Valvular Heart DiseaseValvular Heart Disease

Kenneth S. Korr M.D.Kenneth S. Korr M.D.Associate Professor of Medicine,Associate Professor of Medicine,

Brown Medical SchoolBrown Medical SchoolDirector, Division of CardiologyDirector, Division of Cardiology

The Miriam HospitalThe Miriam Hospital

Normal Valve FunctionNormal Valve Function

Maintain forward Maintain forward flow and prevent flow and prevent reversal of flow.reversal of flow.

Valves open and Valves open and close in response to close in response to pressure differences pressure differences (gradients) between (gradients) between cardiac chambers.cardiac chambers.

Abnormal Valve FunctionAbnormal Valve Function Valve StenosisValve Stenosis

Obstruction to valve flow during that phase of the cardiac Obstruction to valve flow during that phase of the cardiac cycle when the valve is normally open.cycle when the valve is normally open.

Hemodynamic hallmark -“pressure gradient” ~ flow// VAHemodynamic hallmark -“pressure gradient” ~ flow// VA Valve Regurgitation, Insufficiency, IncompetenceValve Regurgitation, Insufficiency, Incompetence

Inadequate valve closure---Inadequate valve closure--- back leakage back leakage A single valve can be both stenotic and regurgitant; A single valve can be both stenotic and regurgitant;

but both lesions cannot be severe!!but both lesions cannot be severe!! Combinations of valve lesions can coexistCombinations of valve lesions can coexist

Single disease processSingle disease process Different disease processesDifferent disease processes One valve lesion may cause another One valve lesion may cause another Certain combinations are particularly burdensome (AS & MR)Certain combinations are particularly burdensome (AS & MR)

Mitral Valve Competence:Mitral Valve Competence:

Integrated function Integrated function of several anatomic of several anatomic elementselements Posterior LA wallPosterior LA wall Anterior & Posterior Anterior & Posterior

valve leafletsvalve leaflets Chordae tendineaeChordae tendineae Papillary musclesPapillary muscles Left ventricular wall Left ventricular wall

where the papillary where the papillary muscles attachmuscles attach

Mitral Valve Disease: Mitral Valve Disease: EtiologyEtiology

Mitral StenosisMitral Stenosis Rheumatic - 99.9%!!!Rheumatic - 99.9%!!! CongenitalCongenital Prosthetic valve stenosisProsthetic valve stenosis Mitral Annular Mitral Annular

CalcificationCalcification Left Atrial MyxomaLeft Atrial Myxoma

Acute Mitral RegurgitationAcute Mitral Regurgitation Infective endocarditisInfective endocarditis Ischemic Heart diseaseIschemic Heart disease

Papillary ms rupturePapillary ms rupture Mitral valve prolapseMitral valve prolapse

Chordal ruptureChordal rupture Chest traumaChest trauma

Chronic Mitral Chronic Mitral RegurgitationRegurgitation Ischemic Heart diseaseIschemic Heart disease

Papillary ms dysfunctionPapillary ms dysfunction Inferior & posterior MIInferior & posterior MI

Mitral Valve prolapseMitral Valve prolapse Infective endocarditisInfective endocarditis RheumaticRheumatic ProstheticProsthetic Mitral annular calcificationMitral annular calcification CardiomyopathyCardiomyopathy

LV dilatationLV dilatation IHSSIHSS

Mitral Regurgitation-Mitral Regurgitation-PathophysiologyPathophysiology

MR: Leakage of blood MR: Leakage of blood into LA during systoleinto LA during systole

1100 Abnormality -Loss Abnormality -Loss of forward SV into LAof forward SV into LA

Compensatory Compensatory MechanismsMechanisms Increase in SV (& EF)Increase in SV (& EF) Forward SV + Forward SV +

regurgitant volumeregurgitant volume LV (LA) dilatationLV (LA) dilatation Left Ventricular Volume Left Ventricular Volume

Overload (LVVO)Overload (LVVO)

