Professional Documents
Culture Documents
disease
VALVULAR STENOSIS
Pressure in upstream chamber IS HIGHER
than Pressure in downstream chamber
during time of flow (when valve is normally
open).
Hemodynamic abnormality = "PRESSURE
GRADIENT"
Upstream
Down stream
High pressure
low pressure
VALVULAR
REGURGITATION
Retrograde flow of blood "upstream" during time when
valve
is normally closed.
Hemodynamic
abnormality = "VOLUME OVERLOAD"
Upstream
Volume overload
Down stream
Aortic stenosis
The AV is located betwn the LVOT and the ascending aorta. It forms the cente
heart and closely approximates many other important cardiac structures; sp
PV anteriorly, MV posterolaterally, and TV posteromedially. [1]
Ref:
1. Anderson RH. Clinical anatomy of the aortic root. Heart. Dec 2000;84(6):670-3.
Picture ref: Anderson RH. Clinical anatomy of the aortic root. Heart. Dec 2000;84(6):670-3.
Picture reference: Anderson RH. Clinical anatomy of the aortic root. Heart. Dec 2000;84(6):670-3.
Pathophysiologic Variants
Ref:
1. Tzemos N, Therrien J, Yip J et al (September 2008)."Outcomes in adults with bicuspid aortic valves".JAMA300(1
Aortic Regurgitation:
overview
AR is a condition due to inadequate closure of
the aortic valve leaflets leading to abnormal
retrograde flow of blood through the aortic valve
during cardiac diastole.
It can be induced either by damage to and
dysfunction of the aortic valve leaflets or by
distortion or dilatation of the aortic root and
ascending aorta
In the developing world, the most common cause of
AR is rheumatic heart disease. However, in
developed countries, AR is most often due to aortic
root dilation or a congenital bicuspid aortic
valve .[1]
Ref:
1. Maurer G. Aortic regurgitation. Heart. Jul 2006;92(7):994-1000.
Causes of Aortic
Regurgitation Aortic root or ascending aorta
Leaflet abnormalities
Rheumatic fever
Systemic hypertension
Endocarditis
Trauma
Reactive arthritis
Ankylosing spondylitis
Rheumatoid arthritis
Myxomatous degeneration
Osteogenesis imperfecta
Ankylosing spondylitis
Acromegaly
Ref:
1. Singh JP, Evans JC, et al. Prevalence and clinical determinants of mitral, tricuspid, and AR (the Framingham Heart Study). Am J Cardiol. M
2. Keane MG, Pyeritz RE. Medical management of Marfan syndrome. Circulation. May 27 2008;117(21):2802-13.
3. Ortiz JT, Shin DD, Rajamannan NM. Approach to the patient with bicuspid AVand ascending aorta aneurysm. Curr Treat Options Cardiova
Pathophysiology
Law of laplace
LV Volume
LV Hypertrophy
Pathophysiology : Acute AR
Sudden large regurgitant volume
imposed on LV of normal size with
normal compliance
Angina
Coronary perfusion
demand myocardial O2
Pathophysiology: Chronic
AR
Regurgitant Volume Load
Compensatory Mechanisms:
1.LV dilatation LVED vol and chamber
compliance
2. LV hypertrophy
Decompensation
Steadily increasing regurgitant volume load
Further ventricular dilatation wall
stress
Inability to continue further hypertrophy
Contractile dysfunction EF/SV/CO
CHF symptoms
Due to both congestion and
CO
Angina
Coronary perfusion pressure &
marked LVH
deMusset's
sign
Quincke's
pulses
Duroziez's
sign
Traube's sign
Mayne's sign
Hill's sign
Rosenbach's
Ref:
1. Choudhry NK, Etchells EE. The rational clinical examination. Does this patient have aortic regurgitation? JAMA 1
Laboratory Studies
Laboratory testing in patients with aortic
regurgitation should be guided by the
clinical scenario.
For example, in patients with AR due to
suspected
infective
endocarditis,
peripheral blood counts and cultures
may help clarify the diagnosis and
identify the causative organism.
Specific serologic tests may assist in
the diagnosis of rheumatological causes.
