Cardiac Catheterization PDF

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CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner Cardiac Catheterization CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner CamScanner Objectives 1. To discuss valvular heart disease in terms of: a. types and epidemiology b. etiology c. pathophysiology d. signs and symptoms e. diagnostics f. management plan Outline 1 Introduction 2 Stenosis Vs. Regurgitation 3 Mitral Valve Disease Outline 4 Aortic Valve Disease 5 Tricuspid Valve Disease 6 Pulmonic Valve Disease Introduction - heart valves ensure unidirectional blood flow thru the heart and prevents backward flow: 1. atrioventricular (AV) valves - between the atria and ventricle; prevents backward flow of blood to atria during ventricular systole a. tricuspid - between RA and RV b. mitral (bicuspid) - between LA and LV Introduction - unidirectional blood flow: 1. atrioventricular (AV) valves - are anchored by chordae tendineae to the papillary muscles; chordae tendineae (“heart strings”) is a group of tough, tendinous strands that holds the AV valves in place while the heart pumps blood Introduction - unidirectional blood flow: 1. atrioventricular (AV) valves - papillary muscles are located in the ventricles and attaches to the cusps of the AV valves via the chordae tendinae; papillary muscles contract to prevent inversion / prolapse of these AV valves during ventricular systole Introduction - unidirectional blood flow: 2. semilunar valves - located in the arteries that leaves the heart to prevent backward flow into the ventricles a. pulmonic - between RV and pulmonary artery b. aortic - between LV and aorta Introduction - base of the heart valve that supports the valve's leaflets is called the annulus - valves open and close due to pressure gradients between chambers relative to the cardiac cycle and blood circulation Introduction - valve closure is what produces heart sounds: st 1. S1 ("lub“) - 1 heart sound caused by the turbulence due to closure of AV valves at the start of ventricular systole 2. S2 ("dub“) - 2nd heart sound caused by the closure of the semilunar valves and marks the end of ventricular systole Stenosis Vs. Regurgitation - general types of valvular disease: 1. stenosis - flow obstruction in valves during that phase of the cardiac cycle when that valve should be open and subjects that chamber behind that stenotic valve to greater stress as that chamber needs more pressure to force blood thru the stenotic valve Stenosis Vs. Regurgitation - general types of valvular disease: 1. stenosis - valve leaflets become thickened or fused so valve can’t open freely thus causing obstruction to normal flow of blood; heart first compensates for the added work thru myocardial hypertrophy and dilatation which then eventually causes heart failure Stenosis Vs. Regurgitation - general types of valvular disease: 1. stenosis - can also lead to insufficiency if thickening of annulus or leaflets results in inappropriate leaf closure Stenosis Vs. Regurgitation - general types of valvular disease: 2. regurgitation - also called insufficiency or incompetence; is the inability of valve to prevent backflow as valve leaflets fail to join (coapt) or close correctly either due to a. scarring and retraction of valve leaflets b. weakening of supporting structures Stenosis Vs. Regurgitation - general types of valvular disease: 2. regurgitation - causes heart to pump same blood twice as blood comes back into that chamber behind the regurgitant valve causing it to dilate to accommodate more blood; dilatation and hypertrophy eventually leads to heart failure Stenosis Vs. Regurgitation - general types of valvular disease: 3. combination either as a. single disease process for valves involved b. different disease processes for each of the valves involved c. valve lesion causing disease to another Stenosis Vs. Regurgitation - general types of valvular disease: 4. atresia - a heart valve lacks an opening for blood to pass thru; usually