Valvular heart disease

Valvular Heart
Disease
(Clinical &
Echocardiographic
Features)

MAINTAIN
ONE-WAY
BLOOD FLOW
THROUGH
YOUR HEART
The four heart valves make sure that blood always flows freely in a
forward direction and that there is no backward leakage.

Any disease of these valves is called valvular heart
disease!

1. Mitral Valve Diseases:
• Mitral regurgitation
• Mitral Stenosis
• Mitral valve prolapse
2. Aortic Valve Diseases:
• Aortic stenosis
• Aortic regurgitation
3. Tricuspid Valve Diseases:
• Tricuspid stenosis
• Tricuspid regurgitation
4. Pulmonary Valve diseases:
5. Prosthetic Valves.
6. Rheumatic Heart Disease.
7. Infective Endocarditis.
8. Valvular Heart Disease in
Pregnant.

Rheumatic disease is the principal cause (in
countries where disease is common)
• Mitral valve prolapse
• Dilatation of the LV and mitral valve ring (Functional)
(e.g. coronary artery disease, cardiomyopathy)
• Damage to valve cusps and chordae (e.g.
rheumatic heart disease, endocarditis)
• Ischaemia or infarction of papillary muscle (MI)
• Congenital, Iatrogenic.

• With every Systole blood
regurgitates from LV to LA.
LA dilates.
• During Diastole The large amount
of blood in the LA flows to LV.
So the mean LA EDP and
Pulmonary venous pressure don't
rise a lot initially.
• LV dilates dt volume overload.
This dilates the MV ring (vicious
circle).
• If MR is severe and prolonged. LV
failure occurs. Pulmonary
congestion. Pulmonary HTN.
RV failure. (less with MR than

Incomplete closure of mitral
valve
 vol. of blood ejected by
left ventricle
 Left atrial pressure
Right-sided heart failure
Left atrial Dilates CO
 Pulmonary pressure
Backflow of blood to the left
atrium
 Right ventricular
pressure

• Symptoms: appear late
• Exertional dyspnea & cough – pulmonary congestion
• Fatigue & weakness – due to  CO – predominant
complaint
• Palpitations – due to increased stroke volume &/or
atrial fibrillation.
• Edema, ascites – Right-sided heart failure
• Signs
• Atrial fibrillation
• Cardiomegally
• Soft S1, apical S3
• Apical pansystolic murmur ± thrill
• Signs of pulmonary venous congestion (crepitations,
pulmonary edema, effusions)
• Signs of pulmonary hypertension & right heart failure

• ECG: p mitrale
• Chest X-ray (CXR): large heart, calcified mv annulus,
pulmonary odema
• Echocardiogram: Dimensions (large LA, LV), valve
morphology, MR severity grading.
• Cardiac catheterization: - dilated LA,LV , mitral
regurgitation severity, pulmonary hypertension,
coexisting coronary artery disease.

Echocardiographic criteria for the definition of Severe MR:
(ESC guidelines 2012):

Medical
• For patients in whom
surgery is contra-
indicated or those
waiting for surgery.
• Vasodilators (e.g. ACE
inhibitors)
• Diuretics
• If atrial fibrillation presents,
• Anticoagulant according to
CHA2DS2 VASC score.
• Rate/Rhythm control
• IE & RF prophylaxis.
Surgical
• Mitral valve repair
OR
• Mitral valve
replacement

Date of download: 12/1/2016 Copyright © The American College of Cardiology. All rights reserved.
From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536
Figure Legend:
Indications for Surgery for MR
*Mitral valve repair is preferred over MVR when possible.
AF indicates atrial fibrillation; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; ERO, effective regurgitant orifice; HF,
heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation,
MV, mitral valve; MVR, mitral valve replacement; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; RF,
regurgitant fraction; RVol, regurgitant volume; and Rx, therapy.

