VALVULAR HEART DISEASE
Valvular stenosis refers to a constriction or narrowing of the valve opening.
Valvular regurgitation (also called valvular incompetence or insufficiency) occurs with
incomplete closure of the valve leaflets and results in the backward flow of blood.
Mitral Valve Stenosis
Adult mitral valve stenosis results from rheumatic heart disease. Less commonly, it
can occur congenitally, from rheumatoid arthritis and from systemic lupus
Clinical manifestations of mitral stenosis include exertional dyspnea, fatigue, palpitations
from atrial fibrillation, and a loud first heart sound and a low-pitched, rumbling diastolic
Mitral regurgitation (MR) is caused by MI, chronic rheumatic heart disease, mitral valve
prolapse, ischemic papillary muscle dysfunction, and IE.
In chronic MR, the additional volume load results in atrial enlargement, ventricular
dilation, and eventual ventricular hypertrophy.
In acute MR, there is a sudden increase in pressure and volume that is transmitted to the
pulmonary bed, resulting in pulmonary edema and life-threatening shock.
Clinical manifestations of acute MR include thready, peripheral pulses and cool, clammy
extremities; and a new systolic murmur.
Patients with asymptomatic MR should be monitored carefully, and surgery considered
before significant left ventricular failure or pulmonary hypertension develops.
Mitral Valve Prolapse
Mitral valve prolapse (MVP) is an abnormality of the mitral valve leaflets and the
papillary muscles or chordae that allows the leaflets to prolapse, or buckle, back into the
left atrium during systole. The etiology of MVP is unknown but is related to diverse
pathogenic mechanisms of the mitral valve apparatus.
In many patients MVP found by echocardiography is not accompanied by any other
clinical manifestations of cardiac disease, and the significance of the finding is unclear.
Clinical manifestations of MVP can include a murmur from regurgitation that gets more
intense through systole, chest pain, dyspnea, palpitations, and syncope. Aortic Valve Stenosis
In older patients, aortic stenosis is a result of rheumatic fever or senile fibrocalcific
degeneration that may have an etiology similar to coronary artery disease.
Aortic stenosis results in left ventricular hypertrophy and increased myocardial oxygen
consumption, and eventually, reduced cardiac output leading to pulmonary hypertension
Clinical manifestations include a systolic, crescendo-decrescendo murmur and the classic
triad of angina, syncope, and exertional dyspnea.
Aortic Valve Regurgitation
Acute aortic regurgitation (AR) is caused by IE, trauma, or aortic dissection.
Chronic AR is generally the result of rheumatic heart disease, a congenital bicuspid aortic
valve, syphilis, or chronic rheumatic conditions.
Clinical manifestations of acute AR include severe dyspnea, chest pain, and hypotension
indicating left ventricular failure and shock that constitute a medical emergency.
Clinical manifestations of chronic AR include exertional dyspnea, orthopnea, and
paroxysmal nocturnal dyspnea after considerable myocardial dysfunction has occurred.
Tricuspid and Pulmonic Valve Disease
Diseases of the tricuspid and pulmonic valves are uncommon, with stenosis occurring
more frequently than regurgitation.
Tricuspid valve stenosis occurs almost exclusively in patients with rheumatic mitral
stenosis, in IV drug abusers, or in patients treated with a dopamine agonist.
Pulmonary stenosis is almost always congenital.
Tricuspid and pulmonic stenosis both result in the backward flow of blood to the right
atrium and right ventricle, respectively.
Tricuspid stenosis results in right atrial enlargement and elevated systemic venous
pressures. Pulmonic stenosis results in right ventricular hypertension and hypertrophy.
Collaborative Care of Valvular Heart Disease
Collaborative care of valvular heart disease includes the prevention of recurrent
rheumatic fever and IE and the prevention of exacerbations of HF, acute pulmonary
edema, and thromboembolism.
Anticoagulant therapy is used to prevent and treat systemic or pulmonary embolization
and is used prophylactically in patients with atrial fibrillation. An alternative treatment for valvular heart disease is percutaneous transluminal balloon
valvuloplasty (PTBV) to split open the fused commissures. It is used for mitral, tricuspid,
and pulmonic stenosis, and less often for aortic stenosis.
Surgical intervention is based on the clinical state of the patient and depends on the
valves involved, the valvular pathology, the severity of the disease, and the patient’s
Valve repair (e.g., mitral commissurotomy [valvulotomy], is typically the surgical
procedure of choice.
Open surgical valvuloplasty involves repair of the valve by suturing the torn leaflets,
chordae tendineae, or papillary muscles and is used to treat mitral or tricuspid
Annuloplasty entails reconstruction of the annulus, with or without the aid of prosthetic
rings (e.g., a Carpentier ring).
Prosthetic mechanical valves are made from manmade materials.
Prosthetic biologic valves are constructed from bovine, porcine, and human cardiac tissue
and usually contain some human-made materials.
Mechanical prosthetic valves are more durable and last longer than biologic valves but
have an increased risk of thromboembolism, necessitating long-term an