Chronic Mitral Regurgitation - Chronic Mitral Regurgitation - LVVOLVVO

LVVOLVVO LV dilatationLV dilatation Eccentric hypertrophyEccentric hypertrophy

Increased LA Increased LA pressurepressure

Pulmonary HTNPulmonary HTN DyspneaDyspnea Atrial arrhythmiasAtrial arrhythmias Low output stateLow output state

Pathophysiology –Acute vs Pathophysiology –Acute vs Chronic Mitral RegurgitationChronic Mitral Regurgitation

Acute MRAcute MR Normal (noncompliant) LANormal (noncompliant) LA Increase LA pressureIncrease LA pressure large “V” waveslarge “V” waves Acute Pulmonary EdemaAcute Pulmonary Edema

Chronic MRChronic MR Dilated, compliant LADilated, compliant LA LA pressure normal or LA pressure normal or

slightly increasedslightly increased Fatigue, low output stateFatigue, low output state Atrial arrhythmias- a. fib.Atrial arrhythmias- a. fib.

Most patients fall Most patients fall between these two between these two extremes!!extremes!!

Mitral Regurgitation: Mitral Regurgitation: Physical FindingsPhysical Findings

Auscultatory FindingsAuscultatory Findings SS11 – soft or normal – soft or normal PP22 – increased – increased Holosystolic blowing murmur @ apexHolosystolic blowing murmur @ apex

MVP – mid-systolic clickMVP – mid-systolic click IHSS – murmur increases with ValsalvaIHSS – murmur increases with Valsalva Acute MR – descrescendo systolic murmurAcute MR – descrescendo systolic murmur

SS33 gallop & diastolic flow rumble gallop & diastolic flow rumble Hyperdynamic Left VentricleHyperdynamic Left Ventricle

Brisk carotid upstrokesBrisk carotid upstrokes Hyperdynamic LV apical impulseHyperdynamic LV apical impulse LA lift; RV tapLA lift; RV tap

Mitral Stenosis -Mitral Stenosis -PathophysiologyPathophysiology

Restriction of blood flow Restriction of blood flow from LAfrom LALV during LV during diastole.diastole.

Normal MVA 4-6cmNormal MVA 4-6cm2.2.

Mild MS 2-4cmMild MS 2-4cm2.2.

Severe MS < 1.0cmSevere MS < 1.0cm2.2.

MV Pressure gradient –MV Pressure gradient – MV grad ~ MV flow//MVA.MV grad ~ MV flow//MVA.

Flow = CO/DFP (diastolic Flow = CO/DFP (diastolic filling period).filling period).

As HR increases, diastole As HR increases, diastole shortens disproportionately shortens disproportionately and MV gradient increases.and MV gradient increases.

Relationship between MV Relationship between MV gradient and Flow for different gradient and Flow for different

Valve AreasValve Areas Cross hatched area indicates Cross hatched area indicates

range of normal resting range of normal resting flow.flow.

The vertical line represents The vertical line represents the threshold for developing the threshold for developing pulmonary edema.pulmonary edema.

Pressure gradient increases Pressure gradient increases as flow increases:as flow increases: to a small degree with to a small degree with

normal valve area(4-6cmnormal valve area(4-6cm22).). to greater degrees with to greater degrees with

smaller valve areas.smaller valve areas. in severe stenosis, a in severe stenosis, a

significant gradient is significant gradient is present at rest.present at rest.

