.
Kriteria diagnostik
 Anamnesis : keluhan berupa pusing, sinkope,
sakit dada, nafas pendek dan cepat, riwayat
demam rheumatic

 Pemeriksaan fisik : tanda Quincke,

Durozeis’s, de Musset’s, trill diastolik,
auskultasi bising diastolik awal, bising Austin
Flint murmur, tekanan darah diastolik rendah
atau nol
 EKG : normal, hyperthrophy ventrikel kiri dan
dilatasi ventrikel kiri
 Foto Roentgen dada : kardiomegali,
pembesaran ventrikel kiri, segment aorta
menonjol, apex jantung ke bawah
Aortic Regurgitation
Treatment of Asymptomatic Aortic Regurg
Medical Therapy – treats the symptoms not the
cause
 SerialCheck ups with Echos (eval EF, Severity AR)
 SBE Prophylaxis
 Vasodialators (ACE-I)
 Diuretics

Treatment of Symptomatic Aortic Regurg

Aortic Valve Replacement
Bioprosthetic vs Mechanical AVR
MITRAL STENOSIS
Cause of MS
Rheumatic : most common
cause
Congenital : parachute mitral
valve, supravalvular mitral ring
Systemic disease : can cause
valvular fibrosis
Pathophysiology
1. The normal area of the mitral orifice is 4-6 cm2.
When the valve area < 2, a pressure gradient
between the left atrium and the left ventricle in
diastole occurs.
2. The increase LA pressure is transmitted to the
pulmonary vasculature, resulting in symptoms of
pulmonary congestion
3. Up to 30 % of patients have a depressed LVEF
4. In severe MS there may be sufficiently low cardiac
output to cause symptoms of poor perfusion
Kriteria diagnostik
 Anamnesis : keluhan dapat berdebar-debar karena
takikardia/fibrilasi atrial, dyspneu, tachypneu
 Pemeriksaan fisik : facies mitral, trill diastolik, bunyi
jantung satu keras, opening snap, bising mid diastolik

 EKG : p mitral, deviasi aksis kanan, hypertrofi

ventrikel kanan
 FotoRoentgen dada : pembesaran atrium kiri,
ventrikel kanan, segmen pulmonal menonjol,
tanda’ bendungan vena pulmonalis

 Echocardiography : dilatasi atrium kiri,

ventrikel kanan, dooming katup mitral,
mencari ada tidaknya trombus
Pengelolaan
 Pengelolaan Medik :
-penggunaan obat”an untuk mengatasi keluhan akibat
adanya obstruksi katup mitral
-penggunaan obat”an untuk pencegahan sekunder
demam rheumatic
-penggunaan obat”an sbg pencegahan thd infektif
endocarditis
 Intervensi :
-intervensi non bedah, bedah, konversi elktrik pada
AF
Cause of MR
Leaflet abnormalities
Mitral annular abnormalities
Chordal abnormalities
Papillary muscle abnormalities
Pathophysiology
 Acute MR : the regurgitans volume that return
from the left atrium causes a sudden increase
in LV end diastolic volume.
 Chronic compensated MR : there is dilatation
of the left ventricle with eccentric hypertrophy
 Chronic decompensated MR : there is LV
dysfunction along with progressive
enlargement of the LV chamber with increase
wall stress
Kriteria Diagnostik
 Anamnesis : keluhan berdebar karena
takikardia/fibrilasi atrial, tachypneu, orthopneu,
riwayat rheuma

 Pemeriksaan fisik : bising pansistolik dari apex

ke axilla

 EKG : pembesaran atrium kiri, ventrikel kiri, dan

tanda” bendungan vena pulmonalis
 Echocardiography : dilatasi atrium kiri dan
ventrikel kiri, gambaran katup dan korda,
derajat regurgitasi
Pengelolaan
 Pengelolaan Medik :
-penggunaan obat”an untuk mengatasi
keluhan akibat adanya regurgitasi katup mitral
-penggunaan obat”an untuk pencegahan
sekunder demam rheumatic
-penggunaan obat”an sbg pencegahan thd
infektif endocarditis
 Intervensi bedah
 Valvular Heart Disease
and
Rheumatic Heart Disease

©2007 World Heart Federation … Updated October 2008

 This presentation is intended to support the Curriculum for training health workers and others
involved in the diagnosis and management of acute rheumatic fever and rheumatic heart disease.

It has been made possible thanks to the support of the Vodafone Group Foundation and the
International Solidarity, State of Geneva, and the ongoing support of Menzies School of Health
Research, Caritas Australia, Fiji Water Foundation, Cure Kids and Accor Hospitality.

