Diagnosis and Management

of Valvular Heart Disesase

M A Sungkar, MD

Division Cardiovascular, Department Internal Medicine

Medical Faculty, Diponegoro University/
Kariadi Hospital Semarang

Evaluation of Valve Disease

History
Inspection

Palpation
Percution

Auscultation

Strategy for evaluating heart murmurs

Present of Cardiac murmur

Systolic murmur
Grade 1 plus 2
and midsystolic

Asymptomatic
And no associated
findings
No further
workup

Diastolic or continuous murmur

Grade 3 or higher
holosystolic or
late systolic
Other sign or
symptoms of
cardiac disease

Echocardiography

Catheterization and angiography

if appropiate

Common Valvular Heart Diseases

(by murmur timing/quality)

Systolic Murmurs:
Aortic stenosis
Mitral insufficiency
Mitral valve prolapse
Tricuspid insufficiency
Diastolic Murmurs:
Aortic insufficiency
Mitral stenosis
S1

S2

S1

Murmurs and the

Cardiac Cycle
Aortic stenosis
1

Mitral Regurgitation
1

Mitral valve prolapse with

late regurgitation

Aortic Stenosis - Clinical features

Symptoms
None, SOB, dizziness, HF, syncope, angina
Examination
Pulse - amplitude, delay, Sustained apex
S2- soft and single paradoxical splitting
ESM - loud late peak soft
Echocardiography
Mean
gradient
(mmHg)
Normal

Peak Ao
velocity

AVA
(cm2)

1.0 -2.0

>2.5

Mild

<20

2.5 -2.9

>1.7

Moderate

20 -40

3.0 -4.0

1.0 -1.7

Severe

>40

>4.0

<1.0

Aortic Stenosis: Physical Findings

S1
S2
Mild-Moderate

S1

S2
Severe

Intensity DOES NOT predict severity

Diamond shaped, systolic crescendodecrescendo
Decreased, delay & prolongation of pulse
amplitude
S4 (with left ventricular hypertrophy)
S3 (with left ventricular failure)

Natural History of AS
Onset severe symptoms
100

% Survival

80

Latent period
(increasing obstruction,
myocardial overload)

60

2
6
0
4
Average survival (yr)

40

Average age
death (male)

20
0

Angina
Syncope
Failure

40

50

60

70

80

Ross J Jr, Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61, 1968

Mitral Regurgitation - Clinical findings

Acute
dyspnoea, orthopnoea, no cardiomegaly,
short murmur, S3
Chronic
variable symptoms, cardiomegaly, murmur,
P2 loud, S3
Quantification

Echocardiography,
Serial studies, LV function
CXR - Cardiomegaly

Mitral Insufficiency
Physical Examination

S1

S2

Apical holosystolic murmur

Radiation to the axilla
Palpable thrill at cardiac
apex

S1

Mitral Valve Prolapse

Symptoms
Majority are asymptomatic for entire life
Palpitations
Chest pain (atypical):
Often substernal, prolonged, poorly related
to exertion, and rarely resembles typical
angina
Syncope

Mitral Valve Prolapse

Complications
Arrhythmias (PVC, PSVT>>VT)
Transient cerebral ischemia (embolic rare)
Infective endocarditis (if assoc w/ MR)
Sudden death (rare)

Mitral Valve Prolapse

Physical Examamination

S1

S2

Most important finding: mid late systolic click

Acute tensing of the mitral valve chordae

Variable murmurs:
high pitched late systolic crescendo-decrescendo
murmur,
Occasionally whooping or honking at the apex

Mitral Valve Prolapse

Treatment
Reassurance
Asymptomatic pts w/o sev MR or arrhythmia.
Follow-up q 2-4 years, with ECHO

-blocker treatment for atypical chest pain

Infective endocarditis prophylaxis with
Systolic murmur &/or
Typical echocardiagraphic findings
Men definitely! Women? No consensus.

Severe sx (e.g. MR) Rxd as mitral

insufficiency.

