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Valvular heart disease diagnosis and treatment

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- [Voiceover] So, the last topic that we should talk about is the diagnosis and treatment of valvular heart disease. Any good diagnostician will tell you that the majority of the diagnosises made are based on a good H and P, or history and physical. Now, these valvular conditions are all very different. There are multiple valves and there are multiple things that can go wrong with them. But, in general, you should be able to elicit certain things from a history and physical exam that'll point you in the direction of the heart, and you move forward with different diagnostic tests to, then, confirm your diagnosis. So, let's start with history. On history, you wanna know if the patient's had any chest pain, any shortness of breath, any trouble with exercise or exercise intolerance, any swelling, it may be in their extremities, and maybe a chronic cough. And, again, none of these are really specific for valvular heart disease, but they could all point you in the direction of something going wrong with the heart. And, maybe some history of syncopal episodes or feinting, or any palpitations. On the physical exam, you wanna look for any jugular venous distention, or JVD, a sign that blood is kind of backing up in the right heart, or any extra heart sounds like an S3 or an S4, changes in blood pressure or wide pulse pressure, or different blood pressures in the arms can all lead you to think that maybe there's something wrong with the heart. A change in pulse, so, maybe the pulse is not regular, and there could be an arrhythmia that's associated with a primary valvular heart condition. You can feel for the PMI, or the point of maximal impulse, and see if it's where it normally should be. You can look for any edema, usually in the extremities and in the gravity dependent portions of the body, so, usually the feet and ankles. And, finally, one that is somewhat specific to valvular heart disease is listen for a murmur. And, so, a murmur is just turbulent blood flow through a valve. So, how do we listen for a murmur? Well, we use our stethoscope and we listen here in the right upper sternal border, and then the left upper sternal border, and then the left lower sternal border, left-mid to lower, and then in the fifth intercostal space, in the mid-clavicular line. And this is also called the apical area. And the right upper sternal border is usually indicative of aortic pathology. The left upper sternal border is usually indicative of pulmonic pathology. The mid to lower left sternal border is usually tricuspid, but can be aortic. And the apex, or mitral area, is usually indicative of mitral valve pathology. So, now, once you've elicited a good history from someone, and you've done a thorough physical exam, now, maybe, it's time to move on to some of your diagnostic tests. So, what are our options? So, with this history and physical, some people may jump to an EKG, or an electrocardiogram, which measures the electrical impulses in the heart, or a chest x-ray, which we'll abbreviate CXR. And so, the EKG kinda looks like this, I'm sure you've all seen drawings of that. And, from this, you can tell if someone has an arrhythmia, and you can also tell, if maybe, some of the chambers of the heart are bigger or more muscular, and you can also diagnose things like a heart attack. And with a chest x-ray, you can tell if the heart is dilated or larger. And so, if the heart silhouette, that I've outlined here, is actually larger than 50% of the thoracic cavity that I'm showing now, then that's actually considered cardiomegaly, meaning the heart is big. And that could be an indication that there's something wrong with the valves, but it's not necessarily specific. Now, when we talk about the gold standard for diagnosing valvular heart disease, we talk about echocardiography, or simply know as echo. And this is the use of sound waves to actually image the heart in real time. And so, you'll see an example here, and this is a specific view called the four-chamber view and that's because there's one, two, three, and four chambers there that you can see. And there are many other views that are used, and those views can see the other valves that aren't shown in this one, like the aortic and the pulmonic. And they show them in real time, and there are also certain modes of echo that can show you the actual flow of blood and if it's traveling in the right direction or the wrong direction, and you can get a lot of good measurements from this that can really give you a firm diagnosis of valvular heart disease and quantify how bad the valvular heart disease, whether it's mild regurgitation or stenosis to severe regurgitation or stenosis. And so, again, this test is diagnostic for valvular heart disease, and it is also the gold standard. So, what happens if, for some reason, the echo is inconclusive, meaning, you can't really tell from it if someone's got valvular heart disease. Well, now you can go to a little bit more invasive of a test called a cardiac catheterization, or just a cardiac cath. And so, what they'll do here is they'll take a catheter, or a wire, and stick it one of the major arteries. So, here something like the femoral artery that I'm circling on this, and I'm not sure if you'll be able to read that, but that says femoral artery. And so, they stick this catheter in your femoral artery and they move it all the way up into the aorta and into the left side of the heart. And in here, that little catheter has a pressure transducer on it, and it can measure pressures in the different chambers and pressures across the different valves that separate the chambers. And there are standards for these measurements and depending on what the measurements are on the particular patient, the cardiologist can use the results from this and different pressure tracings to actually diagnose valvular heart disease. And this is very accurate, but slightly more invasive. Usually, patients don't need this to diagnose valvular heart disease. So, now that we've pretty much diagnosed valvular heart disease in a patient, we need to know what our treatment options are. And, again, they're different based on what the actual valve condition is. But, in general, you have medical treatment, and you have surgical treatment. So, for medical treatment, because these are all very different conditions, there's no one regimen that works for everyone. But, in general, what we're trying to do with medical therapy is to just optimize the cardiac physiology so that we can stop the condition from progressing. And you'll hear people talk about all the common cardiac drugs, such as beta blockers, and calcium channel blockers, and ACE inhibitors, and diuretics, and a lot of these are really aimed at optimizing physiology so that these conditions don't progress. So, lowering the pressure that the heart has to contract against, or decreasing the amount of fluid that returns to the heart so that it doesn't contract as hard. In terms of surgical treatment, you can have what's called a balloon valvuloplasty, and what they do there is, in a similar way to the cardiac catheterization, they put a catheter up through one of the major arteries, and say, for instance, it's the aortic valve, they can actually go and pass the catheter across the aortic valve, and then blow up a balloon on that catheter, and what that does is that actually increases the opening, or the opening size of the valve and can actually reduce symptoms. Although, this is not as permanent of a solution. Now, you also have the option of open heart surgery. And so, this is a pretty invasive strategy, but they go in and they cut out the old valve and they replace it with either a metallic valve, made out of metal, or a bioprosthetic valve. And this is usually made from the sack that surrounds the heart of either a pig or a cow. And there are different advantages to one versus the other that's a little bit beyond the scope of what we're talking about here. And so, let's show a picture of open heart surgery and just to orient you a little bit, the patient's head is up here. And their feet are gonna be down there. And this is the heart right here. And then, you'll notice this tube coming out of the heart. And then, this tube coming out of the heart. And what that is is those are actually connected to the heart-lung machine. So, a machine is actually taking out all the unoxygenated blood, oxygenating it, and then putting it back into the body. And so, it's kind of playing the role of your heart and your lungs, hence the heart-lung machine, or the more formal name, cardiopulmonary bypass. Now, there's a newer intervention that's been kinda hot in the recent years and this is called TAVR, or transcatheter aortic valve replacement. And so, this is specific to the aortic valve, but newer technologies are coming along to help with other valve problems. But, specifically, this is when you take a catheter, again, and put it through the femoral artery, and that catheter goes all the way up to the heart, and they cross the aortic valve, and they basically deploy a valve that has been pretty brilliantly placed onto the catheter in a condensed form, and they deploy this valve over the old valve without ever having to make a large incision in you. And so, this is a minimally invasive form of valve replacement. So, I hope that you have a better idea of a general way to diagnose and treat valvular heart disease.