congenital; most common form is pulmonary atresia (ie - as part of tetralogy of Fallot or TOF) Stenosis Vs. Regurgitation - murmurs are heart sounds due to turbulent blood flow within the heart and can be pathological or physiological; murmurs can be classified by: 1. timing - systolic, diastolic, continuous 2. shape - crescendo, decrescendo, crescendo- decrescendo Stenosis Vs. Regurgitation - murmurs can be classified by: 3. location - where best / loudest heard at a. aortic region - 2nd right ICS b. pulmonic region - 2nd left ICS c. tricuspid region - 4th left ICS th d. mitral region - 5 LICS-MCL 4. radiation Stenosis Vs. Regurgitation - murmurs can be classified by: 5. intensity - using Levine‘s scale 1 - murmur is audible on when listening carefully for some time 2 - murmur is faint but immediately audible on placing the stethoscope on the chest 3 - loud murmur readily audible; no thrill Stenosis Vs. Regurgitation - murmurs can be classified by: 5. intensity - using Levine‘s scale 4 - loud murmur with a palpable thrill 5 - murmur is so loud; audible even when only the rim of stethoscope is touching the chest; with a palpable thrill Stenosis Vs. Regurgitation - murmurs can be classified by: 5. intensity - using Levine‘s scale 6 - murmur is audible even if the stethoscope is not touching the chest but lifted just off it; with a palpable thrill 6. pitch 7. quality - blowing, harsh, rumbling, etc. Stenosis Vs. Regurgitation (Video - Heart Murmurs) 2018 Mitral Stenosis (MS) - narrowing of mitral valve opening causing blood flow obstruction from LA to LV - pure MS is generally rheumatic (RF) in origin - can be caused by heavy calcification in elderly - rheumatic valvulitis results in scarring and fusion leading to a pressure gradient across the stenotic valve followed by LA hypertension Mitral Stenosis (MS) - LA hypertension passively associated with increase in pulmonary artery (PA) pressure - PA hypertension leads to RV hypertrophy and enlargement then RA hypertension and systemic venous congestion ensues Mitral Stenosis (MS) - with asymptomatic interval between initiating event of acute RF and symptomatic MS - initially with little or no gradient at rest after which exertional dyspnea then develops - patients then note orthopnea and paroxysmal nocturnal dyspnea (PND) as mitral valve obstruction increases Mitral Stenosis (MS) - progresses to fatigue rather than dyspnea - systemic venous congestion follows - symptoms of RV failure predominate in patients with severe pulmonary hypertension - palpitations, premature atrial contractions or paroxysmal atrial fibrillation / flutter Mitral Stenosis (MS) - systemic embolism may result in ischemic stroke, occlusion of extremity arterial supply (PAD), occlusion of the aortic bifurcation and visceral or myocardial infarction - progression of symptoms in MS is generally slow but relentless Mitral Stenosis (MS) - signs of: 1. atrial fibrillation (AF) 2. mitral facies - flushed cheeks from cutaneous vasodilation (severe MS) 3. loud S1, opening snap, RV heave, loud P2 4. rumbling mid-diastolic murmur at apex 5. crepitations, pulmonary edema, effusions Mitral Stenosis (MS) - diagnostics: 1. ECG - RVH with tall R waves 2. CXR - enlarged LA and appendage, signs of pulmonary venous congestion 3. 2D echo - enlarged LA, thickened immobile cusps, reduced valve area, reduced diastolic filling of LV, normal LV size, late RVH Mitral Stenosis (MS) - diagnostics: 4. Doppler - pressure gradient across the valve 5. cardiac catheterization - checks on CAD, MS and MR, pulmonary artery pressure Mitral Stenosis (MS) - treatment: 1. medical a. all streptococcal infections should be diagnosed rapidly and correctly treated b. all known previous acute RF / rheumatic carditis w/ or w/o obvious valve disease must receive Penicillin prophylaxis Mitral Stenosis (MS) - treatment: 1. medical c. sodium / salt intake restriction d. oral anticoagulant with Warfarin to reduce embolic events e. Digitalis for control of AF f. diuretics for pulmonary