Updated: 3/16/2021

Valvular Diseases

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Snapshot
  • A 57-year-old man presents to the emergency department complaining of severe chest pain and difficulty breathing. His exam reveals a weak, delayed carotid upstroke and a parodoxically-spliting S2. 
Introduction
  • The leading cause of valvular heart disease in the United States is
    • mechanical degeneration
  • In the developing world
    • rheumatic fever is the most common etiology
  • Types
    • aortic stenosis
    • aortic regurgitation
    • mitral stenosis
    • mitral regurgitation
Aortic Stenosis
  • See topic
Aortic Regurgitation
  • May appear acutely or as a chronic condition
    • acute causes include trauma, aortic dissection, and infection
    • chronic cases include
      • birth defects 
      • rheumatic fever
      • connective tissue disorders
  • Symptoms/Physical exam
    • patients may present with worsening symptoms including
      • dyspnea on exertion
      • paroxysmal nocturnal dyspnea
      • lightheadedness on standing or changing positions too quickly
    • chest ausculation characterized by three distinct murmurs  
      • blowing diastolic murmur at LSB
      • midsystolic murmur at the apex
      • mid-diastolic rumble
    • other signs 
      • head-bobbing with heart beats
        • caused by caudal venous outflow obstruction
      • water hammer pulse
      • femoral bruits on compression of femoral pulse 
        • Duroziez sign
  • Evaluation
    • echocardiography is diagnostic
      • Doppler imaging shows back-flow across the aortic valve during diastole
    • EKG may show signs of dilated ventricles
  • Differential Diagnosis
    • other valvular disease, including aortic stenosis or mitral regurgitation, CHF
  • Treatment
    • Medical management until symptoms warrant intervention
      • Vasodilator therapy
        • CCBs and ACEIs
  • Prevention, Prognosis, and Complications
    • acute cases rapidly progress to pulmonary congestion, shock, and death if not treated 
Mitral Valve Stenosis
  • Most common etiology continues to be rheumatic fever
  • Symptoms/Physical exam
    • presents with wide range of symptoms
      • dyspnea on exertion
      • arrhythmias
      • orthopnea
      • infective endocarditis
      • paroxysmal nocturnal dyspnea
    • chest auscultation may reveal
      • opening snap
    • other signs include
      • crackles and rales indicative of pulmonary edema
  • Evaluation
    • Doppler echocardiography is diagnostic
    • CXR will likely demonstrate mild to severe pulmonary edema
  • Differential Diagnosis
    • other valvular disease, CHF
  • Treatment 
    • Antiarrhythmics for symptom relief
      • Beta blockers, digoxin
    • Severe cases require surgical intervention
      •  Repair by commissurotomy preferred over replacement 
      • Balloon valvotomy 
      • Valve replacement
  • Prevention, Prognosis, and Complications
    • If left untreated, can progress to severe CHF and ultimately death
Mitral Valve Regurgitation
  • Two major causes include
    • rheumatic fever
    • chordae tendonae rupture
  • Symptoms/Physical exam
    • presents with a range of symptoms including
      • dyspnea
      • orthopnea
      • fatigue
    • chest auscultation reveals
      • holosystolic murmur that radiates to the axillae
  • Evaluation
    • Doppler echocardiography is diagnostic
      • shows regurgitant flow
    • CXR may show enlarged left atrium
    • Angiography used to assess severity of disease
  • Differential Diagnosis
    • other valvular diseases, CHF
  • Treatment
    • Decrease afterload
      • ACE inhibitors and ARBs
    • Antiarrythmics may be necessary if AF or others develop
  • Prevention, Prognosis, and Complications
    • at increased risk of developing atrial fibrillation due to enlargement
Cardiac Auscultation in Valvular Disease
  • Aortic Stenosis
    • loud crescendo-decrescendo systolic ejection murmor in right 2nd intercostal space
  • Mitral Regurgitation
    • high pitched holosystolic loudest at apex radiating to axilla
  • Tricuspid Regurgitation
    • soft holosystolic at left sternal border
  • Mitral Prolapse
    • crisp midsystolic click and a delayed or late systolic regurgitation murmur.
  • Aortic Regurgitation
    • high pitched blowing early diastolic decrescendo murmor at left sternal border
  • Mitral Stenosis
    • rumbling mid-diastolic murmor with ccenuated S1. S2, best heard on expiration or when the patient is squating or excercising because venous return is increase

Treatment
  • Medical management as above
  • Surgical management
    • surgical repair
    • surgical replacement: mechanical valve or bioprosthetic valve
      • requires post-surgical anticoagulation
      • can cause hemolysis due to shearing force
        • schistocytes seen on peripheral smear 
        • elevated LDH, decreased haptoglobin, and mild hyperkalemia

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