Valvular Heart Disease and

Heart Failure
Iwan N Boestan
Departement Cardiology and Vascular
Airlangga University-Dr.Soetomo General Hospital

Epidemiology of Valvular Heart Disease

Developed countries, the causes:
Congenital abnormalities
Degenerative processes
Myocardial ischemia
Infections
Postinflammatory conditions
Trauma

Clinical Manifestation
Stenotic valve lesions:
Need a long latent period
Correlates with severity of stenosis

Regurgitant valve lesions:

Present in acute or chronic stages
Correlates less-well with extent of regurgitation

Interested Points:
Medical treatment as alternative realistic
option in high risk patients for surgical
intervention
High exciting advance in medical
treatment to delaying and avoiding for
surgical correction
Valvular lesions is mechanical disease,
need interventions for defintive therapy

Stenotic valve lesions:

Require little additional therapy when
symptom-free
Need mechanical intervention
(non-surgical / surgical correction)

Aortic Stenosis
Congenital abnormalities/Bicuspid Aortic Valve

Mitral Stenosis
Rheumatic Heart Disease/Postinflammatory conditions

Regurgitant valve lesions:

The purposes:
alleviate symptoms
preserve ventricular function

Mild-moderate disease:
medical therapy
periodic follow-up

Severe disease:
closed clinical follow up
frequent serial echocardiography

Regurgitant valve lesions:

No medical therapy is proven to effectively
treat
Almost need surgical correction for
defintive treatment
Surgical approach:
Repair
Replacement

Repair Vs. Replacement

Repair:
better clinical and long-term outcome than
replacement
preserve continuity of mitral annulus and
papillary muscles

Replacement:
better results with maintenance patency of
chordae

Medical treatment in
regurgitant valve lesions
Mitral regurgitation
Depend on etiology
Diuretics are useful for preload condition
affected MR
ACE-I may favor in delaying progressifity of
LV dilation and dysfunction
Digoxin, CCBs, blockers: to control atrial
fibrillation

Medical treatment of Mitral Regurgitation

Fig. the relation between the cause of MR, drug induced changes in
LV preload, and the degree of mitral regurgitation

Medical treatment in
regurgitant valve lesions
Aortic regurgitation:
Vasodilators: reduce LV wall stress and
decrease pressure gradient in aortic valve
during diastolic phase
ACE-I: reduce morbidity and mortality rate in
hypertension and/or heart failure patients
Diuretics: favor in hypervolemic status and
pulmonary congestion
Digoxin: used in existing LV dysfunction and
atrial fibrillation

Recommendation of treatment:
In chronic mitral regurgitation:
Depend upon
status of left ventricle
symptomatic status
type of operation

Medical treatment in
stenotic valve lesions
Mitral stenosis
Diuretics: relief pulmonary congestion
CCBs, -blockers: lengthen diastolic filling
time
Dgoxin: control ventricular contraction in atrial
fibrillation

Medical treatment in
stenotic valve lesions
Aortic stenosis:
HMG CoA Reductase: delaying progressivity
of calcific aortic stenosis (induce disease
regression)
ACE-I: induce LV regression with decrease
RAA system activation. Start with low dose
and tappering up to prevent hypotension

Case
58 y.o woman with SOB
Has noticed significant DOE over last 1
years, progressive
No chest pain or syncope
Diagnosed with valve lesion since 10 yrs
ago

Case
On Exam
HR 74 regular
BP 140/70 R=L
JVP 6 cm ASA. Carotid
pulse normal
Apex sustained, normal
position
Accentuated S1, single
S2
Grade 3/6 DM at aortic
Grade 3/6 SM @ apex

Case
ECG:
Sinus Rhythm with LV High Voltage

Echo:

LVH
normal all chamber size,
normal LV systolic and diastolic function
bicuspid Ao valve, estimated valve area 0.650.74 cm, Vmax 4.6 m/s, mean PG 55.5 mmHg
mild mitral regurgitation

PLAX AS + MR

SAX BICUSPID AV

Case
Coronary Angiography
normal coronary artery

Left Ventriculography

bicuspid Ao Valve
moderate Ao Stenosis (PG LV-Ao 60 mmHg)
severe mitral regurgitation
EF : 67%

Case
How would you manage this woman?
A) begin ACE inhibitor
B) begin digoxin for inotropic support
C) begin diuretic
D) begin ARB
E) begin Ca Channel Antagonist

Case
Which of the following would you next
pursue?
A) closely observe, repeat echo in 6 mos
B) refer for mitral valve replacement/repair
C) refer for aortic and mitral valve
replacement
D) schedule for exercise echocardiography

Case
Does this woman need endocarditis
prophylaxis for a dental extraction?
A) yes
B) only if the tooth is infected
C) only if local anaesthetic will be used
D) no

Ant-lat. Com.

A1
P1

A2

A3

P2
P3

Post-med.
Com.