Valvular defects Lectures from Pathological Physiology Study materials from Pathological Physiology, 2017/2018 Oliver Rácz, Eva Sedláková 1 2 3 1
Valvular dysfunction - introduction Stenosis block of flow; regurgitation backward flow For pathological physiology the hemodynamics is the most important. It helps to understand heart failure also in other diseases. Symptoms. auscultation (murmurs), USG see internal propedeutics. In the past mostly a consequence of rheumatic fever, today this is changing: degenerative processes of valves hereditary causes ( mitral valve prolapse, pulmonary, stenosis) inflammation secondary dilatation (cardiomyopathies, papillary muscle dysfunction) 4 5 Mitral stenosis 10 20 years after febris rheumatica From 1 st symptoms to decompensation: 5 10 years Often in combination with other valvular defects (aortic insufficiency) 25 years after f. rh 33 % NYHA III, 50 % NYHA IV Narrowing of the ostium from 4 6 to 1 cm 2 and less 6 2
Mitral stenosis Pressure gradient between left atrium and ventricle first only during exercise, later also in rest Left ventricle is intact not involved in compesation Postcapillary pulmonary hypertension. Over 30 mmhg danger of pulmonary oedema Overload of right ventricle Symptoms of left heart failure without dysfunction of left ventricle 3 typical complications atrial fibrillation, thrombus formation and the danger of embolisation 7 Grades of mitral stenosis norm mild middle severe Area of ostium (cm 2 ) 4-6 2-4 1-2 < 1 gradient (mm Hg) < 5 5-12 12-20 > 20 Pressure t 1/2 (ms) < 60 60-100 100-200 > 200 8 9 3
An old solution TODAY EARLY VALVULOPLASTIC INTERVENTION THROUGH CATHETRIZATION 10 A short diversion towards atrial fibrillation A common dysrythmic condition Different forms paroxysmal, recurrent, etc... and according to hemodynamics (with or without tachycardia) Dg. also without ECG pulsus irregularis et inaequalis - why? In the past mitral stenosis Today age, sex (m > w) 60 y. cca 1 %, 80 y. up to 6 % Thyreotoxicosis Cardiac disease in general 11 12 4
Atrial fibrillation Management: According ro rythm, cardiac frequency, risk of embolisation Pharmacological cardioversion Electrical cardioversion and modern methods Surgical ablation Catheter Ablation Suppression of AF by pacing Internal Atrial cardioverter/defibrillators Dissolution of blood clots and monitoring of coagulation!!! 13 Mitral regurgation Hemodynamics Regurgitation from LV back into left atrium during systole. Volume overload of LV (to get 5 liters into circulation the heart pumps 7-8 and more). Excentric hypertrophy of LV compensates the hemodynamic disorder. Symptoms (except murmurs, ECG and X ray) are similar to stenosis (left heart failure, pulmonary oedema, complications). 14 15 5
Mitral valve prolapse Classic description: Valve prolapse with acute regurgitation after necrosis of papillary muscles or as a part of inherited diseases of collagen (m. Marfan, Ehlers-Danlos) RARE New view: Small regurgitation due to mitral valve prolapse visible on USG usually without hemodynamic consequences and symptoms. COMMON AD disease? Altered histological structure of valves? Increased risk of sudden death? 16 Prolaps, new data (2009) Prevalence cca 2,4 % Familiar type, AD, degeneration of valves and annulus fibrosus (young women) Marfan and other connective tissue diseases CHD and other pathological conditions of the heart Increased risk of infectiousus endocarditis and arrhytmias Migraine??!! 17 Valvular Causes Aortic stenosis Hereditary (also cardiomyopathy) 1 % of population has bicuspidal aortic valve Degeneration, calcification Postrheumatic In addition to valvular also Subvalvular see hypertrophic cardiomyopathy Supravalvular coarctation of aorta 18 6
Aortic stenosis Hemodynamics Pressure gradient between LV and aorta Pressure overload of LV (as in hypertension) Concentric hypertrophy, well compensated for a long time, diastolic dysfunction. Finally decompensation and left heart failure Pulsus parvus et tardus insufficient perfusion of tissues, especially of heart muscle 19 20 21 7
Grades of aortal stenosis Norm mild middle severe Area of ostium (cm 2 ) 2-3 > 1,5 1,0-1,5 < 1,0 gradient (mm Hg) 0 < 50 50-70 > 70 22 Aortic insufficiency Mostly postrheumatic Hemodynamics: Regurgitation in diastole, volume overload of LV. High systolic and low diastolic pressure disadvantegous for heart muscle perfusion. Pulsus celer et altus 23 Overview of hemodynamics of valvular defects Disorder Timing Overload Notes M.Sten. A V Diastole not of LV! fibrillation embolisatio n M.Ins. A V Systole volume exercise Ao. Sten. V Ao Systole pressure pulsus! Ao. Ins V Ao Diastole volume pulsus! 24 8
The forgotten ventricle* Often as a victim alebo bystander of overall pathological cardiac or pulmonalry conditions USG inverstigation is more complicated Some anatomical, histological and functional specifics (valves, papillar muscles, trabeculisation of the apical part and contraction) *Šimková a Kaldarárová, Kardiológia pre prax, 8, 2010, 181-187 25 The forgotten ventricle etiology of pathological conditions Pressure overload stenosis of a. pulmonalis, pulmonary HT, pulmonary embolism (acute!) Volume overload atrial septum defect, tricuspidal regurgitation Dysfunction of the myocard - MI, cardiomyopathies Obstruction of inflow tricuspidal stenosis, tamponade, constrictive pericarditis Abusus of some drugs cocaine, amphetamine 26 Tricuspidal regurgitation* Common secondary condition in valvular diseases of the left ventricle, in congenital defects and in left ventricle failure Primary in inf. endocarditis (i.v. drug users), danger of septic pulmonary embolisation Prolaps together with the left side Ebstein anomaly *Chňupa P, Kardiológia pre prax 8, 2010, 174 180 27 9