1、 ,Closed valvotomy,Open valvotomy or Mitral valve replacement.Calcific valvular disease is the commonest cause of aortic stenosis and mainly occurs in the elderly.Chest X-ray reveals a relatively small heart with a prominent,dilated,ascending aorta.This occurs because turbulent blood flow above the
2、stenosed aortic valve produces so-called post-stenotic dilatation.The aortic valve may be calcified.The CTR increases in heart failure.ECG shows left ventricular strain pattern due to pressure overload(depressed ST segments and T wave inversion in leads I,AVL,V5,V6).Echocardiogram readily demonstrat
3、es the thickened,calcified and immobile aortic valve cusps.Left ventricular hypertrophy may be seen.Cardiac catheterization.In patients with aortic stenosis,symptoms are a good index of severity and all symptomatic patients should have aortic valve replacement.Asymptomatic patients should be under r
4、egular review for assessment of symptoms and echocardiography.Antibiotic prophylaxis against infective endocarditis is essential.The most common causes of aortic regurgitation are rheumatic fever and infective endocarditis complicating a previously damaged valves.Acute aortic regurgitation:Acute rhe
5、umatic fever,Infective endocarditiS,Dissection of the aorta,Ruptured aneurysm,Failure of prosthetic heart valve.Chronic aortic regurgitation:Rheumatic heart disease,Syphilis,Arthritides(Reiters syndrome,Ankylosing spondylitis,Rheumatoid arthritis),Hypertension(severe),Bicuspid aortic valve,Aortic en
6、docarditis,Marfans syndrome And Osteogenesis imperfecta.In aortic regurgitation,significant symptoms occur late and do not develop until left ventricular failure occurs.As with mitral regurgitation,a common symptom is pounding of the heart because of the increased left ventricular size and its vigor
7、ous pulsation.Angina pectoris is a frequent complaint.Varying grades of dyspnoea occur depending on the extent of left ventricular dilatation and dysfunction.Arrhythmias are relatively uncommon.Pulse:bounding or collapsing.Signs of hyperdynamic circulation:Quinckes sign(capillary pulsation in the na
8、il beds),De Mussets sign (head nodding with each heartbeat),Duroziezs sign(a to-and-fro murmur heard when the femoral artery is auscultated with pressure applied distally-it is a sign of severe aortic regurgitation),pistol shot femorals.Apex beat:is displaced laterally and downwards and is forceful
9、in quality.Auscultation:a high-pitched early diastolic murmur best heard at the left sternal edge in the fourth intercostal space with the patient leaning forward and the breath held in expiration.Commonly an ejection systolic flow murmur.The regurgitant jet can impinge on the anterior mitral valve
10、cusp,causing a mid-diastolic murmur(Austin Flint).Chest X-ray:left ventricular enlargement and possibly dilatation of the ascending aorta.The ascending aortic wall may be calcified in syphilis,and the aortic valve may be calcified if valvular disease is responsible for the regurgitation.ECG:appearan
11、ces are those of left ventricular hypertrophy due to volume overload-tall R waves and deeply inverted T waves in the left-sided chest leads,and deep S waves in the right-sided leads.Echocardiogram:vigorous cardiac contraction and a dilated left ventricle.The aortic root may also be enlarged.Cardiac
12、catheterization.The underlying cause of aortic regurgitation(e.g.syphilitic aortitis or infective endocarditis)may require specific treatment.The treatment of aortic regurgitation usually requires aortic valve replacement.Because symptoms do not develop until the myocardium fails and because the myo
13、cardium does not recover fully after surgery,operation is performed before significant symptoms occur.Antibiotic prophylaxis against infective endocarditis is necessary.This uncommon valve lesion,which is seen much more often in women than in men,is usually due to rheumatic heart disease.It is frequ
14、ently associated with mitral and/or aortic valve disease.It is also seen in the carcinoid syndrome.Tricuspid valve stenosis results in a reduced cardiac output,which is restored towards normal when the right atrial pressure increases.The resulting systemic venous congestion produces hepatomegaly,asc
15、ites and dependent oedema.Usually,patients with tricuspid stenosis complain of symptoms due to associated left-sided rheumatic valve lesions.Abdominal pain(due to hepatomegaly)and swelling(due to ascites)and peripheral oedema.Prominent jugular venous a wave.Presystolic pulsation may also be felt ove
16、r the liver.Rumbling mid-diastolic murmur,heard best at the lower left sternal edge and is louder on inspiration.A tricuspid opening snap may occasionally be heard.Hepatomegaly,abdominal ascites and dependent oedema may be present.Chest X-ray:prominent right atrial bulge.ECG:enlarged right atrium ma
17、nifested by peaked,tall P waves(3 mm)in lead II.Echocardiogram:thickened and immobile tricuspid valve,but this is not so clearly seen as an abnormal mitral valve.Cardiac catheterization.Medical management consists of diuretic therapy and salt restriction.Tricuspid valvotomy is occasionally possible,
18、but tricuspid valve replacement is often necessary.Other valves usually also need replacement because tricuspid valve stenosis is rarely an isolated lesion.Functional tricuspid regurgitation may occur whenever the right ventricle dilates,e.g.in cor pulmonale,myocardial infarction or pulmonary hypert
19、ension.Organic tricuspid regurgitation may occur with rheumatic heart disease,infective endocarditis,carcinoid syndrome,Ebsteins anomaly(a congenitally malpositioned tricuspid valve)and other congenital abnormalities of the atrioventricular valves.ymptoms of right heart failure.Physical signs includ
20、e a large jugular venous cv wave and a palpable liver that pulsates in systole.Usually a right ventricular impulse may be felt at the left sternal edge,and there is a blowing pansystolic murmur,best heard on inspiration at the lower left sternal edge.Atrial fibrillation is common.Functional tricuspi
21、d regurgitation usually disappears with medical management.Severe organic tricuspid regurgitation may require operative repair of the tricuspid valve or valve replacement.This is usually a congenital lesion,but it may rarely result from rheumatic fever or from the carcinoid syndrome.Congenital pulmo
22、nary stenosis may be associated with an intact ventricular septum or with a ventricular septal defect(Fallots tetralogy).Pulmonary stenosis may be valvular,subvalvular or supravalvular.Fatigue,syncope and the symptoms of right heart failure.Physical signs:harsh mid-systolic ejection murmur,best hear
23、d on inspiration,to the left of the sternum in the second intercostal space.This murmur is often associated with a thrill.The pulmonary closure sound is usually delayed and soft.There may be a pulmonary ejection sound if the obstruction is valvular.A right ventricular fourth sound and a prominent ju
24、gular venous a wave are present when the stenosis is moderately severe.A right ventricular heave(sustained impulse)may be felt.Chest X-ray:prominent pulmonary artery owing to post-stenotic dilatation.ECG:both right atrial and right ventricular hypertrophy,although it may sometimes be normal even in severe pulmonary stenosis.Echocardiogram Doppler is the investigation of choice.Cardiac catheterization.Treatment of severe pulmonary stenosis requires pulmonary valvotomy(balloon valvotomy or direct surgery).THANK YOU