Mitral Stenosis-Mitral Stenosis-PathophysiologyPathophysiology

MV gradientMV gradient Incr LA pr Incr LA pr Pulmonary HTNPulmonary HTN

PassivePassive Reactive- 2Reactive- 2ndnd stenosis stenosis

RV Pressure OverloadRV Pressure Overload RVHRVH RV failureRV failure Tricuspid regurgitationTricuspid regurgitation Systemic CongestionSystemic Congestion

Paradoxes of MSParadoxes of MS Disease of Pulm Arts & RVDisease of Pulm Arts & RV LV unaffected (protected)LV unaffected (protected) As RV fails, pulmonary As RV fails, pulmonary

symptoms diminishsymptoms diminish

Mitral Stenosis- Clinical SymptomsMitral Stenosis- Clinical Symptoms Symptoms related to Symptoms related to

severity of MVA reduction-severity of MVA reduction- Symptoms unrelated to Symptoms unrelated to

severity of MS-severity of MS- Atrial fibrillationAtrial fibrillation Systemic Systemic

thromboembolismthromboembolism Symptoms due to Pulmonary Symptoms due to Pulmonary

HTN and RV failure-HTN and RV failure- Fatigue, low output stateFatigue, low output state Peripheral edema and Peripheral edema and

hepato-splenomegalyhepato-splenomegaly Hoarseness –recurrent Hoarseness –recurrent

laryngeal nerve palsylaryngeal nerve palsy

Mitral Stenosis: Physical Mitral Stenosis: Physical FindingsFindings

Auscultatory findingsAuscultatory findings SS1 1 – variable intensity; increased early, progressively – variable intensity; increased early, progressively

decreasesdecreases OS –opening snap, variable intensityOS –opening snap, variable intensity AA22-OS interval – varies inversely with severity of MS; -OS interval – varies inversely with severity of MS;

shortens as MVA diminishesshortens as MVA diminishes Low-pitched diastolic rumble @ apexLow-pitched diastolic rumble @ apex

Duration of murmur correlates with severity of MSDuration of murmur correlates with severity of MS Pre-systolic accentuationPre-systolic accentuation

Increased PIncreased P22

Body habitus – thin, asthenic, femaleBody habitus – thin, asthenic, female Low BPLow BP LA lift & RV tapLA lift & RV tap

Mitral Valve Disease – Echo Mitral Valve Disease – Echo findingsfindings

Mitral StenosisMitral Stenosis Thickened, deformed MV Thickened, deformed MV

leafletsleaflets 2D MVA 2D MVA Doppler GradientDoppler Gradient Associated LAE, RVH, Associated LAE, RVH,

PHTN, TR,MR, LV functionPHTN, TR,MR, LV function Mitral RegurgitationMitral Regurgitation

Determine etiology – Determine etiology – leaflets, chordae, MVP, MIleaflets, chordae, MVP, MI

Doppler severity of MR jetDoppler severity of MR jet LV functionLV function

Mitral Valve Disease : Mitral Valve Disease : TreatmentTreatment

Mitral StenosisMitral Stenosis Medical Rx for Class I & IIMedical Rx for Class I & II

HR control – Dig & BBHR control – Dig & BB Anticoagulation Anticoagulation

Afib, >40yrs, LAE, MR, Afib, >40yrs, LAE, MR, prior embolic eventprior embolic event

Surgical Rx -Class III &IV Surgical Rx -Class III &IV Balloon Mitral Balloon Mitral

ValvuloplastyValvuloplasty Commissural fusionCommissural fusion pliable, noncalcified pliable, noncalcified

leafletsleaflets No MR of LA thrombusNo MR of LA thrombusMitral Valve SurgeryMitral Valve Surgery Open commissurotomyOpen commissurotomy MV replacementMV replacement

Chronic Mitral Chronic Mitral RegurgitationRegurgitation Medical Rx for mild to mod Medical Rx for mild to mod

MR with vasodilators, MR with vasodilators, diuretics, anticoagulationdiuretics, anticoagulation

Surgical Rx –ideally before Surgical Rx –ideally before LV systolic function LV systolic function declines.declines.

MV replacementMV replacement MV ring & CABGMV ring & CABG MR repair – associated MR repair – associated

with improved long-term with improved long-term LV funvtionLV funvtion

MVP, ruptured chords, MVP, ruptured chords, infective endocadritis, infective endocadritis, pap ms rupture.pap ms rupture.

