PENYAKIT KATUP JANTUNG

dr. Erlina Marfianti, MSc, SpPD

Spectrum of VHD
Aortic Valve

Mitral Valve

Tricuspid Valve

Pulmonic Valve

Spectrum of VHD
Regurg Aortic Valve Stenosis Regurg Mitral Valve Stenosis Regurg Tricuspid Valve Stenosis Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute Chronic

Regurg
Pulmonic Valve Stenosis

Cardiac Physiology 101

Systole

S1-S2
Diastole

AV/PV opens MV/TV closes AV/PV closes MV/TV opens

S2-S1

Cardiac Physiology 101

Cardiac Physiology 101

Regurg/ Insuff leaking (backflow) of blood across a closed valve Stenosis Obstruction of (forward) flow across an opened valve

Systole S1-S2 Diastole S2-S1

AV/PV opens-------Aortic Stenosis MV/TV closes------Mitral Regurg AV/PV closes------Aortic Regurg MV/TV opens-------Mitral Stenosis

These concepts are set in stone, it cant occur any other way, It would be anatomically impossible

STENOSIS MITRALIS

Mitral Stenosis Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery

Mitral Stenosis: Etiology

Primarily a result of rheumatic fever

(~ 99% of MVs @ surgery show rheumatic damage )

Scarring & fusion of valve apparatus Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.

Mitral Stenosis:
Pathophysiology

Normal valve area: 4-6 cm2 Mild mitral stenosis:

MVA 1.5-2.5 cm2 Minimal symptoms MVA 1.0-1.5 cm2 usually does not produce symptoms at rest MVA < 1.0 cm2

Mod mitral stenosis

Severe mitral stenosis

Mitral Stenosis: Symptoms

Fatigue Palpitations Cough Left sided failure

Afib Systemic embolism Pulmonary infection Hemoptysis Right sided failure

Orthopnea PND

Hepatic Congestion Edema

Palpitation

Worsened by conditions that cardiac output.

Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy, thyrotoxicosis

Recognizing Mitral Stenosis

Palpation:

Auscultation:

Small volume pulse Tapping apex-palpable S1 +/- palpable opening snap (OS) RV lift Palpable S2 LAE,AFIB, RVH, RAD

ECG:

Loud S1- as loud as S2 in aortic area A2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS & rumble may be inaudible

Mitral Stenosis: Physical Exam

S1

S2 OS

S1

First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm)

Common Murmurs and Timing

Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis
S1 S2 S1

Mitral Stenosis: Natural History

Progressive, lifelong disease, Usually slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. Additional 10 years before disabling symptoms

Mitral Stenosis: Complications

Atrial dysrrhythmias Systemic embolization (10-25%) Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Massive: 20 to ruptured bronchial veins (pulm HTN) Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections

Mitral Stenosis: EKG

LAE RVH
Premature contractions Atrial flutter and/or fibrillation

freq. in pts with mod-severe MS for several years A fib develops in 30% to 40% of pts w/symptoms

Mitral Stenosis There is atrial fibrillation. No P waves are visible. The rhythm is irregularly irregular (random). There is the suggestion of right ventricular hypertrophy. Right axis deviation and deep S waves in the lateral leads. Another important feature of right ventricular hypertrophy not shown here is a dominant R wave in lead V1. The combination of Atrial Fibrillation and Right Axis Deviation on the ECG suggests the possibility of mitral stenosis.

Radiograph of the heart: The abnormalities characteristic of mitral stenosis are more expressed in this case. The heart is enlarged, the dilatation of the left ventricle (arrow) is associated with the dilatation of the right ventricle

Mitral Stenosis: Role of Echocardiography

Diagnosis of Mitral Stenosis Assessment of hemodynamic severity mean gradient, mitral valve area, pulmonary artery pressure Assessment of right ventricular size and function. Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty Diagnosis and assessment of concomitant valvular lesions Reevaluation of patients with known MS with changing symptoms or signs. F/U of asymptomatic patients with mod-severe MS

Mitral Stenosis:Therapy

Medical
Diuretics for LHF/RHF Digitalis/Beta blockers/CCB: Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis

Balloon valvuloplasty

Effective long term improvement

Mitral Stenosis:Therapy

Surgical
Mitral commissurotomy Mitral Valve Replacement

Mechanical Bioprosthetic

Recommendations for Mitral Valve Repair for Mitral Stenosis

ACC/AHA Class I

Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if percutaneous mitral balloon valvotomy is not available Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with the decision to proceed with either repair or replacement made at the time of the operation.

Recommendations for Mitral Valve Repair for Mitral Stenosis

ACC/AHA Class IIB Patients in NYHA functional Class I, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation. ACC/AHA Class III Patients with NYHA functional Class I-IV symptoms and mild MS.

*The committee recognizes that there may be a variability in the

measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.