congestion Mitral Stenosis (MS) - treatment: 1. medical g. Digoxin, rate limiting calcium antagonists, beta-blockers - to control ventricular rate in AF Mitral Stenosis (MS) - treatment: 2. surgical a. mitral balloon valvuloplasty b. catheter balloon commissurotomy (CBC) - for MS with functional class III or IV c. valvulotomy d. valvular replacement Percutaneous Trans-septal Mitral Commissurotomy Star Edwards Caged Ball Valve Medtronic Hall Valve (Bjork-Shiley) St. Jude Bileaflet Valve Mitral Regurgitation (MR) - back flow from LV to LA due to incomplete closure of the mitral valve - can be caused by: 1. mitral valve prolapse (MVP) 2. rheumatic 3. dilatation of LV and mitral valve ring - due to CAD or cardiomyopathy Mitral Regurgitation (MR) - can be caused by: 4. damage to valve cusps or chordae tendineae - due to rheumatic, endocarditis, ischemia or infarction of papillary muscle (ie - AMI) - systolic pressure gradient between LV and LA is the driving force for the regurgitant flow that results in a regurgitant volume Mitral Regurgitation (MR) - regurgitation creates volume overload by: 1. entering the LA in systole 2. entering the LV in diastole - modifies LV loading and function additive to the systolic output of the RV - in acute MR, sudden burden of MR does not allow compensatory dilatation of LA and LV Mitral Regurgitation (MR) - marked elevations of LA and pulmonary venous pressures leads to acute pulmonary edema - symptoms: 1. fatigue, weakness - due to decreased CO 2. exertional dyspnea and cough - due to pulmonary congestion 3. palpitations - due to AF Mitral Regurgitation (MR) - symptoms: 4. edema, ascites - due to right-sided HF - signs of: 1. AF, cardiomegaly, soft S1, apical S3 2. holosystolic murmur (apical) +/- thrill 3. pulmonary venous congestion, pulmonary hypertension and right-sided HF Mitral Regurgitation (MR) - diagnostics: 1. ECG - LA and LV hypertrophy, AF 2. CXR - enlarged LA and LV, pulmonary venous congestion and edema 3. 2D echo - dilated LA and LV with valvular structural abnormalities (ie - prolapse) 4. Doppler - will detect and quantify MR Mitral Regurgitation (MR) - diagnostics: 5. cardiac catheterization - dilated LA and LV, MR, pulmonary hypertension and co-existing CAD - treatment: 1. medical a. vasodilator - ACE inhibitor to increase CO Mitral Regurgitation (MR) - treatment: 1. medical b. diuretics c. AF - Digoxin +/- anticoagulant 2. surgical a. repair, valve clipping (percutaneous) b. valve replacement Mitral Valve Prolapse (MVP) - also called Barlow’s syndrome, floppy-valve syndrome, systolic click-murmur syndrome and billowing mitral leaflet syndrome - excessive or redundant mitral leaflet tissue - pertains to the systolic rolling up of the mitral leaflets into the LA - is also the most common cause of MR Mitral Valve Prolapse (MVP) - posterior leaflet is more affected than anterior - may lead to excessive stress on the papillary muscles leading to dysfunction and rupture of chordae tendineae with progressive annular dilatation and calcification - may be with or without MR Mitral Valve Prolapse (MVP) - more common in women - frequently between 15-30 years old - course is mostly benign being asymptomatic for their entire lives - there is an increased familial incidence for some patients (autosomal dominant form) Mitral Valve Prolapse (MVP) - 2 types: 1. primary - basic trait is marked proliferation of the spongiosa, fibrosa or ventricularis; may occur in a. families - as an autosomal dominant trait b. Marfan’s syndrome c. other heritable connective tissue diseases Mitral Valve Prolapse (MVP) - 2 types: 1. primary - may occur in d. post-inflammatory changes e. hypertrophic cardiomyopathy 2. secondary - from effects of the primary MVP syndrome such as a. fibrosis of surface of valve leaflets Mitral Valve Prolapse (MVP) - 2 types: 2. secondary - such as b. thinning and / or elongation of chordae tendineae c. ventricular friction lesions Mitral Valve Prolapse (MVP) - clinical expression ranges from: 1. mild - systolic