Balloon Mitral Balloon Mitral CommissurotomyCommissurotomy

Aortic Valve Disease: EtiologyAortic Valve Disease: Etiology

Aortic StenosisAortic Stenosis Degenerative calcific Degenerative calcific

(senile)(senile) Congenital – Uni or Congenital – Uni or

bicuspidbicuspid RheumaticRheumatic ProstheticProsthetic

Acute Aortic InsufficiencyAcute Aortic Insufficiency Infective endocarditisInfective endocarditis Acute Aortic DissectionAcute Aortic Dissection

Marfan’s SyndromeMarfan’s Syndrome Chest traumaChest trauma

Chronic Aortic InsufficiencyChronic Aortic Insufficiency Aortic leaflet diseaseAortic leaflet disease

Infective endocarditisInfective endocarditis RheumaticRheumatic Bicuspid Aortic valveBicuspid Aortic valve Prolapse & congenital VSDProlapse & congenital VSD ProstheticProsthetic

Aortic root diseaseAortic root disease Aortic aneurysm/dissectionAortic aneurysm/dissection Marfan’s syndromeMarfan’s syndrome Connective tissue disordersConnective tissue disorders SyphilisSyphilis HTNHTN Annulo-aortic ectasiaAnnulo-aortic ectasia

Aortic Stenosis - Aortic Stenosis - PathophysiologyPathophysiology

Normal AVA 2.5-3.0cmNormal AVA 2.5-3.0cm22

Severe AS <1.0cmSevere AS <1.0cm22

Critical AS <0.7cmCritical AS <0.7cm22; ; <0.5cm<0.5cm22/m/m22

Hemodynamic Hallmark Hemodynamic Hallmark Systolic pressure gradientSystolic pressure gradient AV grad ~ AV flow//AVAAV grad ~ AV flow//AVA

AV flow = CO/SEP (systolic AV flow = CO/SEP (systolic ejection period)ejection period)

50-100mmHg gradients 50-100mmHg gradients are common in severe ASare common in severe AS

Relationship between AV Relationship between AV gradient and Flow for different gradient and Flow for different

Aortic valve areas.Aortic valve areas. Like Mitral Stenosis – Like Mitral Stenosis –

as flow increases so as flow increases so does the gradient.does the gradient.

Unlike Mitral Stenosis Unlike Mitral Stenosis –– Resting flows are higherResting flows are higher

smaller AV area smaller AV area shorter SEPshorter SEP

Larger gradientsLarger gradients Significant (>50mmHg) Significant (>50mmHg)

gradient can be present gradient can be present at rest in asymptomatic at rest in asymptomatic individuals.individuals.

Pathophysiology of Aortic Pathophysiology of Aortic Stenosis- LVPOStenosis- LVPO

Chronic LV Pressure Chronic LV Pressure OverloadOverload Concentric LVH Concentric LVH

““Stiff” noncompliant LVStiff” noncompliant LV Increased LVEDPIncreased LVEDP Increased LV massIncreased LV mass

Increased MVOIncreased MVO22

Well tolerated for decades Well tolerated for decades LV failsLV fails CHF CHF

Atrial fibrillationAtrial fibrillation Poorly toleratedPoorly tolerated

Loss of atrial “kick”Loss of atrial “kick” Rapid HRRapid HR Acute pulmonary edema Acute pulmonary edema

and hypotension.and hypotension.

Aortic Stenosis: Natural Aortic Stenosis: Natural History & Clinical SymptomsHistory & Clinical Symptoms

Asymptomatic for many Asymptomatic for many yearsyears

Symptoms develop when Symptoms develop when valve is critically narrowed valve is critically narrowed and LV function and LV function deterioratesdeteriorates Bicuspid AV 5Bicuspid AV 5thth - 6 - 6thth decade decade Senile AS 7Senile AS 7thth-8-8thth decades decades

Classic Symptom TriadClassic Symptom Triad Angina pectoris – 5 yearsAngina pectoris – 5 years CHF 1-2 yearsCHF 1-2 years Syncope 2-3 yearsSyncope 2-3 years Sudden Death Sudden Death