MOD
SEVERE
Structural parameters
Left ventricular size
N or dilated
Aortic leaflets
N or abnormal
N or abnormal
Abnormal/flail, or wide
coaptation defect
Doppler vena
contracta width
<3 mm
3 to 6 mm
>6 mm
Doppler parameters
Quantitative parameters
Regurgitant volume
<30 mL/beat
30 to 59 mL/beat
60 mL/beat
Regurgitant fraction
<30 percent
30 to 49 percent
50 percent
Regurgitant orifice
area
<0.10 cm2
0.30 cm2
Echo staging of
Decompensation.[1,2,3,4,5,6,7,8]
References:
1. ACC/AHA 2006 guidelines
2. Gaasch WH, Andrias CW, Levine HJ. Chronic aortic regurgitation: the effect of aortic valve replacement on left ventricular volume, mass and function. C
3. Schuler G, Peterson KL, Johnson AD, et al. Serial noninvasive assessment of left ventricular hypertrophy and function after surgical correction of AR. Am
4. Borow KM, Green LH, Mann T, et al. End-systolic volume as a predictor of postoperative LVperformance in volume overload from valvular regurgitation.
5. Henry WL, Bonow RO, et al. Observations on the optimum time for operative intervention for AR. Evaluation of the results of AVR in symptomatic patien
6. Kumpuris AG, Quinones MA, Waggoner AD, et al. Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic
of left ventricular dilatation after valve replacement in chronic aortic insufficiency. Am J Cardiol 1982; 49:1091.
7. Gaasch WH, Carroll JD, Criscitiello MG. Chronic AR: prognostic value of left ventricular end-systolic dimension and end-diastolic radius/thickness ratio. J
8. Stone PH, Clark RD, Goldschlager N, et al. Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement. J Am C
9. Bonow RO, Rosing DR, McIntosh CL, et al. The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function. Ci
10. Bonow RO, Lakatos E. Serial long-term assessment of the natural history of asymptomatic patients with chronic AR and normal left ventricular systolic
11. Siemienczuk D, Greenberg B, Morris C, et al. Chronic aortic insufficiency: factors associated with progression to aortic valve replacement. Ann Intern M
Ref:
1. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update
incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease.
.
Ref:
1.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update
incorporated into the ACC/AHA 2006 guidelines for the management of patients with VHD.
Medical care
In acute severe AR, surgical intervention is
usually indicated, but the patient may be
supported medically with dobutamine to
augment cardiac output and shorten diastole
and sodium nitroprusside to reduce afterload
in hypertensive patients.
In chronic severe AR, vasodilator therapy may
be used in select conditions to reduce afterload
in patients with systolic hypertension to
minimize wall stress and optimize LV function; in
normotensive patients, vasodilator therapy is not
likely to reduce regurgitant volume (preload)
significantly and thus may not be of clinical
benefit.[1]
Ref:
1. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. Jul 5 2005;112(1):125-34.
References:
1. Scognamiglio R, Fasoli G. Long-term nifedipine unloading therapy in asymptomatic patients with chronic severe AR. J Am Coll Cardiol 19
2. Greenberg B, Massie B, et al. Long-term vasodilator therapy of chronic AI: a randomized double-blinded, placebo-controlled clinical trial
3. Lin M, Chiang HT,etal.Vasodilator therapy in chronic asymptomatic AR: enalapril versus hydralazine therapy. J Am Coll Cardiol 1994;24:1
4. Schon HR, Dorn R. Effects of 12 months quinapril therapy in asymptomatic patients with chronic AR. J Heart Valve Dis 1994;3:5009.
1.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update incorporated int
guidelines for the management of patients with valvular heart disease.
Prophylaxis for IE
Antibiotic prophylaxis prior to dental
procedures is no longer routinely
recommended for all patients with AR
under current ACC/AHA guidelines.[1]
Ref:
1. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update incorporated in
2006 guidelines for the management of patients with valvular heart disease
Surgical care
Surgical treatment of AR usually requires
replacement of the diseased valve
with a prosthetic valve, although
valve-sparing
repair
is
increasingly
possible with advances in surgical
technique and technology.
Ref:
1.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update incorporated in
2006 guidelines for the management of patients with valvular heart disease.
Mechanical Vs
bioprosthetic AV
For patients undergoing AV replacement,
careful consideration should be given to the
relative risks and benefits of mechanical
vs bioprosthetic valves.
Mechanical valves : more durable but require
long-term anticoagulation with warfarin due to
increased risk of thrombosis.
Bioprosthetic valves carry a greater risk of
long-term deterioration and risk of reoperation
but avoid the need for long-term warfarin.
