CASE REPORT

VALVULAR HEART
DISEASE
Presented By :
Ruth FJR
Supervised :
dr. Pendrik Tendean, Sp.PD

Patient identity
Name
: Mr. S
Age
: 37 years old
Gender
: Male
Address
: Mario, Bone
MR
: 718600
Date of admittance : July 9th 2015

History Taking
Chief complaint: shortness of breath
History taking:
It has been since 1 year before admitted and
worsen within the last week before admitted to
the hospital and relieved by sitting upright.
Paroxysmal Nocturnal Dyspnea(+). Dyspnea On
Exercise
(+).
Chest
pain
(
+) occurs with the shortness of breath, squeezed-like
pain and spreads to the back, 20 minutes of duration,
palpitation (-) nausea (-) vomitus (-). Cough (-). Fever
(-) and fever history was not exist. Hypertension and
DM were denied. Defecation & micturition were
normal.

PAST ILLNESS HISTORY

History of cardiac disease before (-)

Family history of cardiac disease (-)
Cigarrette smoking (+)

Physical Examination
Present status:
Severe illness / Poor-nourished / Conscious
Vital signs:
BP : 110/50 mmHg
HR : 88 x/ minute
RR : 25 tpm (vesicular)
T
: 36.8C (axilla)

Physical Examination
Head : Anemic (-) Icterus (-)
Neck : No mass, no tenderness, JVP R+3
cmH2O
Chest : Rhonchi +/+ (base of lungs) Wh -/Heart: S1/S2 irregular, systolic murmur
grade 4/6 (apex), diastolic murmur grade
3/6
Abdominal : Ascites (-), peristaltic normal
Extremities : oedem (-)

ECG (7/7/15 )

Rhythm : Sinus rhythm, reguler

QRS Rate : Heart rate 100 bpm
Axis
: Left Axis Deviation
P Wave
: Normal
PR Interval : 0.14 s
QRS Complex : 0.08 s, poor R Wave progression,
S V1+ R V6
ST Segment : ST depression I aVL V5 V6
ST Elevation V3 V4
T Wave
: T inverted in lead I, aVL, V4, V5, V6
Conclusion : Sinus Rhythm,
Left Ventricular Hypertrophy
Ischemic antero lateral wall

Chest X-Ray
Conclusion :

Cardiomegaly with
oedem pulmonal

Right diaphragm
elevated

CVC in the right

hemithorax with the tip
at the level of
Costovertebral Thoracic
8

Pleural Efusion bilateral

Aorta Dilatation

Lab. Findings

Result

Reference of value

RBC

5.56.106/mm3

(3,8 5,8).106/mm3

HGB

16.6 g/dL

12 - 16 g/dL

WBC

14.103/mm3

(4 - 10).103/mm3

PLT

142.103/mm3

(150 - 400).103/mm3

PT

16.9

10-14

INR

1.62

APTT

28.9

22-30

GDS

95 mg/dl

< 200 mg/dL

Urea

89mg/dL

10 - 50 mg/dL

Creatinine

1.32 mg/dL

< 1,1 mg/dL

Uric acid

9.7 mg/ml

2,4-5,7

Natrium

136 mmol/L

136-145 mmol

Kalium

4.2 mmol/L

3.5-5.1 mmol

Clorida

101 mmol/L

97-111mmol

result

Reference of value

units

Total bilirubin

4.94

<1.1

mg/dl

Direct bilirubin

2.6

<0.3

mg/dl

SGOT

95

<38

U/L

SGPT

501

<41

U/L

Total protein

6.6

6.6-8.7

gr/dl

Albumin

3.6

3.5-5.0

gr/dl

Globulin

3.0

1.5-5

gr/dl

CK

1900

<190

U/L

CK-MB

31.1

<25

U/L

Troponin I

0.07

<0.01

ng/ml

Assesment

CHF NYHA II-III

Valvular Heart Disease
Aortic Stenosis, Aortic Regurgitation, Mitral
Stenosis, Mitral Regurgitation
Congestive Liver

Management

O2 4 L/min via nasal canul

IVFD NaCl 0,9% 500cc/24h
Furosemide 40 mg/8h/iv
Captopril 12.5mg/12h/oral

ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY

Complain : possible infective endocarditis

LA Dilatation
LVH (+) Eccentric, LVPWd 20 mm
Systolic function LV good, EDD 57 / ESD 37/ EF 65%
Global Normokinetic
RV contractility good, tapse 3,35cm

Heart Valves
Aorta : 3 vegetative cusps (+), destroyed cusp, AR severe with PHT 288 ms
Mitral: PML Prolapsed ec. Rupture chordae, MR severe, with Jet Eccentric
Tricuspid : TR moderate with TVG 51 mmHg
Pulmonal : PR mild
Other:
SEC (+) LA and LV with thrombus LA
Conclusion :
LVH

Severe AR ec. Vegetation : destroyed cusps

Severe MR ec. Rupture Chordae
Moderate TR, PH
Mild PR
Systolic Function LV good, LVEF 65%: LVH (+) eccentric
RV Contractility good
SEC (+) LA and LV with thrombus

DISCUSSION

INTRODUCTION

Obstruction to left ventricular (LV) outflow

is localized most commonly at the aortic
valve.
AS has become the most frequent type of
VHD in Europe and North America. It
primarily presents as calcific AS in adults
of advanced age (27% of the population
>65 years).

