VALVULAR HEART DISEASE Year 4 Internal Medicine Notes

VALVULAR HEART DISEASE Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.2 / Ngugi -- Slide 1 VALVULAR HEART DISEASE RHEUMATIC AND NON-RHEUMATIC \n\nDR. ROSSLYN NGUGI MBCHB (UON),MMED IMED (UON), PG DIP DIABETES (NSW) Slide 2 LECTURE OBJECTIVES At the end of the lecture the student should be able to:\nDescribe the aetiology of VHD esp RHD\nDescribe the pathology of valvular damage esp in RHD\nDescribe the pathophysiological consequences of valvular disease\nElicit the clinical features of VHD\nCarry out investigations in VHD\nOutline the management of a patient with VHD Slide 3 PREAMBLE Predominantly rheumatic in this environment Most important cause of cardiac disease in teenagers, young adults Epidemiology reflects Rh. Fever: underprivilege, overcrowding, young age group Management unavailable, expensive, complex, risky Hence the significance of prevention – primary, secondary Other causes:\n-Congenital \n-Degenerative \n-Ischaemic, inflammatory etc Slide 4 RHD Consequence of rheumatic endocarditis Only long term sequel of RF Fibrosis, distortion of valvular apparatus Stenosis, regurgitation or both Most often affects left heart valves Mitral Aortic Tricuspid often functional Almost never pulmonic Involvement often multiple Rheumatic fever prophylaxis Slide 5 Specific valvular lesions Slide 6 MITRAL STENOSIS FUNCTIONAL ANATOMY: \n-Leaflets, commissures, chordea tendinae\n\n-MVA – Normal 4-6 cm2 \n- 1-2cm2 - significant stenosis \n- < 1cm2 - critical stenosis\n AETIOLOGY: \n- Almost invariably rheumatic \n- Congenital, Calcification, Inflammatory PATHOLOGY: \n- Commissural fusion \n- Fibrosis, distortion of chordae, leaflets Slide 7 MITRAL STENOSIS PATHOPHYSIOLOGY Impaired opening of MV\nInadequate LA emptying: \n- Increased LA pressures \n- Pulmonary venous congestion \n- Pulmonary Hypertension RV hypertrophy and failure\n\n- Increased LA size \n- LA thrombosis \n- Atrial fibrillation\n\nInadequate LV filling \n- Low cardiac output Slide 8 MITRAL STENOSIS CLINICAL FEATURES – SYMPTOMS: \nEffort intolerance: dyspnoea, easy fatiguablity \nPalpitations, may be at rest \nCough, haemoptysis\nOrthopnea, PND\nAbdominal discomfort, swelling Slide 9 MITRAL STENOSIS CLINICAL FEATURES – SIGNS: \n- Mitral facies \n- Low volume pulse, rapid, ± irregular \n- Apex NOT displaced, tapping (palpable S1)\n- Palpable P2 \n- Left parasternal heave (RVH)\n- Auscultation: \n- Loud S1, P2. \n- Opening snap, mid diastolic murmur, presystolic accentuation - at the apex\n- Features of TR \n- Pulmonic EDM(early diastolic murmur) due to PR(Pulmonary regurgitation) (Graham Steele)\n- Features of heart failure Slide 10 MITRAL STENOSIS COMPLICATIONS: \n- Heart Failure \n- Atrial Fibrillation \n- Thromboembolism \n- Infective Endocarditis Slide 11 MITRAL STENOSIS INVESTIGATIONS: \n- CXR – features of LA enlargement: double shadow, filling of pulmonary bay, widened carina \n- Pulmonary congestion\n- Normal cardio-thoracic ratio (CTR)\n- MV calcification\n- ECG – LAE, RVH, RAD\n- Atrial Fibrillation \n- ECHO – Morphology \n- Doppler – valve area, gradients, pulmonary pressures \n- Secondary changes – LAE, RVH Slide 12 MITRAL STENOSIS MANAGEMENT – PHARMACOLOGICAL \n- Limited \n- Diuretics \n- HR slowing – Beta blockers, digoxin\n- No role for usual HF management \n- Management of Complications Slide 13 MITRAL STENOSIS MANAGEMENT – DEFINITIVE \n- Surgical: \n- Valvotomy – closed, open \n- Valve replacement/repair \n- Interventional: \n- Percutaneous balloon dilatation Slide 14 MITRAL REGURGITATION FUNCTIONAL ANATOMY: \n- Leaflets, annulus, chordea, papillary muscles \n AETIOLOGY:\n- Predominantly rheumatic locally\n- Degenerative (MVP), Ischaemic, ventricular dilatation, inflammatory, endocarditis PATHOLOGY:\n- Fibrosis, distortion – leaflets, chordae (RHD)\n- Rupture – chordae, papillary muscles (Ischaemia, Inf. End.)\n- Annular dilatation – ventricular dilatation \n- Degenerative – leaflets (MVP) Slide 15 MITRAL REGURGITATION PATHOPHYSIOLOGY:\n- Increased SV(Stroke volume) to accommodate regurgitant volume\n- Volume overload\n- Eccentric hypertrophy (dilatation) \n- Enlarged LA Slide 16 MITRAL REGURGITATION CLINICAL FEATURES – SYMPTOMS: \n-Insidious and slowly progressing \n- May be asymptomatic even in severe MR \n- Onset often depends on complications e.g. PHT, A.fib or precipitating factors.\n- Features of CCF Slide 17 MITRAL REGURGITATION CLINICAL FEATURES – SIGNS: \n- Pulse maybe large volume\n- Apex, displaced, heaving \n- Muffled S1, S3+\n- Apical pan systolic murmur, radiating to axilla Slide 18 MITRAL REGURGITATION COMPLICATIONS: \n- CCF \n- Infective endocarditis \n- A.Fib Slide 19 MITRAL REGURGITATION INVESTIGATIONS: \n- CXR- cardiomegaly\n- pulmonary congestion \n- ECG- LAE, LVH, A.Fib\n- ECHO- Morphology \n- Quantification \n- LV size and function Slide 20 MITRAL REGURGITATION MANAGEMENT: Pharmacological:\n- Management of CCF \n- Complications\n- Definitive;\n- Surgery – valve replacement, repair Slide 2