• Almost always rheumatic in
origin
• Older people: can be caused
by heavy calcification of mitral
valve congestion
• Congenital (rare, Parachute MV)
• Tumers (Myxoma, Carcinoid)
• Relative MS

Pathophysiology
Atrial fibrillation due to
progressive dilatation
of the LA is very
common.
Its onset often
precipitates
pulmonary oedema
In contrast, a more
gradual rise in left atrial
pressure tends to cause
an increase in pulmonary
vascular resistance 
pulmo. HTN  RVH, TR
RHF

Narrowing of mitral valve
 CO
O2/CO2 exchange
(fatigue, dyspnea,
orthopnea)
Left ventricular
atrophy
pulmonary
congestion
 pulmonary
pressure
 left atrial
pressure
Hypertrophy
left atrium
 blood flow to
left ventricle
Right-sided
failure
Fatigue

• Breathlessness, cough (pulmonary congestion)
• Hemoptysis (pulmonary congestion or pulmonary
embolism)
• Fatigue (low cardiac output)
• Edema, ascites (right heart failure)
• Palpitation (atrial fibrillation)
• Thromboembolic complications.

• Pulse: Atrial fibrillation, small
volume
• Mitral facies
• (abnormal flushing of the cheeks that
occurs from cutaneous vasodilation)
• Apex beat: -slapping in character, long
diastolic thrill.
• Auscultation:- Loud first heart sound,
opening snap (soften or lost when
immobile)
- Mid-diastolic murmur (Rumbling,
apex)
• Crepitation, pulmonary edema,
effusions (raised pulmonary
capillary pressure)
• RV heave, loud P (pulmonary

• ECG – P mitrale, AF, right ventricular hypertrophy
• CXR:
• Pulmonary congestion,
• large LA:
• mitralization of left border,
• backward displacement of esophagus,
• double contour
• Signs of pulmonary HT and dilated PA.
• Large Right heart.
• Echo: – thickened immobile cusps
• reduced valve area
• enlarged LA
• reduced rate of diastolic filling of LV
• Doppler: - pressure gradient across mitral valve
• Cardiac Catheterization: rarely needed, if Male aged>40 to exclude CAD, to
assess MR.

Mitral Stenosis
Echocardiography
• Gold Standard.
• 2D:
• mitral valve orifice
(≤1cm≤1.5cm≤),
• thickness,
• mobility of the cusps,
• calcification,
• involvement of subvalvular
structures,
• LAA.
• Doppler: Pressure gradient.
• Echocardiographic criteria for the
definition of Severe MS: (ESC
guidelines 2012):
• Valve Area < 0.1cm2.

Medically
• Anticoagulant (AF)
To reduce the risk of
systemic embolism
• Beta blockers, rate
limiting calcium
antagonists or Digoxin
To control ventricular rate in
atrial fibrillation
 Diuretic
To control pulmonary
congestion
• IE prophylaxis
Surgically
• Mitral balloon
valvuloplasty***
• Mitral valvotomy
• Valve replacement

Figure Legend:
Indications for Intervention for Rheumatic MS
AF indicates atrial fibrillation; LA, left atrial; MR, mitral regurgitation; MS, mitral stenosis; MVA, mitral valve area; MVR, mitral valve surgery
(repair or replacement); NYHA, New York Heart Association; PCWP, pulmonary capillary wedge pressure; PMBC, percutaneous mitral balloon
commissurotomy; and T ½, pressure half-time.

• ‘floppy’ mitral valve
• One of the most common cause
of mild mitral regurgitation
• Caused by
• congenital anomalies
• degenerative myxomatous
changes
• feature of connective tissue
disorders like Marfan’s syndrome

• Mildest form:
• Valve remains competent but bulges back into atrium during
systole  mid-systolic click but no murmur
• In the presence of regurgitant valve:
• Click is followed by a late systolic murmur, which lengthens as the
regurgitation becomes more severe
• Severe form:
• Progressive elongation of chordae tendinae increasing
regurgitation Chordal rupture severe regurgitation

• INFANTS, CHILDREN,
ADOLESCENTS
• Congenital aortic stenosis,
bicuspid aortic valve
• Congenital supravalvular
aortic stenosis
• Congenital subvalvular aortic
stenosis
• YOUNG ADULTS TO MIDDLE-
AGED
• Calcification and fibrosis of
congenitally bicuspid aortic
valve
• Rheumatic aortic stenosis
• MIDDLE-AGED TO
ELDERLY
• Senile degenerative aortic
stenosis
• Calcification of bicuspid
valve
• Rheumatic aortic
stenosis

• LVH
•  Cardiac output on
exercise
• LV dilatation and
failure

Stiffening/Narrowing of Aortic
Valve
Incomplete emptying of left
atrium
Left ventricular hypertrophy
Pulmonary congestion
Compression of
coronary arteries
 CO
 Myocardial
O2 needs
Myocardial ischemia
(chest pain)
 O2 supply