REGURGITASI MITRAL
Definisi Regurgitasi Katup Mitral (Inkompetensia Mitral, Insufisiensi Mitral) adalah kebocoran aliran balik melalui katup mitral setiap kali ventrikel kiri berkontraksi. Pada saat ventrikel kiri memompa darah dari jantung menuju ke aorta, sebagian darah mengalir kembali ke dalam atrium kiri dan menyebabkan meningkatnya volume dan tekanan di atrium kiri. Terjadi peningkatan tekanan darah di dalam pembuluh yang berasal dari paru-paru, yang mengakibatkan penimbunan cairan (kongesti di dalam paru-paru.

Gambar 2. mitral valve prolapsed

Penyebab

Dulu demam rematik menjadi penyebab utama dari regurgitasi katup mitral. Tetapi saat ini, di negara-negara yang memiliki obat-obat pencegahan yang baik, demam rematik jarang terjadi. Misalnya di Amerika Utara dan Eropa Barat, penggunaan antibiotik untuk strep throat (infeksi tenggorokan karena streptokokus), bisa mencegah timbulnya demam rematik. Di wilayah tersebut, demam rematik merupakan penyebab umum dari regurgitasi katup mitral, yang terjadi hanya pada usia lanjut, yang pada masa mudanya tidak memperoleh antibiotik.

Gejala

Regurgitasi katup mitral yang ringan bisa tidak menunjukkan gejala. Kelainannya bisa dikenali hanya jika dokter melakukan pemeriksaan dengan stetoskop, dimana terdengar murmur yang khas, yang disebabkan pengaliran kembali darah ke dalam atrium kiri ketika ventrikel kanan berkontraksi. Secara bertahap, ventrikel kiri akan membesar untuk meningkatkan kekuatan denyut jantung, karena ventrikel kiri harus memompa darah lebih banyak untuk mengimbangi kebocoran balik ke atrium kiri. Ventrikel yang membesar dapat menyebabkan palpitasi ( jantung berdebar keras),

Perjalanan Penyakit

Atrium kiri juga cenderung membesar untuk menampung darah tambahan yang mengalir kembali dari ventrikel kiri. Atrium yang sangat membesar sering berdenyut sangat cepat dalam pola yang kacau dan tidak teratur (fibrilasi atrium), yang menyebabkan berkurangnya efisiensi pemompaan jantung.

Jika suatu bekuan darah terlepas, ia akan terpompa keluar dari jantung dan dapat menyumbat arteri yang lebih kecil sehingga terjadi stroke atau kerusakan lainnya. Regurgitasi yang berat akan menyebabkan berkurangnya aliran darah sehingga terjadi gagal jantung, yang akan menyebabkan batuk, sesak nafas pada saat melakukan aktivitas dan pembengkakan tungkai

Diagnosa

Regurgitasi katup mitral biasanya diketahui melalui murmur yang khas, yang bisa terdengar pada pemeriksaan dengan stetoskop ketika ventrikel kiri berkontraksi. Elektrokardiogram (EKG) dan rontgen dada bisa menunjukkan adanya pembesaran ventrikel kiri. Pemeriksaan yang paling informatif adalah ekokardiografi, yaitu suatu tehnik penggambaran yang menggunakan gelombang ultrasonik. Pemeriksaan ini dapat menggambarkan katup yang rusak dan menentukan beratnya penyakit.

Pengobatan

Jika penyakitnya berat, katup perlu diperbaiki atau diganti sebelum ventrikel kiri menjadi sangat tidak normal sehingga kelainannya tidak dapat diatasi. Fibrilasi atrium juga membutuhkan terapi. Obat-obatan seperti beta-blocker, digoxin dan verapamil dapat memperlambat denyut jantung dan membantu mengendalikan fibrilasi. Obat gagal jantung Permukaan katup jantung yang rusak mudah terkena infeksi serius (endokarditis infeksius). Karena itu untuk mencegah terjadinya infeksi, seseorang dengan katup yang rusak atau katup buatan harus mengkonsumsi antibiotik sebelum menjalani tindakan pencabutan gigi atau pembedahan.

Valvular Heart Disease

Aortic Valve
Aortic

Stenosis Aortic Regurgitation

Aortic Stenosis
Etiologies

Congenital Bicuspid Rheumatic Degenerative

0-30 yrs 30-50 yrs 30-60 yrs >60 yrs

Aortic Stenosis

Etiology

Congenital aortic stenosis occurs due to improper development of the aortic valve in the first 8 weeks of fetal growth. It can be caused by a number of factors, though, most of the time, this heart defect occurs sporadically (by chance), with no apparent reason for its development.

Some congenital heart defects may have a genetic link, either occurring due to a defect in a gene, a chromosome abnormality, or environmental exposure, causing heart problems to occur more often in certain families.
Acquired aortic stenosis may occur after a strep infection that progresses to rheumatic fever.