©2007 World Heart Federation … Updated October 2008

 Introduction

Rheumatic heart disease is the result of damage to the heart valves which occur after
repeated episodes of ARF

Early diagnosis and treatment of RHD are important to prevent progression of disease

Signs and symptoms may not develop for many years

The aim of RHD management is to prevent or delay heart valve surgery

RHD can be prevented if ARF is diagnosed and managed early.

50% of people with RHD do not remember having ARF

©2007 World Heart Federation … Updated October 2008

 Definitions

Valve Regurgitation suggests that heart valves

– Are thickened and sticky against the walls of the heart
– Do not meet in the middle
– Leak (the blood flows backwards over the valve)

Valve Stenosis suggests that heart valves

– Become stuck to each other
– Do not allow blood to flow through easily (restricted forward flow)

©2007 World Heart Federation … Updated October 2008

 Signs and Symptoms of RHD

Symptoms of RHD may not develop for many years

– A murmur but no symptoms usually suggests mild-moderate disease
– Symptoms usually suggest moderate-severe disease

Symptoms depend upon the type and severity of disease, and may include
– Breathlessness with exertion or when lying down flat
– Waking at night feeling breathless
– Feeling tired
– General weakness
– Peripheral oedema

©2007 World Heart Federation … Updated October 2008

 Heart valve involvement

Mitral valve is affected in over 90% of cases of RHD

– Mitral regurgitation most commonly found in children & adolescents
– Mitral stenosis represents longer term chronic disease, commonly in adults
– Most common complication of mitral stenosis is atrial fibrillation

Aortic valve next most commonly affected

– Generally associated with disease of the mitral valve.
– Tends to develop as a long term complication of aortic regurgitation

Tricuspid and pulmonary valves are much less commonly affected

– Usually affected in very severe RHD when all valves are affected

©2007 World Heart Federation … Updated October 2008

©2007 World Heart Federation … Updated October 2008
 Clinical Examination

Mitral regurgitation
A pansystolic murmur heard loudest at the apex and radiating laterally to the axilla

Mitral stenosis
A low-pitched, diastolic rumble heard best at the apex with the bell of the stethoscope and with the person
lying in the left lateral position.

Aortic regurgitation
A diastolic blowing decrescendo murmur best heard at the left sternal border with the person sitting up and
leaning forward in full expiration.

Aortic stenosis
A loud, low pitched mid-systolic ejection murmur best heard in the aortic area, radiating to the neck.

©2007 World Heart Federation … Updated October 2008

 Investigations

Electrocardiogram (ECG)
– To determine sinus rhythm

Chest X-ray (CXR)

– To determine size and placement of heart
– To identify cardiac failure (pulmonary congestion)

Echocardiography
– To identify heart valve damage
– To estimate severity of disease
– Useful to compare results with future echocardiogram results

©2007 World Heart Federation … Updated October 2008

©2007 World Heart Federation … Updated October 2008
©2007 World Heart Federation … Updated October 2008
 Key element in RHD Management

Secondary prophylaxis
Functions of secondary prophylaxis with established RHD
– Prevent Group A Streptococcal infections
– Prevent the repeated development of ARF
– Prevent the development of RHD
– Reduce the severity of RHD
– Help reduce the risk of death from severe RHD.

©2007 World Heart Federation … Updated October 2008

©2007 World Heart Federation … Updated October 2008
©2007 World Heart Federation … Updated October 2008
 Elements in RHD Management

Effective baseline assessment, education and referral

Initial management
– heart failure (treatment with diuretics and ACEi)
– atrial fibrillation (Digoxin and anti-coagulation)

Routine review and structured care planning

– Regular secondary prophylaxis
– Regular clinical assessment and follow-up echocardiography (if available)
– Dental care and Infective endocarditis prophylaxis plan
– Family planning referral (for women)
– Vaccination (if available)

Appropriate surgical intervention

Special consideration in particular circumstances (e.g. pregnancy)

©2007 World Heart Federation … Updated October 2008

 RHD and Pregnancy

The cardiovascular changes which occur during pregnancy may threaten the health of
the woman and the foetus. Changes include
– increased heart rate and blood volume
– reduction in systemic and pulmonary resistance
– increased cardiac output.

RHD may be identified for the first time during pregnancy.

Highest risk of complications immediately after delivery

©2007 World Heart Federation … Updated October 2008

 Management of RHD in Pregnancy

Management generally includes

– restricting physical activity and salt intake
– administering secondary prophylaxis (Benzathine penicillin can be continued during pregnancy)
– avoiding community-acquired infectious diseases
– education about monitoring own signs and symptoms and seeking care if shortness of breath
– close monitoring of heart function (specifically in woman who have symptoms of RHD).

Special attention should be given to women with high risk RHD including women with
– mitral and/or aortic stenosis
– atrial fibrillation
– prosthetic heart valves
– those receiving anticoagulant therapy with warfarin.