Aortic Stenosis

INTRODUCTION

Incidence

Prevalence

Affects 5 in 10,000 people

80% of adults with symptomatic AS are men.
In adults undergoing surgery for AS in the United
States, calcific AS accounts for 51% of cases, bicuspid
AS 36%, and rheumatic disease 9%. The prevalence
of bicuspid aortic valve in the general population may
be as high as 1-2% of the general population.

Risk Factors

Age
Dyslipidemia
Male

ETIOLOGIES

Congenital : congenital mono or bicuspid valve.

(about 1% to 2% of the population)
Degenerative : Calcific disease progresses
causing a reduction in leaflet motion and
effective valve area without commissural fusion.
Calcific AS is an active disease process by lipid
accumulation, inflammation, and calcification.
Rheumatic : Rheumatic AS due to fusion of the
commissures with scarring. Approximately 95%
of patients who are found to have rheumatic AS
have coexisting involvement of the mitral valve.

MAJOR TYPES OF AORTIC VALVE

STENOSIS

Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine Ninth Edition. 2012;1468-78.

VALVE HISTOLOGY

Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine Ninth Edition. 2012;1468-78.

PATHOPHYSIOLOGY

Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine Ninth Edition. 2012;1468-78.

PHYSICAL EXAM

Pulse: pulsus tardus and pulsus parvus.

Murmur: The characteristic sign is a
crescendo-decrescendo systolic murmur
over the right second intercostal space. The
murmur radiates to the carotids and to the
apex (the latter is referred to as the
Gallavardin phenomenon).

PHYSICAL EXAM

The second heart sound (S2) is diminished

or absent in severe AS.
A fourth heart sound (S4) is common and
reflects increased atrial contribution to
ventricular filling.

CARDIAC IMAGING

Chest Radiography
Echocardiography
Cardiac Catheterization
Dobutamine-Stress Echocardiography

Categories Of Aortic Stenosis

Severity

Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine Ninth Edition. 2012;1468-78.

Recommended Intervals For Follow-up Of

Adults With Asymptomatic Aortic Stenosis

Vahanian. Alec, Catherine M. Otto. Risk stratification of patients with aortic stenosis. European
Heart Journal. 2010.

Natural History Of Asymptomatic

Patients With Aortic Stenosis

Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine Ninth Edition. 2012;1468-78.

ESC And ACC/AHA Guidelines For

Management Of Aortic Valve Stenosis (1)

Vahanian. Alec, Catherine M. Otto. Risk stratification of patients with aortic stenosis. European
Heart Journal. 2010.

ESC And ACC/AHA Guidelines For

Management Of Aortic Valve Stenosis (2)

Vahanian. Alec, Catherine M. Otto. Risk stratification of patients with aortic stenosis. European
Heart Journal. 2010.

Management of
severe aortic
stenosis.

The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2012

Recommendatio
ns For The Use of
TAVI

The Joint Task Force on the Management of Valvular Heart Disease of the
European Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2012

Contraindications For TAVI

PERCUTANEOUS AORTIC
BALLOON DILATATION

Percutaneous balloon dilatation offers

little benefit for adults with calcific AS or
with secondary calcification of a bicuspid
aortic valve.
This procedure is reserved for patients
with serious severe comorbidities that are
not candidates for AVR, patients requiring
urgent noncardiac surgery, and as a
bridge to AVR.

Medical Therapy
Recommendations
Class I : Hypertension in patients at risk for
developing AS (stage A) and in patients with
asymptomatic AS (stages B and C) should be
treated according to standard GDMT, started at a
low dose, and gradually titrated upward as
needed with frequent clinical monitoring (Level
of Evidence: B)
Class IIb : Vasodilator therapy may be reasonable
if used with invasive hemodynamic monitoring in
the acute management of patients with severe
decompensated AS (stage D) with NYHA class IV
HF symptoms (Level of Evidence: C)
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

PROGNOSIS

Prognosis is similar to that for agematched normal adults during the

asymptomatic period.
Development of symptoms is associated
with a grave prognosis, showing a 2-year
survival rate of ~50% without surgical
intervention.