[1]
Ref:
1. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update incorporated in
2006 guidelines for the management of patients with valvular heart disease.
.
EDD
Stable Dimension
Incresing
Dimension
<45 mm
< 60 mm
Evaluate 6-12 mn
Repeat Echo in 12
mnth
3mnth
3 mnth
45-50
mm
60-70 mm
Evaluate 6 mn
Repeat Echo in 12
mnth
3 mnth
3 mnth
50-55
mm
70-75 mm
Evaluate in 6 mn
Repeat Echo 6 mnth
3 mnth
3 mnth
>55 mm
> 75 mm
Surgery
Complications
Left untreated, acute severe AR is likely
to lead to considerable morbidity and
mortality from either the underlying
cause (typically infective endocarditis or
aortic dissection) or from hemodynamic
decompensation of the LV.
Potential complications in patients with
chronic severe AR include progressive LV
dysfunction and dilation, CHF, MI,
arrhythmia, and sudden death.
Prognosis
The prognosis for patients with severe AR depends on the
presence or absence of LV dysfunction and symptoms, as
follows:[1]
In asymptomatic patients with normal EF
1.Rate of progression to symptoms &/or LVD = < 6% per
yr
2.Rate of progression to asymptomatic LVD = < 3.5% per
yr
3.Rate of sudden death = less than 0.2% per yr
In asymptomatic patients with decreased EF, rate of
progression to symptoms = >25% per year.
In symptomatic patients, mortality rate = >10% per yr.
The
strongest
predictors
of
outcome
are
echocardiographic
parameters (EF and LV end-systolic dimension).
Ref:
1.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 2008 focused update
incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart
disease.
Mitral Valve
Diseases
Mitral stenosis
Uptodate 20.3
Mitral stenosis
MS is characterized by obstruction to
left ventricular inflow at the level of
MV due to structural abnormality of the
MV apparatus.1
MS
is
due
to
thickening
and
immobility of the mitral valve
leaflets.
The normal MVO has a CSA of 4-6 cm2.
Carabello, B. A. (2005). "Modern Management of Mitral Stenosis".Circulation112(3):
4327
Etiology
Rheumatic heart disease
Congenital MS
Mitral annular calcification (particularly in
patients with ESRD).
Conditions that simulate MS: IE with large
vegetation,
LA
myxoma,
ball
valve
thrombus, and cor triatriatum.
Less
common
causes:
malignant
carcinoid
disease,
SLE,
RA,
mucopolysaccharidoses,
Fabry
disease,
Whipple disease, and methysergide therapy.
Pathophysiology
LAE
Atrial Fibrillation
Thromboemboli
sm
Stroke
Ventricular filling
Palpitation
Pulmonary Hypertension
Backward transmission of the elevated left atrial pressure
Loud P2, later
becomes
palpable
JVD
Parasternal
heave
Prominent a
wave
TR
Prominent v wave
Hepatomegaly
& Pulsatile liver
Peripheral
edema
RV hypertrophy &
enlargement
Tricuspid regurgitation
Pathophysiology: MS
LAP
LA remodelling
MVA
LAP, LAE
AFib
LA clot
Pul
congestion
PVR ,PHTN
Exertional
Dyspnea /Pul
edema
RV pressure overload
RVH
CO (first
with exercise
then at rest)
History
Generally asymptomatic at rest during the early stage.
However, factors that HR such as fever, severe
anemia, thyrotoxicosis, exercise, and Afib dyspnea.
Systemic embolization may lead to stroke, renal
failure, orMI.
Hoarseness :compression of the LRLN against the
pulmonary artery by the enlarged LA. Also, compression
of bronchi by the enlarged LA can cause persistent
cough. Cough also occurs due to pul congestion
Hemoptysis may occur.
Palpitation
Chest pain (due to pul hypertension)
Oedema / Ascites (Right heart failure)
Pregnant women with mild MS may become
symptomatic during their 2nd trim (in blood vol ).
Physical examination
Presence of mitral facies (pinkish-purple
patches on the cheeks) indicate chronic
severe
MS
(reduced
CO
&
vasoconstriction).
JVD may be seen.
In
pt
with
sinus
rhythm,
a
prominentawave : RA pressure from
pul HTN & RVfailure.
A prominentvwave :is seen with TR.
Palpation
The arterial pulses are reduced in volume
due to the decreased SV.
Pulses may be irregular in Afib.
Tapping apex beat that is not displaced.
