Valvular heart disease

A. Presentation

Mitral stenosis

Symptoms of pulmonary congestion (dyspnoea, cough, and occasionally haemoptysis)

Signs of pulmonary venous congestion

HS: loud S1, early opening diastolic snap, rumbling (mid-)diastolic murmur, presystolic accentuation of the diastolic murmur (if in sinus rhythm).

 

Mitral regurgitation

Enlarged left ventricle

Well-preserved carotid pulsation

HS: Apical pansystoilc murmur, S3 (often present)

HS in MR due to prolapse: systolic click (usually mid-systolic) usually followed by a murmur extending till the end of systole.

 

Aortic stenosis

Triad: Angina, Syncope (exertional), Dyspnoea

Symptoms of heart failure

Sustained slowly rising cartoid pulse

HS: Mid- to late-peaking systolic murmur radiating to the neck (murmur may be soft in severe AS).

HS: In congenital aortic valve deformity, ejection click may be heard, which is then followed by the murmur.

HS: In severe AS, S4 and paradoxical splitting of S2 (P2 then A2)

 

Aortic regurgitation

A collapsing (water-hammer) pulse with wide pulse pressure

Other signs indicating severe disease:

• Quincke's sign (visible capillary pulsation in the nailbed)
• De Musset's sign (head bobbing)
• Durozier's sign (systolic bruit heard on compression of the femoral artery)

HS: Aortic early diastolic murmur

HS: (sometimes) mid-systolic murmur due to increased flow

HS: (sometimes) an apical mid-diastolic murmur (Austin-Flint murmur) due to aortic backflow closing the mitral valve

 

B. Investigation

Two dimensional and doppler echocardiography (for all patients)

Transoesophageal echocardiography (TEE) (for mitral lesions)

 

Preoperative coronary angiography to determine the extent of coronary artery disease in patients considered for surgical treatment of the valves.

 

C. Treatment

Treat heart failure if present.

 

Mitral stenosis

Medical treatment

Anticoagulant therapy recommended except in mild MS.

Beta-blockers or calcium channel blockers to slow heart rate.

Treatment of atrial fibrillation.

Consider diuretics for treatment of pulmonary congestion and oedema.

 

Surgical treatment

Percutaneous ballon mitral valvuloplasty

Valve replacement

Open valvotomy and valvuloplasty

 

Mitral regurgitation

Medical treatment

Consider anticoagulation therapy (atrial fibrillation occurs in late stages of MR)

Consider diuretics for treatment of pulmonary congestion and oedema

Nitrate, digoxin, vasodilators may improve systolic function

 

Surgical treatment

Mitral valve repair or replacement

 

Aortic stenosis

75% of patients with symptoms will die within 3 years unless valve is replaced.

Medical treatment

Digoxin

Avoid: diruretics, nitrate.

 

Surgical treatment

Aortic valve replacement. (Also consider PTCA or CABG at the time of AVR, if there is coexisting coronary disease)

Intra-aortic ballon counterpulsation

Percutaneous ballon aortic valvuloplasty (use only if poor surgical candidate for AVR)

 

Aortic regurgitation

Medical treatment

Fluid and salt restriction, diuretics, digoxin, and vasodilators.

 

Surgical treatment1

Aortic valve replacement

D. Other notes

Causes

(most common causes underlined)

Mitral stenosis

• Rheumatic heart disease

 

Mitral regurgitation

Abnormal leaftlets

• Rheumatic heart disease
• Infective endocarditis
• Myxomatous degeneration (mitral valve prolapse)

Abnormal tensor apparatus

• Rupture of papillary muscle
• Papillary muscle dysfunction (fibrosis)
• Rupture of chordae tendinae

Abnormal ventricle

• LV enlargement due to myocarditis, dilated cardiomyopathy
• Calcification of mitral annulus

 

Aortic stenosis

• Rheumatic heart disease
• Calcification of normal valve with aging (senile calcific aortic stenosis)
• Calcification of congenitally deformed valve (e.g. bicuspid aortic valve)

 

Aortic regurgitation

Intrinsic valvular disease

• Rheumatic heart disease
• Infective endocarditis

Aortic disease

• Degenerative aortic dilation
• Syphilitic aortitis
• Arthritides
  - Ankylosing spondylitis
  - Rheumatoid arthritis
  - Reiter's syndrome
• Marfan syndrome
• Aortic dissection
• Osteogenesis imperfecta

 

Prophylaxis

Prophylaxis against endocarditis should be considered with patients (with acquired valvular heart disease) undergoes certain procedures:

• Dental procedures that causes bleeding from the gingiva, mucosa, or bone.
• Other procedures where bactermia is a likely potential complication.

 

In dental procedures

Use:

Amoxycillin 2g (or ampicillin if IM/IV) as a single dose.

If PO, use 1hr before. If IM, 30min before. If IV, just before procedure.

 

For penicillin allergies, use instead:

PO:

Clindamycin 600mg, 

     OR

Cephalexin 2g

 

IV:

Clindamycin 600mg,

     OR

Lincomycin 600mg,

     OR

Vancomycin 1g,

     OR

Teicoplanin 400mg.

 

In genitourinary and gastrointestinal procedures:

Use:

Gentamicin 2mg/kg IV/IM

     PLUS

Amoxycillin or Ampicillin 2g IV/IM

     FOLLOWED BY

Amoxycillin or Ampicillin 1g IV/IM/PO 6 hours later

 

For penicillin allergies, substitute for amoxycillin or ampicillin:

Vancomycin 1g IV,

     OR

Teicoplanin 400mg IV