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Dr.Suhaemi,SpPD, Finasim
Types
• Mitral Stenosis
• Mitral Regurgitation
• Mitral Valve Prolapse
• Aortic Stenosis
• Aortic regurgitation
• Tricuspid valve
– Tricuspid stenosis
– Tricuspid regurgitation
Tricuspid Valve
Mitral Valve:
hockey stick
appearance
indicating
Rheumatic Valve
Disease
Valve area varied
between 1.4 to 1.6
Exercise Echo was
done
Rheumatic Heart Disease
• Inflammatory process that may affect the
myocardium, pericardium and or endocardium
• Usually results in distortion and scarring of the
valves
Rheumatic Heart Disease
• Subjective symptoms • Objective symptoms
– Prior history of – Temperature
rheumatic fever – Murmurs
– General malaise – Dyspnea
– Pain – may or may not – Polyarthritis
be present
Rheumatic Heart Disease
• Diagnosis
– H/P
– WBC and ESR
– C-reactive protein
– Cardiac enzymes
– EKG
– Chest x-ray
– Echo
– Cardiac cath
– Cardiac output
Rheumatic Heart Disease
• Nursing Care
– Vital signs
– Rest and quiet environment
– Give antibiotics, digitalis, and diuretics
– Provide adequate nutrition
– Monitor I/O
– Explain treatment and home care
Mitral Stenosis
• Usually results from rheumatic carditis
• Is a thickening by fibrosis or calcification
• Can be caused by tumors, calcium and thrombus
• Valve leaflets fuse and become stiff and the cordae tendineae
contract
• These narrows the opening and prevents normal blood flow
from the LA to the LV
• LA pressure increases, left atrium dilates, PAP increases, and
the RV hypertrophies
• Pulmonary congestion and right sided heart failure occurs
• Followed by decreased preload and CO decreases
Mitral Stenosis, cont.
• Mild – asymptomatic
• With progression – dyspnea, orthopneas, dry cough,
hemoptysis, and pulmonary edema may appear as
hypertension and congestion progresses
• Right sided heart failure symptoms occur later
• S/S
– Pulse may be normal to A-Fib
– Apical diastolic murmur is heard
2-D Echo showing heavily calcified
Mitral valve leaflets and Mitral
stenosis
3-D Echo of Mitral Stenosis
LA view LV view
Real Time TTE of MS
A B C
LA
D E F G
Mitral Stenosis
Management Principles
• Severe MS
- is usually symptomatic
- Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority
- PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
- PMC in skilled centers has a mortality of < 1%
- Success of PMC depends on the pre-PMC valve anatomy
- Commissural calcification is a predictor of suboptimal outcome
- Complications: severe MR, embolization and cardiac perforation
Mitral Stenosis
Management Principles
• Surgical treatment
- valve replacement
Mitral Regurgitation
• Primarily caused by rheumatic heart disease, but may be
caused by papillary muscle rupture form congenital, infective
endocarditis or ischemic heart disease
• Abnormality prevents the valve from closing
• Blood flows back into the right atrium during systole
• During diastole the regurg output flows into the LV with the
normal blood flow and increases the volume into the LV
• Progression is slowly – fatigue, chronic weakness, dyspnea,
anxiety, palpitations
• May have A-fib and changes of LV failure
• May develop right sided failure as well
Mitral Valve Anatomy
Pathophysiology
• Hemodynamic changes much more
pronounced than in chronic MR due to lack of
time for adaptation
• The abrupt increase in left atrial pressure is
transmitted to the pulmonary circulation
• Cardiac output falls and systemic vascular
resistance increases
Echo performed…
Mitral Valve Prolapse
• Cause is variable and may be associated with
congenital defects
• More common in women
• Valvular leaflets enlarge and prolapse into the LA
during systole
• Most are asymptomatic
• Some may report chest pain, palpitations or exercise
intolerance
• May have dizziness, syncope and palpitations
associated with dysrhythmias
• May have audible click and murmur
Mitral Valve Prolapse
Types
• Women 20 to 50 years
• Echo:
- thickened, redundant leaflets
- leaflet excursion (prolapse) into LA in systole
- redundant chordae tendinae, trivial or mild MR
• Men 40 to 70 years
• Endocarditis prophylaxis
• Clinical
- pulsus parvus et tardus (absent in hypertensives and elderly)
- systolic thrill and typical heaving apical impulse
- S4 and late peaking ejection systolic murmur
- paradoxical split of 2nd HS in severe AS
- other auscultatory signs modified by co-existing disease
• ECG
- LVH with strain
• CXR
- dilated ascending aorta (post-stenotic dilatation)
- Valve calcification
Aortic Stenosis
Management Principles
• Asymptomatic
- no specific therapy
- endocarditis prophylaxis
- if appropriate, rheumatic fever prophylaxis
• Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm)
- Normal physical activity
- No specific therapy, restoration of NSR in case of AFib
- approx. progression is a decrease by 0.1 sq cm per year
- annual echo follow-up
Aortic Stenosis
Management Principles