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Updated: May 25 2023

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.
      • 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
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