Left parasternal heave - presence of RVH
due to pulmonary HTN
A P2 may be palpable in the 2LICS.
Parasternal Heave
Grade 1 : visible but not palpable
Grade 2 : Visible & palpable and
obliterable
Grade 3: Visible & palpable but not
obliterable
Cardiac auscultation:
Heart sounds
The S1 is accentuated because of a wide
closing excursion of the mitral leaflets.
The degree of loudness of the S1 depends
on the pliability of the MV.
The intensity of the S1 as the valve
becomes more fibrotic, calcified, and
thickened.
The S2 is initially normal but, with the
development of PHTN, P2 becomes in
intensity .
Cardiac auscultation:
Opening snap
An OS of the MV is heard at the apex when
the leaflets are still mobile .
The OS is due to the abrupt halt in
leaflet motion in early diastole.
Note: The OS following S2 may be mistaken for
a split S2 (OS is best appreciated at the apex,
not the base. )
Cardiac auscultation:
murmur
low-pitched diastolic rumble that is most
prominent at the apex.
Although the intensity of the diastolic murmur
does not correlate with the severity of the
stenosis, the duration of the murmur is helpful
since it reflects the transvalvular gradient and
the duration of blood flow across the valve.
The in atrial pressure after atrial contraction,
results in an increase in the loudness of the
murmur, termed "presystolic accentuation"
.
MS:
The diastolic murmur and OS are diminished with
inspiration, but augmented with expiration (in
contrast to TS). With inspiration, the A2-OS interval
widens .
Increasing venous return, eg, by lying the patient
down and lifting the legs, augments the gradient; as
a result, the diastolic murmur lengthens while
the A2-OS intervals shorten. (Similar changes
are seen in response to exercise.)
In contrast, reducing venous return with amyl
nitrate, the Valsalva maneuver, or standing after
squatting shortens the murmur and lengthens the
A2-OS interval.
MS: murmur
On auscultation of mitral area of the heart, s1 is
short ,sharp and accentuated and s2 is normal.
Opening snap is heard just after s2.
There is low pitched, mid diastolic, rumbling
murmur with presystolic accentuation of Grade
4 intensity in the mitral area without any
radiation.
The murmur is best heard at cardiac apex with
bell of steths ,in left lateral position ,at the
height of expiration and after doing mild
exercise.
MDM: D/D
It is not Carey coombs murmur (occurs in active
rheumatic vulvulitis and oedema of MV cusps gives rise to
soft MDM) because there is absence of loud s1, OS and
diastolic thrill.
It is not Austin flint murmur (which is a functional low
pitch mid diastolic murmur in pt with AI in which murmur is
produced as the regurgitant jet flow hits the anterior mitral
leaflets) because in AFM, the presystolic component is
absent, there is no thrill, and S1 is not loud. And there is no
OS. Moreover in AFM of AI ,there are features of LVH and
peripheral signs of AI which is not present in this case.
It is not MDM of TS ,because the murmur of TS would be
best heard in LSB and increases at the height of
inspiration.
CXR
CXR
Backward displacement of esophagus by
enlarged LA(in lat view)
Enlarged LA , Double shadow due to enlarged LA
Straightening of left heart border
Splaying of carina (The left main bronchus is
lifted up by the enlarged LA)
Prominent upper zone pulmonary veins (Inverted
moustache sign / Antlers horn sign /
Cephalisation pulmonary of blood flow)
Kerley B lines (indicating fluid collection in the
interlobular septa)
Management
Patients with minor symptoms should be treated
medically.
Intervention by balloon valvuloplasty, mitral
valvotomy or MVR should be considered if the
patient remains symptomatic despite medical Rx
or if PHTN develops.
Anticoagulation :to reduce the risk of systemic
embolism,
Ventricular rate control (digoxin, -blockers CCB)
in AFib
Diuretic therapy to control pulmonary congestion.
Antibiotic
prophylaxis
against
infective
endocarditis is no longer routinely recommended.
Etiology
Congenital (rare)
Acquired
1. Rheumatic (most common)
- Most common valve lesion after RF
- Stenosis occurs due to fibrosis/calcification of:
a. Commissures
b. Cusps
c. Chords
d. Combination
2. CTD (SLE, RA)
3. Obstructive masses ( Atrial Myxoma, large
vegetation)
RA
RV
RV Pressure
Overload
RVH
RV Failure
Pulmonary HTN
Pulmonary
Congestion
LA Enlargement
Atrial Fib
LA Thrombi
LA Pressure
LA
LV
LV Filling
Mitral Regurgitation
Overview
Anatomy: MV Annulus
The mitral annulus is a fibrous ring
that connects with the leaflets.
