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. murmur located at apex 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 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