• Asymptomatic
• Angina
• Syncope
• Heart Failure
• Sudden Death
• Slow rising carotid pulse
• Signs of Pulmonary venous congestion.
• LV heave (sustained Apical impulse)
• Ejection systolic murmur radiating to
carotids
Cardinal symptoms
(ASH)
Symptoms
Signs

• ECG – LVH
• CXR: may be normal, enlarged LV & dilated ascending aorta (PA view), calcified
valve on lateral view.
• Echo: – LVH, calcified restricted valve, AS severity by (velocity, peak gradient,
mean gradient, estimated AVA).
• Echocardiographic criteria for the definition of Severe AS: (ESC guidelines 2012):
• Valve Area (cm2): < 0.1
• Indexed Valve Area (cm2/m2 BSA): < 0.6
• Mean Gradient (mmhg): > 40
• Maximum Jet Velocity (m/s): >4.0
• Velocity Ratio: <0.25
• Cardiac Cath.: – Aortic valve gradient, Assess coronary arteries.

 Asymptomatic aortic stenosis  kept under review
 Moderate/severe stenosis  evaluated every 1-2 years with Doppler
echocardiography (to detect progression in severity)
 Symptomatic severe aortic stenosis  valve replacement
 Congenital aortic stenosis  aortic balloon valvuloplasty
 Atrial fibrillation or post valve replacement with a mechanical prosthesis 
anticoagulant
 IE prophylaxis.
(as the development of angina, syncope,
symptoms of low CO or heart failure
has a poor prognosis and is an indication
for prompt surgery)

From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines
Figure Legend:
Indications for AVR in Patients With AS
*AVR should be considered with stage D3 AS only if valve obstruction is the most likely cause of symptoms, stroke volume index is <35 mL/m2, indexed AVA
is ≤0.6 cm2/m2, and data are recorded when the patient is normotensive (systolic BP <140 mm Hg).
AS indicates aortic stenosis; AVA; aortic valve area; AVR, aortic valve replacement by either surgical or transcatheter approach; BP, blood pressure; DSE,
dobutamine stress echocardiography; ETT, exercise treadmill test; LVEF, left ventricular ejection fraction; ΔPmean, mean pressure gradient; and Vmax,
maximum velocity.

• Congenital:
• Bicuspid valve or disproportionate cusps
• Acquired:
• Rheumatic disease
• Infective endocarditis
• Trauma
• Aortic dilatation (marfan’s syndrome, aneurysm,
dissection, syphilis)

• During Diastole : LV relaxes and
part of the blood in the Ao
regurgitates back into LV. Sudden
marked drop of pressure in Ao.
DBP is low. Reduced coronary
blood flow. Together with the
increased work of myocardium and
hypertrophy myocardial
ischemia.
• LV receives both regurgitant blood
and blood from LA
1. LV dilates and hypertrophies.
2. LV pumps abnormally high stroke
volume high systolic BP.
3. Eventually HF.

Incomplete closure of the
aortic valve
Backflow of blood to Left
ventricle
Left ventricular hypertrophy
& dilation
 Left atrial pressure
Left-sided heart failure
(late stage)
Left atrium hypertrophy
 CO
 Pulmonary pressure
 Right ventricular
pressure

• Mild or moderate aortic regurgitation:
• Usually asymptomatic
• Awareness of heartbeat, ‘palpitations’
• Severe aortic regurgitation:
• Breathlessness (pul. Congestion)
• Angina (in severe cases only)
(because compensatory ventricular
dilatation & hypertrophy occur)
particularly when lying on the left side,
which results from increased in stroke volume

• General:
• Large volume or ‘collapsing’ pulse
• Low diastolic and increased pulse pressure
• Generalized body throbbing and marked arterial pulsations in the nech:
Corriggan’s sign.
• Capillary pulsation in nail beds: Quincke’s sign
• Femoral bruit: Pistol shot
• Forward and backward flow in femoral artery: Duroziez’s sign
• Head nodding with pulse: de Musset’s sign
• BP is much higher in the LL than UL: Hill’s sign.
• Warm sweaty hands