The annulus functions as a
sphincter that contracts and
reduces the surface area of the
valve during systole to ensure
complete closure of the leaflets.
Annulus contraction during systole
promotes valve competence
Thus, annular dilatation of the
mitral valve causes poor leaflet
apposition, which results in mitral
regurgitation.
Annulus may dilate in ischemic or
dilated cardiomyopathy.
1. Figure2: http://emedicine.medscape.com
Inflammatory,
degenerative,
or
infectious diseases can result in
Picture source: http://emedicine.medscape.com
perforation
poorin the
coaptation
of with
leaflets
Harken DE, Ellis LB, Dexter L, Farrand RE, Dickson JF. The
responsibility of theor
physician
selection of patients
mitral stenosis
1.
2.
Circulation. Mar 1952;5(3):349-62.
1.
Anatomy: Chordae
tendineae These are
small
fibrous
strings that originate either
from the apical portion of the
papillary muscles or directly
from the ventricular wall and
insert into the valve leaflets
or the muscle.
Chordal
rupture
or
foreshortening
prevents
leaflet coaptation
Anatomy: Papillary
muscles
These 2 structures
represent the
muscular components of the mitral
and left ventricular
wall
apparatus.
Mitral regurgitation:
etiology
Acute
Chronic Primary MR
Endocarditis
Papillary muscle rupture (postMI) Trauma
Chordal rupture/leaflet flail
(MVP, IE)
Myxomatous (MVP)
Rheumatic fever
Endocarditis (healed)
Mitral annular calcification
Congenital (cleft, AV canal)
\HOCM with SAM
Radiation
Chronic secondary MR
Ischemic (LV remodeling)
Dilated cardiomyopathy
Laplace Law
The
hemodynamic
changes in acute MR
are more severe than
those in chronic MR due
in part to the lack of
time for the left atrium
and left ventricle to
adapt to the MR.
This is in contrast to
chronic MR where these
adaptations have time
to develop and typically
preserve hemodynamic
stability.
Chronic MR:
Pathophysiology
Vol load imposed on LA & LV (usually it gradually
over time)
LVEDP &
LAP
Chronic MR:
Pathophysiology..
continue
Contractile
dysfunction
EF, end-systolic
volume
LVEDP/ vol,
LAP
Pathophysiology: AMR
Flail leaflet
Chordae tendineae
rupture
Papillary muscle
rupture
MR
Abnormal reversal of
blood flow from :LV
LA.
LA volume /LAP
Pulmonary congestion
Forward SV
CO
Compensatory HR
Neurohumoral
Response :
Vascular resistance
Shock
Neurohumoral Responses
Activation
Activation
Low output
of
of
state
RAAS Contribute to maintenance of perfusion of
SNS
vital organs:
1.Maintenance of systemic pressure by
vasoconstriction, resulting in redistribution of
blood flow to vital organs
2.Restoration of CO by
myocardial
contractility and HR and by expansion of the
ECF volume
Catecholamine-stimulated contractility and HR.
Volume expansion venous return EDV SV(via FSM)
Neurohumoral Maladaptive
Responses
Activation of
RAAS
Activation of
SNS
Eccentric vs concentric
hypertrophy
Functional mitral
regurgitation
In patients with functional or secondary mitral regurgitation
(MR), the papillary muscles, chordae, and valve leaflets are
normal.
There are two major causes of this problem:
1.ischemia
2.any cause of dilated left ventricle.
In these settings, MR may result from one or both of the
following [1]:
Annular enlargement secondary to left ventricular dilatation
Papillary muscle displacement due to left ventricular
remodeling, which results in tethering and excess tenting of
the leaflet .2
1.Trichon BH, O'Connor CM. Secondary mitral and tricuspid regurgitation accompanying left ventricular systolic
dysfunction: is it important, and how is it treated? Am Heart J 2002; 144:373.
2.Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in
patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation 2000; 102:1400.
PREVALENCE of FMR
Some degree of functional MR is almost always
present
in
patients
with
severe
dilated
cardiomyopathy, regardless of etiology [1,2,3].