click and murmur 2. severe - due to chordal rupture, leaflet flail - condition progresses over years or decades or in others, it worsens rapidly as a result of chordal rupture or endocarditis Mitral Valve Prolapse (MVP) - arrhythmias cause light-headedness, palpitations, syncope: 1. PVCs (premature ventricular contractions) 2. SVT (supraventricular tachycardia) 3. VTAC (ventricular tachycardia) 4. AF (atrial fibrillation) Mitral Valve Prolapse (MVP) - symptoms: 1. palpitations - most common; due to PVCs 2. chest pain - usually atypical 3. dyspnea, fatigue 4. symptoms of embolization Mitral Valve Prolapse (MVP) - diagnostics: 1. ECG - usually normal 2. 2D echo - most useful - treatment: 1. medical a. normal lifestyle, exercise - if asymptomatic b. beta blockers sometimes relieve chest pain Mitral Valve Prolapse (MVP) - treatment: 1. medical c. volume expansion - if with hypotension d. watchful monitoring every 2-3 years e. antiplatelets for patients with TIA, use anticoagulants for recurrent TIAs f. prophylaxis for IE (infective endocarditis) Mitral Valve Prolapse (MVP) - treatment: 2. surgery recommended if with class III-IV symptoms, LVEF (ejection fraction) 1.0 cm2 Normal Aortic Valve Aortic Stenosis - Rheumatic Aortic Stenosis - Degenerative Aortic Stenosis - Bicuspid Aortic Stenosis (AS) - outflow obstruction imposes a pressure overload on the LV which compensates by LVH - when preload reserve is no longer adequate, a decrease in systolic function and LV dilatation occurs - loss of effective LA contraction causes elevation of LA pressure, reduction in CO or both Aortic Stenosis (AS) - in severe AS, myocardial oxygen needs to increase because of an increased muscle mass, elevations in LV pressures and prolongation of the systolic ejection time - patients may have classic angina pectoris even in the absence of coronary artery disease (CAD) Aortic Stenosis (AS) - symptoms: 1. mild or moderate AS - asymptomatic 2. cardinal symptoms of exertional dyspnea, angina (due to demands of LVH) and exertional syncope that occurs when CO (cardiac output) fails to rise to meet demand 3. pulmonary edema, cardiac death (5%) Aortic Stenosis (AS) - signs: 1. ejection systolic murmur 2. slow-rising carotid pulse (pulsus parvus et tardus), narrow pulse pressure 3. thrusting apex beat (AB) due to LV pressure overload 4. signs of pulmonary venous congestion A low amplitude pulse (parvus) with a slow rising and late peak (tardus)  Mild AS Moderate AS Severe AS Carotid pulse normal slow rising parvus et tardus LV apical impulse normal heaving heaving & sustained S4 gallop - +/- ++ Systolic ejection click + +/- - SEM, peaking early systole midsystole mid-to-late systole S2 normal normal or single single or paradoxical Aortic Stenosis (AS) - diagnostics: 1. ECG - LVH, LBBB 2. CXR - may be normal, enlarged LV and dilated ascending aorta (PA view), calcified valve (lateral view) 3. 2D echo - calcified valve with restricted opening, LVH Aortic Stenosis (AS) - diagnostics: 4. Doppler - measurement of severity of AS and detection of associated AR 5. cardiac catheterization - identifies associated CAD and may also be used to measure pressure gradient between LV and aorta Aortic Stenosis (AS) - treatment depends on severity: 1. asymptomatic - keep under review; presence of angina, syncope, symptoms of low CO or heart failure has poor prognosis and is an indication for prompt surgery 2. moderate to severe - evaluate every 1-2 years with Doppler (to detect progression) Aortic Stenosis (AS) - treatment depends on severity: 3. AF - anticoagulant 4. sodium / salt restriction 5. cautious administration of diuretics and Digitalis in CHF 6. Nitroglycerin - to relieve angina Aortic Stenosis (AS) - treatment depends on severity: 7. statins (HMGCoA reductase inhibitors) - slows down progression of calcification(?) 