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1、Valvular Heart Disease,Kenneth S. Korr M.D. Associate Professor of Medicine, Brown Medical School Director, Division of Cardiology The Miriam Hospital,Normal Valve Function,Maintain forward flow and prevent reversal of flow. Valves open and close in response to pressure differences (gradients) betwe
2、en 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 s
3、ingle 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:,Int
4、egrated 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 Rheumatic - 99.9%! Congenital Prosthetic valve stenosis Mitr
5、al Annular Calcification Left Atrial MyxomaAcute Mitral Regurgitation Infective endocarditis Ischemic Heart disease Papillary ms rupture Mitral valve prolapse Chordal rupture Chest trauma,Chronic Mitral Regurgitation Ischemic Heart disease Papillary ms dysfunction Inferior & posterior MI Mitral Valv
6、e prolapse Infective endocarditis Rheumatic Prosthetic Mitral annular calcification Cardiomyopathy LV dilatation IHSS,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 +
7、 regurgitant volume LV (LA) dilatation Left Ventricular Volume Overload (LVVO),Chronic Mitral Regurgitation - LVVO,LVVO LV dilatation Eccentric hypertrophy Increased LA pressure Pulmonary HTN Dyspnea Atrial arrhythmias Low output state,Pathophysiology Acute vs Chronic Mitral Regurgitation,Acute MR N
8、ormal (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,Au
9、scultatory Findings S1 soft or normal P2 increased Holosystolic blowing murmur apex MVP mid-systolic click IHSS murmur increases with Valsalva Acute MR descrescendo systolic murmur S3 gallop RV tap,Mitral Stenosis -Pathophysiology,Restriction of blood flow from LALV during diastole. Normal MVA 4-6cm
10、2. Mild MS 2-4cm2. Severe MS 40yrs, LAE, MR, prior embolic event Surgical Rx -Class III &IV Balloon Mitral Valvuloplasty Commissural fusion pliable, noncalcified leaflets No MR of LA thrombus Mitral Valve Surgery Open commissurotomy MV replacement,Chronic Mitral Regurgitation Medical Rx for mild to mod MR with vasodilators, diuretics, anticoagulation Surgical Rx ideally before LV systolic function declines. MV replacement MV ring & CABG MR repair associated with improved long-term LV funvtion MVP, ruptured chords, infective endocadritis, pap ms rupture.,