A review of 50 patients with DCM(36 idiopathic, 14
ischemic) referred for heart transplantation found that
all patients had at least moderate MR by Doppler echo
[2].
Functional MR is also a common problem in patients
with ESRD on maintenance HD. In this setting, volume
expansion rather than intrinsic cardiac disease is
primarily responsible for the cardiac enlargement.
1. Trichon BH, O'Connor CM. Secondary mitral and tricuspid regurgitation accompanying left ventricular
systolic dysfunction: is it important, and how is it treated? Am Heart J 2002; 144:373.
2. Strauss RH, Stevenson LW, Dadourian BA, Child JS. Predictability of mitral regurgitation detected by
Doppler echocardiography in patients referred for cardiac transplantation. Am J Cardiol 1987;
59:892.
3. Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid
regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
Ischemic mitral
regurgitation
Ischemic MR is a complication of coronary
heart disease.
It primarily occurs in patients with a prior
myocardial infarction (MI).
MR may also occur with acute ischemia, a
setting in which the MR typically resolves
after the ischemia resolves.
Following an MI, the MR is usually due to
infarction with permanent damage to the
papillary muscle or adjacent myocardium.
IMR:classified by the
mechanism of the valve
1.
IMR secondary to papillary muscle rupture is a
dysfunction
Auscultation
S1 is generally absent, soft, or buried in the
holosystolic murmur of chronic MR.
In patients with severe MR, the AV may close
prematurely, resulting in wide but physiologic
splitting of S2.
A low-pitched S3 occurring 0.120.17 s after the
AV closure sound, i.e., at the completion of the
rapid-filling phase of the LV, : DUE TO sudden
tensing of the papillary muscles, chordae
tendineae, and valve leaflets. It may be
followed by a short, rumbling, mid-diastolic
murmur, even in the absence of structural MS.
S4 is often audible in ps with acute severe MR
who are in sinus rhythm.
Auscultation
Chronic severe MR: A systolic murmur
of at least grade III/VI intensity and is
usually holosystolic.
The systolic murmur of chronic MR is
usually most prominent at the apex and
radiates to the axilla.
Acute severe MR: is decrescendo and
ceases in mid- to late systole .
Auscultation
Ruptured chordae tendineae or primary involvement
of the posterior mitral leaflet with prolapse or flail
: regurgitant jet is eccentric, directed anteriorly, and
strikes the LA wall the systolic murmur is
transmitted to the base of the heart (therefore,
may be confused with the murmur of AS).
ruptured chordae tendineae, the systolic
murmur may have a cooing or "sea gull" quality.
A flail leaflet: murmur with a musical quality.
The systolic murmur of chronic MR not due to MVP is
intensified by isometric exercise (handgrip:LVV) but
is reduced during the strain phase of the Valsalva
maneuver because of the associated decrease in
LV preload.
Acute vs Chronic MR
TRICUSPID VALVE
DISEASE
Tricuspid Stenosis
Etiologi
Commonly of a multivalvular process
Rheumatic heart disease >90% cases
Carcinoid heart disease
Pathophysiology TS
TS mean diastolic pressure
gradient right atrial
pressure(RAP)systemic venous
congestion
Prominent a wave
Clinical Presentation
Fatigue
Systemic congestion signs and symptoms
Fluttering discomfort neckbecause
giant a waves
Giant a wave
Diastolic murmur(low pitched) rivero
carvallo sign
Opening snap
Diagnostic testing
ECG: RAE, or biatrial enlargement if MS
Echo:most useful, reduction TV orifice
diameter and thickening and diastolic
doming of TV leaflets
Cath: confirmation RAP and tall a
wave
Therapy
Sodium restriction and diuretics
Ballon valvuloplasty and TV replacement
Tricuspid Regurgitation
(TR)
Primary TRanatomically abnormal valve
: congenital Ebstein anomaly, AV canal
defect and VSD
Secondary TR functional abnormality:
leaflet tethering, annular dilatation,
pulmonary hipertention etc
Clinical Presentation
Fatigue
Systemic congestion signs and symptoms
Neck pulsations because prominent cv
waves
Diagnostic Testing
ECG: nonspecific,incomplete RBBB, af
Echo: right ventricular volume overload
pattern , RV enlargement, RAE
Cath: dominant v wave
Therapy
Diuretics and afterload reduction if RV
failure develops
Valve repair or replacement
TERIMAKASIH
MOHON BIMBINGAN