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Valvular Heart Disease

Stenosis (S) Regurgitation (R)
Pure   : Only S or R
Mixed : Both S & R in same valve
Combined : Multiple valve involvement
Isolated : Single valve involvement
Extra Edge :
Most frequent chronic causes of functional valvular lesions:
Mitral value insufficiency - Myxomatous degeneration (M VP)
Aortic stenosis - Calcification of anatomically normal & congenitally bicuspid aortic values Q
Aortic insufficiency. - dilatation of ascending aorta related to H-t aging. Q

Aortic Stenosis:
  1. Most frequent of all valvular abnormalities
  2. Usually as a result of calcification owing to progressive and advanced ,age associated "wear and tear" of either previously anatomically normal aortic valve or congenitally tricuspid valves. Q
  3. Rheumatic: < 10% of AS
  4. Calcific AS: heaped up calcific masses within aortic cusps
  5. Calcific deposits distort cuspal architecture at the base, free cuspal edges are usuallyno involved Q                                                
    In Bicuspid A V: Calcification of RAPHE
Myxomatous Degeneration of Mitral Value (MVP): Q
  1. Young women
  2. M. common valvular heart disease in industrialized world.
  3. Mitral leaflets: enlarged, hooded, redundant, floppy
  4. Prolapse in LA during systole
  5. Leaflets: thick, rubbery
  6. Tendinea: elongated, thinned or ruptured
  7. Annular dilation is characteristic Q
  8. Commissural fusion (typical of RHD) – absent Q
  9. Connective tissue anomaly (Marfan's Syndrome) Q
  10. 3% of pts. Develop complications
  11. Infective endocarditis
  12. Mitral insufficiency
  13. Stroke
  14. Arrhythmias
  15. Concomitant involvement of tricuspid valve - 20-40% cases

Rheumatic Fever & RHD

RF is acute immunologically mediated, multi system inflammatory disease that occurs few wks. Q
After episode of gp A (b- hemolytic) streptococcal pharyngitis often involves the heart
Develops in 3% of pts. With gp A streptococcal pharyngitis
  1. In Acute Rheumatic Fever:
  1. Pancarditis
  2. Aschoff bodies: Q (in any of 3 layers) Foci of fibrinoid degeneration, surrounded by T lymphocytes, plasma cells & plump macrophages (Anitschkow cells) à have abundant amphophilic cytoplasm, Round to avoid nucleus with chromatin dispersed in central slender, wavy ribbon à caterpillar cells.
  3. Pericardium - Bread & Butter Pericarditis Q
  4. Myocardium – Aschoff bodies in perivascular location.
  5. Verrucae: Q along line of closure. Small, warty,   sterile vegetations
  6. Subendocardial thickening:
    MacCallum plaques in LA Q
    1. Chronic: M V - almost always involved
      (leaflet thickening, commissural fusion, shortening thickening, & fusion of tendinous cords)(fish mouth Button hole stenosis) Q
    2. Involvement of:
      1. M V alone: 65-70% of cases                              
      2. MV + AV: 25%
  7. Vegetations can occur in acute rheumatic fever as small masses found in a row along the lines of closure of the valves.
  8. Pathology:
    Antibodies against M proteins of streptococci cross Q react with tissue glycoproteins in heart, joints & other tissues. Q
    1. Hypersensitivity reaction induced by beta haemolytic streptococci Q
    2. 1% in die from acute rheumatic fever,
    3. Repeated bouts of recurrence - worsening of carditis
Infective endocarditis:
Colonization or invasion of heart valves and mural endocardium by microbiologic agent leading to formation of bulky, friable vegetations composed of thrombotic debris & organisms with destruction of underlying cardiac tissues
  1. Acute
  2. Sub acute
Acute Endocarditis                                                              Sub. Acute
i. Destructive, infection, necrotizing, ulcerative, invasive        i. App. Insidiously, protracted cause
ii. Prev. (n) heart valves                                                      ii. Previous abnormal, deformed valves
iii. Highly virulent organisms                                                 iii. Low virulence
iv. Deaths within ten day to weeks in > 50% of patients          iv. Recover after antibiotic therapy                                                                                    
  1. Now Comm.: Myxomatous mitral valve - Q
  1. Degenerative Calcific valvular stenosis
  2. Bicuspid aortic valves
  3. Prosthesis
  1. Organism
  1. Streptococcus viridans -Pre. Deformed valves Q
  2. Staphylococcus aureus - Healthy or deformed valves Q
  3. Major offender in I/V drug abuser. HACEK - Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella Q
  4. Prosthetic valve endocarditis Q- caused most common by coagulase negative Staph epidermidis Q
  5. Culture negative endocarditis Q - No organism isolated because of prior antibiotic therapy
  1. ​Pathology
    1. Friable, bulky destructive vegetations containing fibrin, bacteria, inflammatory cells. Found on valve cusps. Can extend on to chordae
    2. AV& MV more comm. involved Rt side of heart in I/V drug abusers.  Q
      1. When erode into myocardium - abscess cavity à Ring abscess
      2. Systemic emboli with septic infarcts.
  1. Cardiac complications
    1. Valvular insufficiency or stenosis                     
    2. Myocardial ring abscess
    3. Suppurative pericarditis                                     
    4. Valvular dehiscence
  2. Embolic complication Q              
    1. With left sided lesion - brain, spleen, kidney, abscess
    2. With right sided lesion - lung infarct, abscess
  3. Renal complication
    1. Embolic infarct                    
    2. Focal / diffuse glomerulonephritis Q
Marantic Endocarditis (NBTE)
  1. Also Known as Non Bacterial Thrombotic endocarditis.
  2. Seen in patients suffering from debilitating diseases like malignancy Q & hypercoagulable states Q
  3. Vegetations on -heart valves
  4. Small bland vegetations along the line of closure, single or multiple.
Libman - Sacks Endocarditis (LSE)
  1. Seen in patients of SLE Q
  2. Vegetations on heart valves              
  3. Small or medium sized sterile granular, pink vegetations on either or both sides of valve leaflets.
  4. Mitral and tricuspid valves involved Q
  5. The development of Libman-Sacks endocarditis is associated with the presence of the lupus anticoagulant (antiphospholipid syndrome), an antibody that makes platelets sticky and increases the chance of thrombosis.
  6. They have venous & arterial thrombosis and may be associated with recurrent spontaneous miscarriages and focal cerebral or ocular ischemia.
  1. Carcinoid heart disease:
  1. Rt sided fibrous intimal thickening. Involves endocardium and valves of right heart.
  2. Left sided plaques: Methysergide, ergotamine

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