• Local:
• Displaced, heaving apex beat (Hyperdynamic Apex)
• 4th heart sound
• Signs of pulmonary congestion.
• Murmurs:
• Early, long, high pitched, decrecendo diastolic murmur.
• Systolic murmur (increased stroke volume, soft, functional)
• Austin Flint murmur (soft mid-diastolic, functional)characteristic murmur is best heard
to the left sternum during held expiration

Functional AS MurmurOrganic AS Murmur
Hyperdynamic circulationLow COPGeneral
Large VolumeSmall volumePulse
Usually absentUsually presentThrill
Murmur
ShortLong• Duration
Localized to Ao area.Well propagated to the
neck
• Propagation
Differentiation between Organic and Functional AS

• ECG – LVH
• CXR
• Dilated Aorta and prominent Aortic Knob.
• LV Enlargement.
• Echo
• Thick wall of LV.
• Degree of LV and Aortic dilatation.
• Any deformity of the Aortic valve.
• Degree of the AR by color doppler.
• Assessment of other valves (MS versus Austin Flint)
• Aortic dissection, fluttering anterior mitral leaflet.
• Catheterization – assess degree of AR – Assess coronary arteries.
Aortic configuration

• Treatment may be required for underlying conditions, such as endocarditis
or syphilis.
• Aortic regurgitation with symptoms aortic valve replacement (may be
combined with aortic root replacement and coronary bypass surgery).
• Asymptomatic patients  annually follow up with echocardiography for
evidence of increasing ventricular size.
• Systolic BP should be controlled with vasodilating drugs, such as nifedipine
or ACE inhibitors.
• IE & Rheumatic prophylaxis.

Figure Legend:
Indications for AVR for Chronic AR
AR indicates aortic regurgitation; AVR, aortic valve replacement (valve repair may be appropriate in selected patients); ERO, effective
regurgitant orifice; LV, left ventricular; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left
ventricular end-systolic dimension; RF, regurgitant fraction; and RVol, regurgitant volume.

• usually occurs together with aortic or mitral stenosis
• may be due to rheumatic heart disease (<5%)
•  blood flow from right atrium to right ventricle
  right ventricular output
  left ventricular filling   co
•  systemic pressure

Symptoms
• symptoms of right-sided heart
failure
• hepatomegaly
• ascites
• peripheral edema
• neck vein engorgement
•  co – fatigue, hypotension
Signs
• Raised JVP
• Mid-diastolic murmur (best
heard at lower left or right sternal edge)

Management:
• Valvotomy
• Balloon valvuloplasty

 Common, and is most frequently
‘functional’ as a result of enlargement of
right ventricle
 An insufficient tricuspid valve allows
blood to flow back into the right atrium 
venous congestion &  right ventricular
output   blood flow towards the
lungs.

Primary:
• Rheumatic heart disease.
• Endocarditis, particularly
in injection drug-users.
• Ebstein’s congenital
anomaly.
Secondary:
• Right ventricular dilatation
due to chronic left heart
failure (‘functional tricuspid
regurgitation’).
• Right ventricular infarction.
• Pulmonary hypertension
(e.g. cor pulmonale).
Tricuspid Regurgitation
Causes:

Symptoms
• Usually non-specific
• Tiredness (reduced
forward flow)
• Oedema
• Hepatic enlargement
(venous congestion)
Signs
• Raised JVP
• Pansystolic murmur (left
sternal edge)
• Pulsatile liver

Management:
• Correction of the cause of right ventricular overload (if TR
is due to right ventricular dilatation)
• Use of diuretic and vasodilator treatment of CHF
• Valve repair

Figure Legend:
Indications for Surgery
*See Table 19 for definition of stages. TA dilation is defined by >40 mm on TTE (>21 mm/m2) or >70 mm on direct intraoperative measurement.
LV indicates left ventricular; PHTN, pulmonary hypertension; RV, right ventricular; TA, tricuspid annular; TR, tricuspid regurgitation; TTE,
transthoracic echocardiogram; TV, tricuspid valve; and TVR, tricuspid valve replacement.