Natural History Studies-Natural History Studies- Pts grad 25mmHg –20% Pts grad 25mmHg –20%

chance of intervention in chance of intervention in 15 years15 years

Pts with asymptomatic Pts with asymptomatic severe AS require close severe AS require close f/uf/u

Gradient progressionGradient progression 6-10mmHg/yr6-10mmHg/yr

Risk FactorsRisk Factors Age > 70Age > 70 CAD, hyperlipidemiaCAD, hyperlipidemia Chronic renal failureChronic renal failure

Aortic Stenosis: Physical Aortic Stenosis: Physical FindingsFindings

Severity of Severity of ASAS

MildMild ModerateModerate SevereSevere

Carotid pulseCarotid pulse normalnormal Slow risingSlow rising Parvus et Parvus et TardusTardus

LV apical LV apical impulseimpulse

normalnormal heavingheaving Heaving & Heaving & sustainedsustained

AuscultatioAuscultationnSS44 gallop gallop - - +/-+/- ++++Systolic Systolic ejection ejection ClickClick

++ +/-+/- --

SEM, SEM, peakingpeaking

Early Early systolesystole

midsystolemidsystole mid-to-late mid-to-late systolesystole

SS22 normalnormal Normal or Normal or singlesingle

Single or Single or paradoxicalparadoxical

Aortic Insufficiency- Aortic Insufficiency- PathophysiologyPathophysiology

1100 abnormality – LVVO abnormality – LVVO Severity of LVVOSeverity of LVVO

Size of regurgitant orificeSize of regurgitant orifice Diastolic pressure gradient Diastolic pressure gradient

between Ao & LVbetween Ao & LV HR or duration of diastoleHR or duration of diastole

Compensatory MechanismsCompensatory Mechanisms LV dilatation & eccentric LV dilatation & eccentric

LVHLVH Increased LV diastolic Increased LV diastolic

compliancecompliance Peripheral vasodilationPeripheral vasodilation

LV Volume vs Pressure LV Volume vs Pressure OverloadOverload

FeatureFeature LVPO (AS)LVPO (AS) LVVO (MR,AI)LVVO (MR,AI)LV VolumeLV Volume normalnormal Dilated**Dilated**

Wall Wall thicknessthickness

Conc. LVHConc. LVH Normal to Normal to slightly slightly increasedincreased

LV LV compliancecompliance

““stiff” stiff” noncompliantnoncompliant

Increased Increased compliancecompliance

LV diastolic LV diastolic PrPr

increasedincreased Normal to Normal to slightly slightly increasedincreased

LV systolic PrLV systolic Pr Increased**Increased** Normal to Normal to slightly slightly increasedincreased

LVEFLVEF normalnormal increasedincreased

Acute vs Chronic AR Acute vs Chronic AR Pathophysiology and Clinical Pathophysiology and Clinical

PresentationPresentation Acute Aortic RegurgitationAcute Aortic Regurgitation

Sudden AoV incompetenceSudden AoV incompetence Noncompliant LVNoncompliant LV Acute Pulmonary EdemaAcute Pulmonary Edema Emergency AVREmergency AVR

Chronic Aortic Chronic Aortic RegurgitationRegurgitation Long asymptomatic phaseLong asymptomatic phase Progressive LV dilatationProgressive LV dilatation DOE, orthopnea, PNDDOE, orthopnea, PND Frequent PVC’sFrequent PVC’s

Chronic Aortic Regurgitation: Chronic Aortic Regurgitation: Physical FindingsPhysical Findings

Widened Pulse Pressure > 70mmHg (170/60)Widened Pulse Pressure > 70mmHg (170/60) Low diastolic pressure <60mmHgLow diastolic pressure <60mmHg Hyperdynamic LV – Hyperdynamic LV –

DeMusset’s signsDeMusset’s signs Corrigan’s pulseCorrigan’s pulse Quincke’s pulsations, Quincke’s pulsations, Durozier’s murmurDurozier’s murmur

Auscultation:Auscultation: Diminished ADiminished A22 Descrescendo diastolic blowing murmur @ LSBDescrescendo diastolic blowing murmur @ LSB Austin-Flint murmur – diastolic flow rumble @ apexAustin-Flint murmur – diastolic flow rumble @ apex

Due to interference with trans-mitral filling by impignement from aortic Due to interference with trans-mitral filling by impignement from aortic regurgitant jet.regurgitant jet.