Aortic Stenosis pathophysiology

Aortic Stenosis pathophysiology

Aortic Stenosis
Physical Exam

Harsh Systolic Ejection Murmur late peaking S4 gallop (from LVH) Sustained Bifid LV impulse (from LVH)

Symptomp

fatigue dizziness with exertion shortness of breath irregular heartbeats or palpitations chest pain

Aortic Stenosis
Symptoms

Angina Syncope Congestive Heart Failure (CHF)

Aortic Stenosis

Aortic Stenosis

Aortic Stenosis
Diagnosis

Ecg LAE, LVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries

Aortic Stenosis
Treatment of Symptomatic Aortic Stenosis or Decreased LV Function Medical Therapy treats the symptoms not the cause Aortic Valve Replacement Bioprosthetic vs Mechanical AVR

Treatment

balloon dilation valvotomy - surgical release of adhesions that are preventing the valve leaflets from opening properly. aortic valve replacement - the aortic valve is replaced with a new mechanism. Replacement valve mechanisms fall into two categories: tissue (biological) valves, which include animal valves, and mechanical valves, which can be metal, plastic, or another artificial mechanism. Children who have undergone a valve replacement will need to follow antibiotic prophylaxis throughout their lifetime. aortic homograft - a section of aorta from a tissue donor with its valve intact is used to replace the aortic valve and a section of the ascending aorta. pulmonary homograft (Ross procedure) - a section of the child's own pulmonary artery with the valve intact is used to replace the aortic valve and a section of the aorta. A section of pulmonary artery from a tissue donor with its valve intact is used to replace the transferred pulmonary artery

Valvular Heart Disease

Aortic Valve
Aortic

Stenosis Aortic Regurgitation

Aortic Regurgitation

Aortic Regurgitation
Etiologies

Abnormalities of the Leaflets

Rheumatic, Bicuspid, Degenerative Endocarditis Aortic Aneurysm / Dissection Inflammatory (Syphyllis, Giant Cell Arteritis. Vasc Dis-Ankylosis Spondylitis, Reiters) Inheritable (Marfans, Osteogensis Imperfecta)

Dilation of the Aortic Annulus

Coll

Aortic Regurg pathophysiology

Aortic Regurg pathophysiology

Aortic Regurg pathophysiology

Aortic Regurgitation

Aortic Regurgitation
Physical Exam

Diastolic Decrescendo Blowing Murmur Hyperdynamic LV apical impulse Bounding Pulses S4, S3 Gallop-advanced AI Apical Rumble Austin Flint Murmur

Aortic Regurg Austin Flint Murmur

Due to the vibration of the anterior leaflet of the mitral valve as it is buffetted simultaneously by the blood jets from the left atrium and the aorta.

Aortic Regurgitation
Diagnosis

Ecg LAE, LVH Echo 2D/color doppler test of choice Cardiac Cath helpful, confirmatory, needed if the pt is older look at the coronaries

Aortic Regurgitation
Treatment of Asymptomatic Aortic Regurg

Medical Therapy treats the symptoms not the cause

Serial Check ups with Echos (eval EF, Severity AR) SBE Prophylaxis Vasodialators (Nifedipine, ACE-I) Diuretics

Treatment of Symptomatic Aortic Regurg Aortic Valve Replacement Bioprosthetic vs Mechanical AVR

Tricuspidalis

Regurgitasi trikuspidalis:
Keadaan kembalinya sebagian darah ke atrium kanan pada saat sistolik Primer: akibat kelainan organik dari katup Sekunder: hipertensi pulmnal, perubahan fungsi karena dilatasi ventrikel kanan, maupun anulus trikuspid Lebih sering bersamaan dengan katup lain

Manifestasi klinis

Tanpa hipertensi pulmonal biasanya asimptomatik Lebih sering bersamaan dengan stenosis mitral (lebih dominan stenosis mitral) Tanda tanda gagal jantung kanan Tanda tanda gagal jantung kiri (bila dengan stenosis mitralis)

Diagnostik

Klinis = gejala dan tanda Pemeriksaan fisik EKG Ro thorax Echo

Stenosis trikuspidalis

Jarang ditemui Sering bersamaan dengan penyakit katup lain Disebabkan RHD

Tricuspid valve

Penyebab

Kongenital ( misal Tetralogi Fallot) Didapat

Demam reumatik, Sarkoidosis Jarang karena Rematik heart disease, seringnya bersamaan dengan katup lain yang terkena

PULMONAL VALVE

Stenosis pulmonalis Regurgitasi pulmonalis

DIAGNOSTIK

Manifestasi klinis

Ringan berat

Ro thorax EKG Echocardiografi Cath jantung

Treatment

Tergantung derajat beratnya Manifestasi klinis yang timbul Perlu operatif apa tidak Terapi erdikasi streptokokus dan pencegahan sekunder bila ada PJR

Alhamdulillah
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