8. surgery - indications a. severe AS (90% of cases, 5-15% of rheumatic mitral valve disease (MS) have concurrent TS - does not occur as an isolated lesion - more common in women than men Tricuspid Stenosis (TS) - decreases blood flow from RA to RV, decreases RV output and eventually decreases LV filling and CO - increases systemic venous pressure - development of MS generally comes before TS hence initially have symptoms of pulmonary congestion and fatigue Tricuspid Stenosis (TS) - severe TS has relatively little dyspnea for the degree of hepatomegaly, ascites and edema - fatigue and hypotension secondary to a low CO; discomfort due to hepatomegaly, edema, ascites are common in advanced TS and / or TR - may be missed unless considered as it occurs in presence of other obvious valvular disease Tricuspid Stenosis (TS) - with signs of systemic venous congestion such as a raised JVP, with mid-diastolic murmur (best heard at lower left or right sternal edge) - treatment: 1. initially, diuretics and sodium restriction may improve the symptoms due to fluid retention Tricuspid Stenosis (TS) - treatment: 2. definitive therapy are balloon valvuloplasty, valve replacement, balloon valvulotomy 3. if with severe concomitant MS, surgical treatment of the TS should be carried out at the same time as the MS Tricuspid Regurgitation (TR) - >80% TR are secondary (functional) in nature and related to tricuspid annular dilatation and leaflet tethering in the setting of RV remodeling (caused by pressure / volume overload or both), myocardial infarction or trauma - blood backflow to RA causes venous congestion and decreases RV output and blood to the lungs Tricuspid Regurgitation (TR) - mild or moderate degrees of TR are usually well tolerated in the absence of other hemodynamic disturbances - most often coexists with left-sided valve lesions, LV dysfunction or PA hypertension hence symptoms related to these lesions may dominate the clinical picture Tricuspid Regurgitation (TR) - fatigue, exertional dyspnea owing to reduced forward CO are early symptoms in isolated TR - as disease progresses and RV function declines, may report neck pulsations, fullness / bloating of abdomen, anorexia, muscle wasting although with progressive weight gain, painful swelling of the lower extremities Tricuspid Regurgitation (TR) - signs: 1. raised JVP - prominent V waves 2. holosystolic murmur (left sternal edge) that increases with inspiration (Rivera-Carvallo’s sign) 3. accentuated or attenuated P2 (in the setting of pulmonary hypertension) Tricuspid Regurgitation (TR) - signs: 4. pulsatile liver, ascites, peripheral cyanosis and lower extremity edema - diagnostics: 1. ECG - may see AF, RA enlargement 2. CXR - cardiomegaly 3. 2D echo - for reference standard Tricuspid Regurgitation (TR) - diagnostics: 4. right sided cardiac catheterization - for pulmonary hypertension - treatment: 1. correction of cause of RV overload 2. diuretics and vasodilators 3. valve repair / replacement Pulmonic Stenosis (PS) - least likely acquired valvular disease and almost all are congenital - valve is either dome shaped (due to fusion of leaflets) or thickened and dysplastic - less common non-congenital causes include the carcinoid syndrome, RF and stenosis of a bio- prosthetic valve Pulmonic Stenosis (PS) - symptoms: 1. fatigue, dyspnea on exertion, cyanosis 2. poor weight gain or failure to thrive (infants) 3. hepatomegaly, ascites, edema - signs: 1. ejection systolic murmur preceded by an ejection sound (click) Pulmonic Stenosis (PS) - signs: 2. wide splitting of S2 3. thrill (best when patient leans forward & breathes out) - ECG shows RAE, bi-atrial if also with MS - 2D echo shows thickened tricuspid leaflets with diastolic doming Pulmonic Stenosis (PS) - treatment: 1. mild to moderate isolated PS - does not usually progress or require treatment 2. severe - percutaneous pulmonary balloon valvuloplasty or surgical valvotomy Pulmonic Regurgitation (PR) - pulmonic valve consists of the annulus leaflets, and commissures; no chordal attachments thus making opening and closing a passive process - a rare clinical entity, usually associated with pulmonary hypertension which can be due to diseases