MEDIAN SURVIVAL TIME IN

SYMPTOMATIC SEVERE AORTIC
STENOSIS

EDUCATION

Diet : Low-salt diet

Activity:
Asymptomatic patients with mild AS: Physical activity is
not restricted and patients can participate in
competitive sports.
Patients with moderate AS: They should avoid
competitive sports that involve high dynamic and static
muscular demands. Other forms of exercise can be
performed after an exercise test with no ST-segment
changes or sustained arrhythmias.
Patients with severe AS should be advised to limit their
activity to relatively low levels.

Prevention : Prophylaxis against infective

endocarditis and recurrent rheumatic fever, if
applicable, is indicated.

Aortic Regurgitation

DEFINITION

Aortic regurgitation (AR) is the abnormal

retrograde flow of blood through the
aortic valve during cardiac diastole.

EPIDEMIOLOGY

Stenosis Aorta is the most common Valvular Heart

Disease. 43.1% was found among 1197 patients.
Mitral Regurgitation 31.5% among 877 patients
Aortic Regurgitation 13.3% among 369 patients
Mitral Stenosis 12.1% among 336 patients

From the study of Framingham, 4.9% case of Aortic

Regurgitation . 13% on male and 8.5% on female.
Aortic Regurgitation worsen with age, especially with
Marfan syndrome.

ETIOLOGY
Ddilatiation of aortic root:
1.Aortic aneurysm (e.g Marfan Syndrome)
2.Annuloaortic ectasia
3.Aorta dissection
4.Syphilis
Abnotmalities of valve leaflets:
1.Rheumatic Heart Disease
2.Endocarditis
3.Aorta artificial congenital
4.Ventricular Septal Defect (VSD)
5.Aortic left ventricular tunnel
6.Rupture (trauma)

PATOPHYSIOLOGY

Symptoms
Acute aortic regurgitation
sudden severe shortness of breath

rapidly developing heart failure

chest pain

Symptoms
Chronic Aortic
Regurgitation

Palpitations, often described as the sensation of

having forceful heart beats, due to widened
pulse pressure with hyperdynamic circulation

Shortness of breath, which may not worsen with

exertion in the early stages due to
compensatory tachycardia with shortened
diastole

Chest pain, if LV end-diastolic pressure

compromises coronary perfusion pressure
gradients

Physical Findings

de Musset sign head bobbing with heartbeat

Corrigan pulse water hammer pulse
Bisferiens pulse brach/ fem arteries
Hill sign popliteal > brachial by 60mmHg
Traube sign pistol shot sounds over fem artery
Duroziez sign sys m when femoral artery compressed
proximally and diastolic m when compressed distally

Quincke sign capillary pulsations

Apical impulse - diffuse, hyperdynamic and displaced

inf/lat

systolic thrill

base/suprasternal notch / carotid arteries

Physical Findings

Diastolic murmur

Austin Flint murmur

high frequency, sitting up, leaning forward

duration > intensity correlates with severity
mild AR early diastole, hi pitched blowing
severe AR holodiastolic, rough
musical (cooing dove) eversion/perforation of Ao
cusp
Primary valve dz heard best LSB 3-4 intercostal
Ao Root dz heard best RSB

mid-late diastolic apical rumble severe AR

Wide Pulse Pressure

Systolic flow murmur (/thrill)

INVESTIGATION
*ECG :-

LVH + T inversion
*Chest XR :- Cadiac dilatation
Aortic dilatation
Pulmonary congestion
*ECHO : Dilated LV
Hyperdynamic LV
Fluttering AML
Doppler detects reflux
*Cardiac Catheterization :Dilated LV
AR
Dilated aortic root

Medical Management

Vasodilators (Nifedipine, Hydralizine, ACEI, Nipride)

goal is to reduce SBP, improve forward SV, reduce
regurgitant volume

Diuretics for pulmonary congestion

Prophylaxis against Infective Endocarditis

Criteria for Aortic Valve

Replacement in Chronic Aortic
Regurgitation
Symptoms

Congestive heart failure.

Declining exercise tolerance on exercise

testing.

Angina

Anatomy, regardless of symptoms:

Left ventricular dysfunction: EF <50%

Progressive left ventricular dilation or decline

in
EF on serial studies

Severe dilation (echo):

- Left ventricular diastolic dimension >75 mm
- Left ventricular systolic dimension >55 mm
-Aortic root dimension >50 mm

PROGNOSIS

Patient with EF 45% pre-operative survive

longer post operation than EF<45% and
heart index <2.5 liter/minute/m2

Patient with regurgitation and pulmonary

edema has a bad prognosis, need to
undergone surgery

THANK YOU