Rheumatic valvular heart disease is caused by rheumatic fever, an inflammatory response to Group A streptococcal infection. It most commonly results in mitral regurgitation or stenosis from scarring of the mitral valve. Physical exam may reveal murmurs. Echocardiography is the gold standard for assessing valve structure and function. Long-term management involves serial monitoring, medications to control symptoms, and possibly surgery for severe or symptomatic cases. Complications include heart failure, arrhythmias, embolism and infective endocarditis.
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Rheumatic valvular diseases - Dr. S. Srinivasan
1. Rheumatic
Valvular Heart Disease
S . Srinivasan
Professor of Paediatrics
MGMCRI, Plillayaarkuppam
Puducherry
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
2. Learning Objectives
⢠To discuss the common etiologies of
valvular stenosis and regurgitation.
⢠To recognize the signs and symptoms of
valvular stenosis and regurgitation
⢠To clinically recognize, identify clinical
features of Rh. Mitral and Aortic Valvular
Diseases and their attendant
complications
⢠To offer a plan of investigative work up
and interpret a few important findings
⢠To offer preventive and treatment
modalities recommended in treating and
preventing complications
⢠To identify & refer children with RHD for
further work up, medical and surgical
management
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
3. Rheumatic fever
⢠Inflammatory autoimmune response
triggered by Group A beta-hem.
streptococcal pharyngitis
⢠Children & Adolescents
⢠Poor SE Status, overcrowding, poor
sanitation, developing &
underdeveloped countries
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
4. Acute rheumatic Carditis
Pancarditis
ENDOCARDITIS ď MV Insufficiency (65 -100%)
ď AV Regurgitation (20-30%)
ď TV (10% - ass.with MR,AR or both)
MYOCARDITIS ď Marked Sinus tachycardia
ď S3;
ď changing Murmurs ;
ď Carey-Coombâs MDM
Pericarditis ďChest pain over the left chest and axilla
ďPericardial Rub on auscultation
Rarely affects cardiac function
Rarely results in large effusions or constrictive
pericarditis
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
5. PREVALENCE RHD IN INDIA
( ECHO proven)
ď˝0.67/1000 to 0.12/1000 children
(Periwal et al Bikaner) 2006
ď 0.5 per 1000 children
(Misra et al. 2003 -2006)
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
6. Genetic studies in RF
Progression to Chronic RHD
Strong correlation to:
HLA antigen DR class II alleles
Inflammatory protein-
encoding genes MBL2 and
TNFA
Genes
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
7. Chronic Rheumatic Heart Disease
in Children & Young Adults
Worldwide occurrence of RHD
Estimated
occurrence
5-30 million Children
& Young Adults
New Cases 2.5 - 3 Lakhs of RHD
added every year
Deaths
attributed to
Chronic RHD
90 Thousands â 2.5
Lakhs / Year
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
8. Rheumatic heart disease
Valvular Stenosis
and/or Insufficiency
( Regurgitation)
( structural damage due to
fibrosis, thickening,
shortening and fusion
of valvular cusps and
apparatus )
Post Infective ( GpA-ᾌ hemolytic Strep) Autoimmune mediated
Cardiac inflammation and scarring
Pancarditis
-Myocarditis
-Endocarditis &
-Pericarditis)
Acute RF Chronic RH Disease
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
9. RHD
⢠More severe in females than in males
⢠Mitral Insufficiency of Ac.RF resolves
in 60-80% of patients who adhere to
antibiotic prophylaxis
⢠Aortic Regurgitation in 20-30 % of ARF
persists in spite of strict adherence to
Secondary Rheumatic Prophylaxis
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
10. Rheumatic ( Valvular )
Heart Disease
ď Permanent structural alterations to
heart valve cusps and supporting
structures caused by a single or more
attacks of ARF.
ď RHD.: 40-60% of children with ARF
ď Valves involved :
-- Mitral > Aortic > TV>PV
-- MR(MI) > MR+MS > MS
-- MR+AR > MS+AR > AR
-- Rt. Heart Valves in RHD : Rare
-- AS of Rheumatic etiology : Uncommon
-- ( seen beyond Adolescent age group )
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
11. ďEtiology
ďPathophysiology
ďHistory & Physical Exam
ďNatural History
ďInvestigative Evaluation
ďComplications
ďTreatment
ď Prevention
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
13. Most commonly observed Murmurs
of ARF
Aortic
Regurgitation
ďHigh-pitched, blowing,
decrescendo, early diastolic murmur
of Aortic Regurgitation ,heard best
along the right upper and mid-left
sternal border after deep expiration
while the patient is leaning forward.