©2007 World Heart Federation … Updated October 2008

 Infective Endocarditis

Infective Endocarditis is a serious complication of RHD

Endocarditis is caused by bacteria in the bloodstream.

In RHD, endocarditis most commonly occurs in the mitral or aortic valves

Uncommonly occurs during dental or surgical procedures but often the source of the
infection is not clear

May occur after heart valve surgery

Antibiotics prior to dental and surgical procedures are given to help prevent
endocarditis.

All people with ARF and RHD should have regular dental care to prevent
dental decay and the potential risk of endocarditis.

©2007 World Heart Federation … Updated October 2008

 Procedures that increase risk of Endocarditis

DENTAL PROCEDURES OTHER PROCEDURES

Dental extractions Tonsillectomy/adenoidectomy
Periodontal procedures Bronchoscopy with a rigid bronchoscope
Dental implant placement Surgery involving the bronchial mucosa
Gingival surgery Sclerotherapy of oesophageal varices
Initial placement of orthodontic appliances Dilatation of oesophageal stricture
Surgical drainage of dental abscess Surgery of the intestinal mucosa or biliary tract

Maxillary or mandibular osteotomies Endoscopic retrograde cholangiography

Surgical repair or fixation of a fractured jaw Prostate surgery
Endodontic surgery and instrumentation Cystoscopy and urethral dilatation
Intra-ligamentary local anaesthetic injections Vaginal delivery in the presence of infection,
prolonged labour or prolonged rupture of membranes
Dental cleaning where bleeding is expected Surgical procedures of the genitourinary tract in the
presence of infection

Placement of orthodontic bands

©2007 World Heart Federation … Updated October 2008

 Surgery for RHD

The need for surgery depends on

– Severity of symptoms
– Evidence that the heart valves are severely damaged
– Left ventricular chamber size and function
– Availability of long-term management after surgery (i.e. anticoagulation)

Heart valves can be repaired or replaced

Assessment before surgery includes
– Echocardiogram to assess severity of heart valve damage
– Complete dental assessment and treatment (if required)
– Review and management of other health problems (e.g. kidney, vascular and chronic respiratory
disease, cancers and obesity)

©2007 World Heart Federation … Updated October 2008

 Surgery Outcomes

Heart valve Heart valve

REPLACEMENT REPAIR

Anticoagulation required No Anticoagulation

Longer time before re-operation Shorter time before re-operation

RHD
©2007 World Heart Federation … Updated October 2008
 Guidelines for managing Mild RHD

Definition - RHD with any trivial to mild valve lesion.

Secondary Prophylaxis Long-term prevention of recurrent ARF

Primary care management By local Medical Officer

Specialist medical review for children aged to 18 years Every 12 months

Earlier if clinical deterioration

Echocardiogram (if available) Every 2 years for children

Every 5 years for adults
Specialist medical review Before ceasing secondary prophylaxis

Dental review following diagnosis With appropriate endocarditis prevention

©2007 World Heart Federation … Updated October 2008

 Guidelines for managing Moderate RHD

Definition - Any moderate valve lesion, no symptoms, and normal LV function with stable
metallic prosthetic valves, or children (to 18 years old) with a history of chorea including
those with no valve damage

Secondary Prophylaxis Long-term prevention of recurrent ARF

Primary care management By local Medical Officer

Specialist medical review Every 12 months

Earlier if clinical deterioration

Echocardiogram (if available) Every 1 years for children

Every 2 years for adults
Specialist medical review Before ceasing secondary prophylaxis

Dental review following diagnosis With appropriate endocarditis prevention

©2007 World Heart Federation … Updated October 2008

 Guidelines for managing Severe RHD

Definition - Any moderate-severe valve lesion with shortness of breath, tiredness, oedema,
angina or syncope and impaired or increased left ventricular function or a history of
valve surgery including mitral valvotomy, any valve repair and bio-prosthetic valves
(porcine and homograph)

Secondary Prophylaxis Long-term prevention of recurrent ARF

Primary care management By local Medical Officer

Specialist medical review Every 6 months

Refer to Heart Specialist Management Plan

©2007 World Heart Federation … Updated October 2008

 Summary

RHD presents as damage to the heart valves

The mitral valve is most commonly affected, followed by Aortic, Pulmonary and Tricuspid

RHD can be mild, moderate or severe

RHD may be asymptomatic

Management of RHD includes

– Treatment of cardiac and other symptoms
– Long-term secondary prophylaxis (to prevent recurrent ARF)
– Regular medical and cardiology review
– Management of existing pregnancy
– Dental assessment, family planning referral

©2007 World Heart Federation … Updated October 2008