,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Valvular Heart Disease,Dr.Randa Al-Harizy,Prof.of Internal Medicine,Tricuspid Valve,MITRAL STENOSIS,Almost all mitral stenosis is due to rheumatic heart disease.,It is much more common in women.,Other causes include:Lutembachers syndrome,which is the combination of acquired mitral stenosis and an atrial septal defect,carcinoid tumours and SLE.,Valvular Heart Disease,SYMPTOMS,Usually there are no symptoms until the valve orifice is moderately stenosed(i.e.has an area of 2 cm2).,Because of pulmonary venous hypertension and recurrent bronchitis,progressively severe dyspnoea develops.,A cough productive of blood-tinged,frothy sputum and occasionally frank haemoptysis may occur.,Right heart failure and its symptoms of weakness,fatigue and abdominal or lower limb oedema.,Atrial fibrillation,giving rise to palpitations.,Atrial fibrillation may result in systemic emboli.,Valvular Heart Disease,SIGNS,Face:mitral facies or malar flush.,Pulse:a small-volume pulse,may be an irregularly irregular pulse.,Jugular veins:Distension of jugular veins in right heart failure.,Palpation:There is a tapping impulse felt parasternally on the left side(palpable first heart sound).A sustained parasternal impulse due to right ventricular hypertrophy may also be felt.,Auscultation:loud first heart sound,and opening snap.This is followed by a low-pitched rumbling mid-diastolic murmur at the apex with presystolic accentuation.,Valvular Heart Disease,INVESTIGATIONS,Chest X-ray:small heart with an enlarged left atrium,Pulmonary venous hypertension,a calcified mitral valve,signs of pulmonary oedema or pulmonary hypertension.,ECG:shows a bifid P wave or AF,features of right ventricular hypertrophy(right axis deviation and perhaps tall R waves in V1),Echocardiogram:assessment of the mitral valve apparatus and calculation of mitral valve area,also determines left atrial and right ventricular size and function.Estimate of pulmonary artery pressure,Cardiac catheterization,Valvular Heart Disease,TREATMENT,Mild mitral stenosis may need no treatment other than prompt therapy of attacks of bronchitis.,Antibiotic prophylaxis for infective endocarditis.,Mild dyspnoea is treated with low doses of diuretics.,Atrial fibrillation requires treatment with digoxin and anticoagulation to prevent atrial thrombus and systemic embolization.,If pulmonary hypertension develops,surgical relief of the mitral stenosis is advised.,Surgical treatment includes;Trans-septal balloon valvotomy,Closed valvotomy,Open valvotomy or Mitral valve replacement.,Valvular Heart Disease,CAUSES,The most common cause is rheumatic heart disease(50%),and a prolapsing mitral valve.,Other causes include;aortic valve disease,acute rheumatic fever,myocarditis,dilated cardiomyopathy,hypertensive heart disease,ischaemic heart disease,infective endocarditis,hypertrophic cardiomyopathy,SLE,Marfans syndrome,Ehlers-Danlos syndrome,rupture of the chordae tendineae(e.g.due to myocardial infarction).,MITRAL REGURGITATION,PATHOPHYSIOLOGY,Regurgitation into the left atrium produces left atrial dilatation but little increase in left atrial pressure.,With acute mitral regurgitation the left atrial,v,wave is greatly increased and pulmonary venous pressure rises to produce pulmonary oedema.,Since a proportion of the stroke volume is regurgitated,the stroke volume increases to maintain the forward cardiac output and the left ventricle therefore enlarges.,MITRAL REGURGITATION,SYMPTOMS,Mitral regurgitation can be present for many years before any symptoms occur.,The increased stroke volume is sensed as a palpitation.,Dyspnoea and orthopnoea develop owing to left ventricular failure.,Fatigue and lethargy develop because of the reduced cardiac output.,In the late stages of the disease the symptoms of right heart failure also occur and eventually lead to congestive cardiac failure.,Cardiac cachexia may develop.,Thromboembolism is less common than in mitral stenosis,but,subacute infective endocarditis,is much more common.,MITRAL REGURGITATION,SIGNS,L,aterally displaced(forceful)diffuse apex beat and a systolic thrill(if severe).,Soft first heart sound.,Pansystolic murmur,radiating widely over the precordium and into the axilla.,Prominent third heart sound.,The signs related to atrial fibrillation,pulmonary hypertension,and left and right heart failure develop later in the disease.,MITRAL REGURGITATION,INVESTIGATIONS,Chest X-ray:left atrial and left ventricular enlargement.There is an increase in the CTR,and valve calcification is seen.,ECG shows the features of left atrial delay(bifid P waves)and left ventricular hypertrophy as manifested by tall R waves in leads I and V6 and deep S waves in the right-sided precordial leads V1 and V2.Atrial fibrillation may be present.,Echocardiog