Mitral Regurgitation - Treatment

Acute
Diuretics
- LV filling P, p. oedema
Vasodilators
- forward SV
IABP

Chronic
No known effective therapy
Vasodilators - theoretical risks
Treat complications

Left Ventricular Function

Survival

When to Intervene in Mitral Regurgitation

Time

Tricuspid Regurgitation
History

Fatigue
SOB
Edema
Sensation of pulsations in the neck.
Right upper quadrant abdominal
fullness or discomfort due to liver
congestion.

Tricuspid Regurgitation
Clinical Features
Systolic waves on JVP (time with
carotid pulse) therefore not v waves.
RV+
S3 + pansystolic murmur in 4th
intercostal space
Pulsatile liver
Ascites
Peripheral oedema
Echocardiography

Murmurs and the

Cardiac Cycle

Aortic regurgitation
1

Mitral Stenosis
OS

Physical Findings in Aortic Regurgitation

Wide pulse pressure:
Bounding pulses
Soft aortic second sound (A2)
Early diastolic murmur (blowing) immediately
after A2
- Upper RSB with root dilation
- Mid to lower LSB with leaflet dysfunction
Systolic murmur at base (similar to aortic
stenosis)
Austin Flint murmur: mid to late diastolic
rumble at apex

Austin Flint - Murmur

1

LV

AR

AV

Diastolic
Filling

MV
Anterior leaflet of mitral valve vibrates between AR and filling jets

Clinical Signs in Aortic Regurgitation

Wide pulse pressure / low diastolic blood
pressure
de Mussets sign head bobbing
Corrigans pulse collapsing / waterhammer
Traubes sign - pistol shot femorals
Mullers sign systolic pulsation of the uvula
Duroziez sign systolic murmur over the
femoral artery
Quinckes - capillary pulsation

Clinical Signs in Aortic Regurgitation

Investigations
ECG LVH
CXR - Cardiomegaly
Echocardiogram
- Assess severity

Coronary angiography
- Exclude coronary disease

Natural history of aortic regurgitation

(1) Pump function maintained
(2) Myocardial function deteriorates
100

% Surviving

80

(1) Progressive
Cardiomegaly
(2) LV dilatation
(3) Maintenance of
myocardial and
pump failure

Symptoms of low CO
Insidously begin

Established
myocardial
disease

60

40

20
0

Onset

? Decades

Another
Decade

Symptoms of
increasing filling
pressure
appear
( LVEDP + MR)

Stages of Mitral Stenosis

Class
Minimal

MVA (cm2)
> 2.5

Symptoms
None

Mild

1.4 2.5

Dyspnea with exertion

Moderate

1.0 1.4

Dyspnea, OT,PND, pulmonary

edema

Severe

< 1.0

Resting dyspnea, disable

(NYHA IV), bed chair

Reactive PH

< 1.0

As in severe, plus fatique &

RVH

Mitral Stenosis
Clinical manifestation
Dyspnea ,cough, palpitation, fainting, orthopnea
Hemoptysis, Hoaseness (ortners syndrome)
Cerebral embolism

Physical examination
Mitral facies (malar facial flush),
Pulse : irregular, low amplitude
JVP : distention, prominent A wave
Palpation
Apex : Tapping ,Diastolic thrill
RV heave
Palpable P2 (if PHT)

Mitral Stenosis (Cont)

Physical examination
Auscultation

Loud S1 ; Loud P2 (PHT)

Mitral opening snap; Diastolic rumbling murmur
Presystolic accentuation

Investigation
- CXR
- EKG
- Echocardiography

Mitral Stenosis
Physical Examination

S1

S2

OS

S1

First heart sound (S1) is accentuated and

snapping
Opening snap (OS) after aortic valve closure
Low pitch diastolic rumble at the apex
Pre-systolic accentuation (esp. if in sinus
rhythm)

Mitral Stenosis
Natural History
Progressive, lifelong disease
Slow & stable in the early years
Progressive acceleration in the later years
20-40 year latency from rheumatic fever to
symptom onset
Additional 10 years before disabling
symptoms

Mitral Stenosis
Complications

Atrial dysrrhythmias
Systemic embolization (10-25%)
Congestive heart failure
Pulmonary infarcts (result of severe CHF)
Hemoptysis
Endocarditis
Pulmonary infections

Mitral Stenosis
Treatment
Endocarditis prophylaxis
Anticoagulation if concurrent A-Fib or
previous embolic event
Valve repair/replacement