of left side of heart, primary pulmonary vascular disease or Eisenmenger’s syndrome Pulmonic Regurgitation (PR) - most common cause is pulmonary HPN - other causes are Marfan’s, infective endocarditis and idiopathic dilatation of pulmonary artery - associated with other congenital disorders such as TOF and congenital PS murmur identical to AR - symptoms of organic PR may be tolerated Pulmonic Regurgitation (PR) - blood flows back into RV leading to RV and RA hypertropy with symptoms of right-sided HF; chronic RV overload leads to symptoms of RV failure - high pitched decresendo, diastolic blowing murmur along the left sternal border Graham Steell murmur Pulmonic Regurgitation (PR) - diagnostics: 1. ECG - RBBB, RV hypertrophy 2. CXR - non-specific findings 3. cardiac MRI - mild to moderate isolated PS does not usually progress or require treatment Pulmonic Regurgitation (PR) - percutaneous pulmonary balloon valvuloplasty or surgical valvotomy required for severe cases and to prevent right sided HF Multiple Valvular Disease Guideline #1 - determine the predominant lesion A.Most severe lesion is the predominant lesion Ex. #1 Patient has mild MS, severe AS and mild MR Ans. AS is the predominant lesion Multiple Valvular Disease Guideline #1 - determine the predominant lesion B.Lesion that causes most chamber enlargement is usually the predominant lesion Ex. #2 Patient has moderate AR, moderate MS, severely dilated LV, slightly dilated LA Ans. AR is the predominant lesion Multiple Valvular Disease Guideline #2 - left-sided lesions are more important than right-sided lesions, tailor your treatment more for the left-sided lesions Guideline No. 3 - significant stenotic lesions (MS or AS) should be given more serious attention compared to regurgitant lesions (MR or AR) Multiple Valvular Disease Guideline #4 - in severe valvular disease, surgical correction of the mechanical defect should be given prime consideration as it is likely that response to medical treatment is poor References 1. J. Jameson MD PhD, D. Kasper MD, et. al.; 2018; Harrison’s Principles Of Internal Medicine 20th Ed. 2. R. Walsh MD FACC FAHA, J. Fang MD, et. al.; 2013; Hurst’s The Heart Manual of th Cardiology 13 Ed. CVS II - Surgical Management of Valvular Heart Diseases Outline Valvular Heart Disease Aortic Valve Disease General Principles Aortic Stenosis Surgical Options Aortic Insufficiency Mitral Valve Disease Aortic Valve Operative Techniques and Results Mitral Stenosis Mitral Regurgitation Tricuspid Valve Disease Mitral Valve Operative Techniques Tricuspid Stenosis and and Results Insufficiency / 829 Multivalve Disease Objective To learn the General Principles of Valvular Heart Diseases To know the different Valvular Heart Disease To understand its Etiology, Clinical Manifestation, Diagnostic Procedures and their importance To know the different surgical procedures of valvular heart diseases General Principles The number of patients undergoing surgical management of valvular heart disease has increased, aortic or mitral valve procedures reported in 2006 to 2015. Congenital and inherited etiologies represent important clinical entities, age-associated and acquired conditions still represent the primary causes of valvular heart disease.  The most common screening method for valvular heart disease is cardiac auscultation, with murmurs classified based primarily on their timing in the cardiac cycle, but also on their configuration, location and radiation, pitch, intensity, and duration. (Table 21-6) Although some systolic murmurs are related to normal physiologic increases in blood flow, some may indicate cardiac disease, such as valvular aortic stenosis (AS), that are important to diagnose, even when asymptomatic. Classification of Cardiac Murmur  Diastolic and continuous murmurs, on the other hand, are frequently pathologic in nature. Dynamic cardiac auscultation provides further evidence as to the significance and origin of many murmurs. (Table 21-7) Hemodynamic alterations in cardiac murmur