6. • Involvement of more than one heart valve
• Clinically significant – alters natural history,
management
• Valve may or may not be pathological but
must be grossly dysfunctional
10. • Presentation
• Symptoms
• Physical signs
• Natural history
• Management
Relative severity of
separate lesions
Order of development
of separate lesions
13. • Significant stenosis at multiple valves are
usually Rheumatic
• Significant regurgitation at multiple valves are
likely Non Rheumatic
• Significant stenosis and regurgitation together
are usually Rheumatic
14. • Quadrivalvular disease is most likely due to
combination of causes – Rheumatic, infective,
congenital, inflammatory or degenerative
disease
• A unitary cause for quadrivalvular disease is
either rheumatic or myxomatous
degeneration
33. MS
• Exertional dyspnoea – 1st and MC symptom
– PND
– Orthopnea
– 5-10 yrs from ARF to symptoms (15-20 yrs in
western population)
– Progresses over 3-5 yrs from NYHA II to IV
(5-10 yrs in western population)
• Hemoptysis
• Systemic embolism
• RVF – but after NYHA IV state
34. MR
• History
– Long asymptomatic period – 10-20 yrs from ARF
to symptoms (a decade longer than MS)
– Once severe MR – Symptomatic within 6-10 yrs
– Symptoms herald LVSD or AF – Rapid decline in
survival
• Chronic weakness/Fatigue/Exercise
Intolerance – MC
• Dyspnoea – less common and late
35. AS
• History
– Long asymptomatic period – 10-20 yrs from ARF to
symptoms (a decade longer than MS)
– 10-15 yrs from Mild to Severe AS
– Once severe AS – Symptomatic within 2 yrs
– Symptoms – Rapid decline in survival
– 2 HF/3 Syncope/5 Angina
• Exercise intolerance and dyspnoea – MC
• Exertional Angina
• Exertional Presyncope (> than Syncope)
36. AR
• Long (perhaps longest!) asymptomatic period
– After ARF
– After development of AR
– Once symptomatic – course similar to AS
• Exercise intolerance and dyspnoea - MC
• Palpitations – exertional and resting – even
painful! – may precede other symptoms by
months-yrs
• Nocturnal (and exertional) angina
37. TS
• Never solitary
• RVF – (Tender hepatomegaly, ascites,
anasarca) – without disabling dyspnoea
• Fatigue/Exercise intolerance more prominent
than dyspnoea – d/t low CO
44. Things that Stand are
• AV disease
– Pulse
– Hill’s sign
• Murmur characteristic (except MR)
• Diastolic thrill
• S2
– Paradoxical spilt – AS
– Wide split – MR
• A2 OS gap - mostly
46. Non valvular Factors
Modify/Precipitate presentation
– Arrhythmias
– Infective endocarditis
– RF recurrence – valvulitis and myocarditis
– Volume overload states – Anemia, worsening
Renal failure, Dietary non-compliance
– Pressure overload states – Uncontrolled HTN
– Ischemia – CAD/ACS, Respiratory illness, altitude
– SIRS – Infection, MC Pneumonia
47. Non valvular Factors
Modify/Precipitate presentation
– Arrhythmias
– Infective endocarditis
– RF recurrence – valvulitis and myocarditis
– Volume overload states – Anemia, worsening
Renal failure, Dietary non-compliance
– Pressure overload states – Uncontrolled HTN
– Ischemia – CAD/ACS, Respiratory illness, altitude
– SIRS – Systemic Infection, MC Pneumonia
48. Some Rules of Combined Valve Lesions
Severe
lesions
dominate
Proximal
lesions
dominate
Multivalvular
disease – 1+1
may not be 2
• Ability to
compensate
57. MS Vs. Austin Flint
Characteristic MS Austin Flint
Diastolic Murmur Prolonged with thrill Soft/shorter
Apex RV
Tapping
LV
Hyperkinetic
Added sounds OS S3
PAH Severe mild
S1 Loud (mostly) -
AF Suggestive -
Hand grip
62. • Exception to proximal distal rule – AR usually
predominates in physical signs
• In Severe MR, mild-mod AR well tolerated
• In Severe AR, even mild-mod MR worsens
symptoms as LV dilates further
70. • Doppler-echocardiographic methods have
been validated in single valve disease but not
in multivalve disease
• Interactions between different valve lesions.
• Methods that depend less on loading
conditions are preferred, such as direct
planimetry of the stenotic valves
76. • In the EuroHeart Survey, the operative risk ranged from
0.9% to 3.9% for single valve interventions and rose to
6.5% in cases of multiple valve disease
Ann Thorac Surg 1999;67:943-51
• In the Society of Thoracic Surgeons National Database,
mortality was 4.3% and 6.4% for isolated aortic and
mitral valve replacement, respectively, to 9.6% for
multiple valve replacement (Doubles)
Eur Heart J 2003;24:1231-43
77. • TVR: overall operative mortality was 22 %
Ann Thorac Surg 2005;80:845-850
• Operative mortality was similar for TVR 13%
vs. repair 18% p = 0.64.
• Higher mortality for higher NYHA class
Ann Thorac Surg 2009;87:83-89