ď Apical high-pitched,
blowing-quality murmur
pansystolic murmur
radiating to the left
axilla
MV insufficiency
⌠Apical diastolic murmur (also known as a Carey-
Coombs murmur) in active carditis and
accompanies severe mitral insufficiency
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
14. Mild (physiological) MR:
80% of normal individuals
Mitral Regurgitation
Definition
Backflow of blood from the
LV to the LA during systole
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
15. Chronic Mitral Regurgitation
Age Group Etiologies
YOUNG ď Rheumatic
ď MVP
ď Her. Connective Tissue Disorders
ď Ac. Collagen Vascular Disorders
Elderly ď Rheumatic heart disease
ď Myxomatous degeneration
(MVP)
ď Ischemic MR
ď Infective Endocarditis
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
16. Mitral Regurgitation
Pathophysiology
Volume Overload
Compensatory
Mechanisms
ďLA enlargement
ďLVH
ďIncreased contractility
Progressively
increasing VO in
Chronic MR
ď Progressive LA dilation
ď Pulm.Arterial Hypertension
ď RV Dysfunction
ď Progressive LV volume
overload
ď LV dilationMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
17. Mitral Regurgitation
Physical Exam findings
Symptoms ďExertion Dyspnea (exercise Intolerance)
- Worsening with severity
ď Palpitation ( more marked in
combined MS &MR)
Signs Pulse : NV/HV/LV; Irregularly irregular in
AF
Precardial prominence, LV type of APEX
Auscultation
Heart Sounds soft S1; Loud S2 in PAH;
S3 (CHF/LA overload)
Murmurs Holosystolic murmur at
18. Rheumatic Mitral Regurgitation:
Natural History
Compensatory
phase
10-15 years
Asymptomatic
severe MR
5%/year mortality rate
Severe
Symptomatic MR
Sharp Rise in mortality
rate
MR with EF <60%
Cause of
Mortality
Progressive CHF,
Complications of MR like
Arrhythmias, EmbolismMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
19. Mitral Regurgitation : imaging studies
Chest
X-Ray
LA enlargement, Central
Pulmonary Artery enlargement
ECG To look for : LA enlargement,
Atrial Arrhythmias like Atrial
flutter, fibrillation and LVH
ECHO ďTo estimate LA, LV size and
function
ďTo assess valve structure
TEE inconclusive transthoracic ECHO
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
20. Mitral Regurgitation-
Medical Management
1. Hydralazine & other Vasodilators
2. ď˘-blockers, CCB, digoxin : To
control Heart Rate in atrial
fibrillation with MR
3. Anticoagulants in atrial fibrillation
and flutter
4. Diuretics for fluid overloadMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
21. Management of MR
⢠Serial Echocardiography:
â Mild: 2-3 years
â Moderate: 1-2 years
â Severe: 6-12 months
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
22. IE prophylaxis
ď Dental procedures
ď Prosthetic valves
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
25. MR: Important Indications for
MV Replacement
ď Symptomatic Severe MR
⢠Any cardiac related Symptoms at
rest or exercise with (repair if
feasible)
ď Asymptomatic MR
EF <60%
New onset Atrial Fibrillation
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
27. Mitral Stenosis
⢠Recurrent episodes: Progressive Valvular
Damage
⢠Residual and progressive valve deformity
⢠10-40% of older children 2-10 years after
previous ARF with MR
⢠Fusion of the valve apparatus (at the level
of the valve commissures, cusps, chordal
attachments, or any combination of these )
resulting in stenosis or a combination of
stenosis and insufficiency
99% of MS in adults:
Rheumatic etiology
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
28. Mitral Stenosis
Definition
LV inflow Obstruction:
ď Impaired LV diastolic filling
Normal MV Area : 4-6 cm2
Basic Facts
Onset of
Symptoms
MV Area < 2 cm2 With Increasing
Transmitral gradients
Predominant
Cause
Rheumatic HD
Prevalence and
incidence
Decreasing due to a
reduction of RHD
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
29. Etiology of Mitral Stenosis
Rheumatic
heart disease
77-99% of all
cases
Mitral annular
calcification
2.7%
Infective
endocarditis
3.3%
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
30. Mitral Stenosis
Pathophysiology
Cause Physical Symptoms & Signs
impaired LA
emptying resulting in
Increasing PV
Pressue in capillaries
ďProgressive Dyspnea (70%)
due to pulmonary congestion
ď Palpitations
(worsening with exercise,
fever, tachycardia, and
pregnancy)
Increasing