DDx - mitral stenosis(increases intensity with amyl nitrite)DDx - mitral stenosis(increases intensity with amyl nitrite)

Aortic Valve Disease:Aortic Valve Disease:Diagnostic TestingDiagnostic Testing

Aortic StenosisAortic Stenosis EKG- NSR, LVH with EKG- NSR, LVH with

strain, strain, LAE,LADLAE,LAD CXRay – frequently normalCXRay – frequently normal 2D-ECHO2D-ECHO

Aortic cusps –thickened, Aortic cusps –thickened, calcified, decreased calcified, decreased mobilitymobility

Assessment of LVH & LV Assessment of LVH & LV systolic functionsystolic function

Concomitant MR, ARConcomitant MR, AR Doppler assesment of AoV Doppler assesment of AoV

gradientgradient Planimetry of AV areaPlanimetry of AV area

Aortic regurgitaitonAortic regurgitaiton EKG- LVH without strainEKG- LVH without strain CXRay-CXRay-

Chronic AI – “cor bovinum”Chronic AI – “cor bovinum” Acute AI – pulmonary Acute AI – pulmonary

edema with nl heart sizeedema with nl heart size 2D ECHO2D ECHO

Assess Ao valve and rootAssess Ao valve and root Assess LV Assess LV

function/dilatationfunction/dilatation LVES dimension>55mmLVES dimension>55mm

Doppler severity of Doppler severity of regurgitant jetregurgitant jet

Relationship between AV Relationship between AV gradient and Flow for different gradient and Flow for different

Aortic valve areas.Aortic valve areas. Like Mitral Stenosis – Like Mitral Stenosis –

as flow increases so as flow increases so does the gradient.does the gradient.

Unlike Mitral Stenosis Unlike Mitral Stenosis –– Resting flows are higherResting flows are higher

smaller AV area smaller AV area shorter SEPshorter SEP

Larger gradientsLarger gradients Significant (>50mmHg) Significant (>50mmHg)

gradient can be present gradient can be present at rest in asymptomatic at rest in asymptomatic individuals.individuals.

Balloon Aortic ValvuloplastyBalloon Aortic Valvuloplasty

Indications for BAV in critical Aortic StenosisIndications for BAV in critical Aortic Stenosis Younger patients with congenital AS and Younger patients with congenital AS and

predominant commissural fusionpredominant commissural fusion Bridge to eventual AVRBridge to eventual AVR Moderate to severe heart failure/cardiogenic shock Moderate to severe heart failure/cardiogenic shock Extremely high risk for AVRExtremely high risk for AVR Urgent/emergent need for noncardiac surgeryUrgent/emergent need for noncardiac surgery Patient with limited lifespan – cardiac or noncardiac Patient with limited lifespan – cardiac or noncardiac Patient refuses surgeryPatient refuses surgery

Aortic Valve Surgery: Ross Aortic Valve Surgery: Ross ProcedureProcedure

Autotransplant of Autotransplant of pulmonic valve to the pulmonic valve to the aortic positionaortic position

Reimplantation of the Reimplantation of the coronary arteriescoronary arteries

Homograft valve in the Homograft valve in the pulmonic positionpulmonic position

IndicationsIndications Younger patientsYounger patients No anticoagulationNo anticoagulation Requires similar sized Requires similar sized

aortic and pulmonic aortic and pulmonic rootsroots

Valvular Heart DiseaseValvular Heart Disease

The EndThe End