Symptoms
• Fatigue, dyspnea on
exertion, cyanosis
• Poor weight gain or failure
to thrive in infants
• Hepatomegaly, ascites, edema
Signs
• Ejection systolic murmur
(loudest at the left upper sternum &
radiating towards the left shoulder)
• Murmur often preceded by an ejection
sound (click)
• May be wide splitting of second heart
sound (delay in ventricular ejection
• May be a thrill (best felt when patient
leans forward and breathes out)

• ECG: - right ventricular hypertrophy
• CXR: - post-stenotic dilatation in the pulmonary artery
• Doppler echocardiography is the definitive investigation

• Mild to modearate isolated pulmonary stenosis is
relatively common and does not usually progress or
require treatment
• Severe pulmonary stenosis  percutaneous Pulmonary
balloon valvuloplasty
OR
surgical valvotomy

 A rare condition
 Usually associated with pulmonary hypertension
• which may be
• Secondary of the disease of left side of the heart
• Primary pulmonary vascular disease
• Eisenmenger’s syndrome
 Blood flows back into right ventricle  right ventricle
• and atrium hypertrophy  symptoms of right-sided
• heart failure
 Trivial PR is a frequent finding in normal individuals and has no clinical
significance

• Types of Prosthetic Valves: These differ in durabiliy,
thrombogenicity and hemodynamic performance.
• Bioprosthetic:
• Heterografts.
• Aortic Homografts. (cadaveric human aortic valves)
• Autografts. (Ross operation)
• Mechanical.
• Single leaflet tilting disk.
• Bileaflet tilting disk.
• Caged ball.

• Arrhythmias: AF, conduction disturbances.
• Endocarditis: Early, Late.
• Hemolysis.
• Thrombosis & Embolism.
• Dehiscence.
• Patient-Prosthesis mismatch.
• Pannus formation.
• Mechanical Failure.

Minor Jones CriteriaMajor Jones CriteriaGAS infection
FeverCarditisCulture
ArthralgiaArtheritisASO titres
High ESR or CRPSydenham’s choreaAnti-DNase B
Prolonged PRSubcutaneous nodulesOther Anti-streptococcal
anti-bodies.
Erythema marginatumStreptococcal Antigens
The diagnosis of RF requires confirmation of previous GAS infection with
either two major criteria or one major and two minor criteria

• Both acquired and congenital Valvular heart diseases are
important causes of maternal and fetal morbidity and mortality.
• Rheumatic heart disease remains a major problem in
developing countries (50-90%) and is still seen in western
countries (15% of cardiac complications).
• Stenotic valve diseases carry a higher pregnancy risk than
regurgitant lesions, and left-sided valve diseases have a
higher complication rate than right-sided valve lesions.
• Specific problems, mainly related to anticoagulant therapy, are
present in women with mechanical valve prostheses.

Valvular heart Disease in Pregnant women:

Figure Legend:
Anticoagulation for Prosthetic Valves
Risk factors include AF, previous thromboembolism, LV dysfunction, hypercoagulable condition, and older-generation mechanical AVR.
AF indicates atrial fibrillation; ASA, aspirin; AVR, aortic valve replacement; INR, international normalized ratio; LMWH, low-molecular-weight
heparin; MVR, mitral valve replacement; PO, by mouth; QD, every day; SC, subcutaneous; TAVR, transcatheter aortic valve replacement; UFH,
unfractionated heparin; and VKA, vitamin K antagonist.

Figure Legend:
Evaluation and Management of Suspected Prosthetic Valve Thrombosis
*See text for dosage recommendations.
CT indicates computed tomography; IV, intravenous; NYHA, New York Heart Association; Rx, therapy; TEE, transesophageal
echocardiography; and TTE, transthoracic echocardiography.

From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.
Figure Legend:
Anticoagulation of Pregnant Patients With Mechanical Valves
aPTT indicates activated partial thromboplastin time; ASA, aspirin; INR, international normalized ratio; LMWH, low-molecular-weight heparin;
QD, once daily; and UFH, unfractionated heparin.

From: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease:
Figure Legend:
Evaluation and Management of CAD in Patients Undergoing Valve Surgery
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CT, computed tomography; IE, infective endocarditis; LV, left
ventricular; and PCI, percutaneous coronary intervention.

1. http://www.escardio.org/Guidelines/Clinical-Practice-
Guidelines
2. http://cardioland.org/Echo/Feigenbaum/html/VID.htm
3. http://professional.heart.org/professional/GuidelinesStat
ements/searchresults.jsp?q=&y=&t=
4. Topol & Griffin’s Manual of cardiovascular medicine 4th
Edition.
5. Mohamed Khairy Abdel Dayem (Understanding
Cardiology) 8th Edition.

Valvular heart disease

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