Transmitral
Pressures
Haempotysis, Progressive
Dyspnea , PND, Pedal Oedema,
Increased JVP, Hepatomegaly
ďLA enlargement; LA
Dilatation
ďPulmonary venousMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
31. Natural History of MS
⢠Disease of plateaus:
â Mild MS: 1 - 10 years after initial
ARF
â Moderate: 5 -10 years later
â Severe: Beyond 10 years
Mortality ďPulmonary Oedema
ďInfections-BE,LRI, and
ďThromboembolism
ďPulmonary EmbolismMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
32. Physical Exam Findings of MS
JVP prominent "a" wave
Signs of right-sided
heart failure
in advanced disease
Mitral facies Severe MS &
Cachexia with
GRetdn
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
33. ⢠Loud S1
⢠Opening S1 snap: Apex when leaflets
are still mobile
Due to the abrupt halt in leaflet motion
in early diastole, after rapid initial
rapid opening, due to fusion at the
leaflet tips
ď Shorter the S2 -OS interval, severer
the MS
Heart Sounds in MS
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
34. ďLow-pitched Diastolic Rumble
ď Most Prominent at the Apex
ď Best heard in the Left lateral
position
ď Bell of the steth
ďExpiration
ď Mild Exercise when in doubt
Heart Murmur in Mitral Stenosis
MidDiastolic Murmur
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
35. Evaluation of MS
CXR ďLA enlargement
ďPulmonary congestion
ďSigns of PAH
ECG ďLA enlargement
ďAtrial Fibrillation
ECHO: GOLD STANDARD
To
Assess
ďMV Leaflet mobility
ďGradient
ďMV Area
ďNature of damage
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
38. Management of MS
Serial echocardiography
ď˘-blockers, CCBs, Digoxin
which control heart rate and
hence prolong diastole for
improved diastolic filling
Duiretics for fluid overload
Mild: 3-5 Years
Moderate:1-2 Years
Severe: Yearly
Medications
Medical therapy does not prevent
progression as MS is a mechanical problem
and
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
39. Management of MS
⢠Identify patient early who might
benefit from percutaneous mitral
balloon valvotomy
ď REMEMBER to Implement :
ď IE Prophylaxis & Secondary RHD
Prophylaxis
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
40. Simplified Indications for Mitral
valve replacement
⢠ANY SYMPTOMATIC Patient with
NYHA Class III or IV Symptoms
⢠Asymptomatic moderate or
Severe MS with a pliable valve
suitable for PMBV
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
47. Pathophysiology of AR
⢠Combined pressure & volume
overload
⢠Compensatory Mechanisms
⢠LV dilation, LVH
⢠Progressive dilation
⢠Heart Failure
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
48. Natural History of AR
⢠Asymptomatic until 4th or 5th decade
⢠Rate of Progression: 4-6% per year
⢠Progressive Symptoms include:
- Dyspnea: exertional, orthopnea, and
paroxsymal nocturnal dyspnea
- Nocturnal angina: due to slowing of
heart rate and reduction of diastolic
blood pressure
- Palpitations: due to increased force of
contraction
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
49. Physical Exam findings of AR
⢠Wide pulse pressure: most sensitive
⢠Hyperdynamic and displaced apical
impulse
⢠Auscultation-
â Diastolic blowing murmur at the left
sternal border
â Austin flint murmur (apex): Regurgitant
jet impinges on anterior MVL causing it
to vibrate
â Systolic ejection murmur: due to
increased flow across the aortic valve
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
51. Evaluation of AR
CXR enlarged cardiac silhouette
and aortic root enlargement
ECHO Evaluation of the AV and
aortic root with
measurements of LV
dimensions and function
(cornerstone for decision
making and follow up
evaluation)
AortographyMGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
52. Management of AR
⢠General: IE prophylaxis in dental
procedures with a prosthetic AV
or history of endocarditis.
⢠Medical: Vasodilators (ACEIâs),
Nifedipine improve stroke volume
and reduce regurgitation only if pt
symptomatic or HTN.
⢠Serial Echocardiograms: to
monitor progression.
⢠Surgical Treatment: Definitive Tx
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16
53. Simplified Indications for
Surgical Treatment of AR
⢠ANY Symptoms at rest or exercise
⢠Asymptomatic treatment if:
âEF drops below 50% or LV
becomes dilated
MGMCRI- 8th&9th Semesters MBBS-UG PEDIATRICS Theory Lecture 12th Feb 16