intensity Auscultation provides initial evidence to the existence of valvular disease, Signs and symptoms may help narrow the diagnosis. Abnormalities in the splitting of the heart sounds and additional heart sounds should be noted, as should the presence of pulmonary rales. Peripheral pulses should be checked for abnormal intensity or timing, and the presence of a jugular venous wave should be documented. Syncope, angina pectoris, heart failure, and peripheral thromboembolism are important and may help guide diagnosis and management. Examinations that aid in the Diagnosis and Classification of various Valvular Disorders EKG provides information regarding ventricular hypertrophy, atrial enlargement, arrhythmias, conduction abnormalities, prior myocardial infarction, and evidence of active ischemia that would prompt further workup.  Posteroanterior and lateral chest X-rays are also easy to obtain and may yield information regarding cardiac chamber size, pulmonary blood flow, pulmonary and systemic venous pressure, and cardiac calcifications.  The gold standard for the evaluation of valvular heart disease is transthoracic echocardiography (TTE), which is helpful in the noninvasive evaluation of valve morphology and function, chamber size, wall thickness, ventricular function, pulmonary and hepatic vein flow, and pulmonary artery pressures.  Valvular heart disease can produce numerous hemodynamic derangements. If left untreated, it can produce significant pressure and volume overload on the affected cardiac chamber.  Heart can initially compensate for alterations in cardiac physiology, cardiac function eventually deteriorates, leading to decreased patient functional status, ventricular dysfunction, heart failure, and eventually death. In order to optimize long-term survival, surgery or transcatheter therapeutics are recommended in various forms of valvular heart disease and in an increasing number of elderly and high-risk patients. Structural and functional remodelling following pharmacologic intervention in volume overload heart failure Kristin Lewis, DVM Pathology Resident/Graduate. Surgical Options  Valve repair is indicated in patients with aortic, mitral or tricuspid insufficiency, Mitral valve regurgitation - Symptoms and causes - Mayo Clinic  Valve replacement is appropriate in certain patient populations, it can be accomplished with either mechanical or biological prostheses, Choice of valve depends on many patient-specific factors such as age, health status, and desire for future pregnancy indications or contraindications to anticoagulation therapy. Pinterest Prosthetic heart valves are classified as either mechanical... Mechanical Valve The first bileaflet mechanical valve was introduced in 1977. Bileaflet valves are comprised of two semicircular leaflets that open and close, creating one central and two peripheral orifices Bileaflet mechanical valves have demonstrated excellent flow characteristics, low risk of late valve-related complications, including valve failure, and are currently the most commonly implanted type of mechanical valve prosthesis in the world Mechanical Valve Current options for mechanical valve replacement include either tilting disc valves or bileaflet valves. Mechanical valves are highly durable, but require permanent anticoagulation to mitigate the risk of valve thrombosis and thromboembolic sequelae. https://www.youtube.com/watch?v=hmU7UtzxowU Tissue Valves A xenograft valve is one implanted from another species, such as porcine xenograft valves, or manufactured from tissue such as bovine pericardium. Stented bovine pericardial valve is the most most commonly implanted, and the most popular valve. https://www.youtube.com/watch?v=ojW7wZRF7Cg Stentless vs Stented The chief disadvantage of stented tissue valves is a smaller effective orifice area, which increases the transvalvular gradient referred to as patient prosthetic mismatch. This effect is most pronounced in patients with small prosthetic valve areas, specifically