PENYAKIT KATUP

JANTUNG

dr. Tjatur Winarsanto SpPD

RS Ciremai

Spectrum of VHD
Aortic Valve

Mitral Valve

Tricuspid Valve

Pulmonic Valve

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

Cardiac Physiology
Systole
AV/PV opens
S1-S2 MV/TV closes
Diastole
AV/PV closes
S2-S1 MV/TV opens

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:

Mod mitral stenosis

MVA 1.5-2.5 cm2

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

Severe mitral stenosis

MVA < 1.0 cm2

Symptoms

Fatigue
Palpitations
Cough
Left sided failure

Orthopnea
PND

Palpitation

Afib
Systemic embolism
Pulmonary infection
Hemoptysis
Right sided failure

Hepatic Congestion
Edema

Worsened by conditions
that cardiac output.

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

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

Murmur
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

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

Mitral Stenosis :ECG

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: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.

Mitral Regurgitation
Etiologies

Alterations of the Leaflets, Commissures, Annulus

Rheumatic
MVP
Endocarditis

Alterations of LV or LA size and Function

Papillary Muscle (Ischemic, MI, Myocarditis, DCM)

HOCM
LV Enlargement Cardiomyopathies LA Enlargement from MR
MR begets MR

Gambar 2. mitral valve prolapsed

Mitral Regurgitation
Symptoms

Fatigue and weakness

Dyspnea and orthopnea
Right sided HF
MVP Syndrome (if present)

Mitral Regurgitation
Physical Exam

Holosystolic Apical Blowing Murmur

Laterally displaced apical impulse
Split S2 (but is obscured by the murmur)
S3 Gallop (increased volume during diastole)
Radiation depends on the etiology

Mitral 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

Mitral Regurgitation

- SBE
Prophylaxis

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
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
Etiologies

Abnormalities of the Leaflets

Rheumatic, Bicuspid, Degenerative

Endocarditis

Dilation of the Aortic Annulus

Aortic Aneurysm / Dissection

Inflammatory (Syphyllis, Giant Cell Arteritis.
Coll Vasc Dis-Ankylosis Spondylitis, Reiters)
Inheritable (Marfans, Osteogensis Imperfecta)

Aortic Regurg pathophysiology

Aortic Regurg pathophysiology

Aortic Regurgitation

Aortic Regurgitation
Physical Exam

Diastolic Murmur
Hyperdynamic LV apical impulse
Bounding Pulses
S4, S3 Gallop-advanced AI

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

Tricuspid valve disease

ausculatory findings

Stenosis
: Low-to medium-pitch diastolic
rumble with inspiratory accentuation

Regurgitation : Soft, early, or holosystolic

murmur Augmented with inspiratory effort
(Caravallos sign)

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

Pulmonary Stenosis

Majority of PS is congenital (accounts for

7.6% of CHD)
Rarely due to carcinoid disease,
compression of PA due to intracardiac or
extracardiac masses
Mild PS may be asymptomatic
Symptoms include shortness of breath,
chest pain, fainting, or exertional
syncope,
sudden death

Pulmonary Regurgitation

Common complication after surgical or

percutaneous relief of pulmonary stenosis
May occur secondary to a dilated
pulmonary valve ring due to pulmonary
hypertension
PR occurs rarely as a congenital anomaly
PR leads to progressive right ventricular
dilatation, right ventricular dysfunction,
exercise
intolerance,
ventricular
tachycardia and sudden cardiac death

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