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Valvular Heart Disease

From Mediwikis

All left sided valve lesions can produce pulmonary hypertension due to elevated left atrial pressure and subsequent changes in pulmonary vasculature. Anything that causes atrial dilatation can eventually lead to atrial fibrillation which is an important risk factor to pick up on as individuals have an increased risk of strokes and heart attacks.

Stenosis Narrow, obstructive valves, causing pressure overload in the chamber.

  • Aortic stenosis produces left ventricular hypertrophy
  • Mitral stenosis produces left atrial dilatation

Regurgitation Leaking valves, producing volume overload with resulting dilatation. Think of too much blood being forced into a small space which causes the space to enlarge to compensate.

Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation Pulmonary Stenosis Pulmonary Regurgitation Tricuspid Stenosis Tricuspid Regurgitation
Left - Systolic - Common Left - Diastolic - Moderate Left - Diastolic - Rare Left - Systolic - Common Right - Systolic - Rare Right - Diastolic - Rare Right - Diastolic - Rare Right - Systolic - Rare
  • Calcification
  • Congenital
  • Rheumatic fever
  • Congenital
  • Infective endocarditis
  • Rheumatic fever
  • Rheumatic heart disease
  • Rheumatic heart disease
  • Aortic valve disease
  • Myocarditis
  • Cardiomyopathy
  • Hypertensive heart disease
  • Ischaemic heart disease
  • Infective endocarditis
  • Drugs
  • Congenital
  • Rheumatic fever
  • Pulmonary hypertension
  • Rheumatic heart disease
  • Carcinoid syndrome
  • Functional - right ventricle dilatation
    • Cor pulmonale
    • Myocardial infarction
    • Pulmonary hypertension *Organic
    • Rheumatic heart disease
    • Infective endocarditis
  • Organic
    • Rhuematic heart disease
    • Infective endocarditis
  • Slow rising pulse as the ventricle takes longer to empty
  • Narrow pulse pressure due to the pressure overload in the heart
  • Forceful apex due to left ventricular hypertrophy (but the apex beat is not normally displaced)
  • Collapsing pulse
  • Wide pulse pressure because the blood drops back into the left ventricle causing a big pressure drop between systole and diastole
  • Thrusting apex beat due to left ventricular volume overload
  • Apex beat displaced
  • Shorter early diastolic murmur indicates more severe disease
  • Malar flush
  • Atrial fibrillation
  • Tapping apex beat but not displaced
  • Forceful, displaced, apex beat to left ventricular volume overload
  • Atrial fibrillation due to left atrial enlargement
  • Dyspnoea
  • Fatigue
  • Oedema
  • Ascites
  • Pulmonary hypertension
  • Fatigue
  • Ascites
  • Oedema
  • Fatigue
  • Hepatic pain on exertion
  • Ascites
  • Oedema
Ejection Systolic Murmur mini.jpg

Ejection Systolic Murmur

Early Diastolic Murmur mini.png Early Diastolic Murmur Mid Diastolic Murmur mini.png Mid-Diastolic Murmur Pansystolic Murmur mini.png Pansystolic Murmur Ejection Systolic Murmur mini.jpg Ejection Systolic Murmur Early Diastolic Murmur mini.png Early Diastolic Murmur Early Diastolic Murmur mini.png Early Diastolic Murmur Pansystolic Murmur mini.png Pansystolic Murmur


  • Diamond-shaped pattern crescendo/decrescendo murmur (harsh sounding ba-whoosh)
  • Aortic area, radiates to neck
  • The second heart sound may be softer due to the restricted movement of the valve
  • There may be an ejection click when the murmur starts
  • Severe stenosis may lead to splitting of the second heart sound as the slow ejection of blood from the left ventricle delays the closing of the aortic valve leading to the pulmonary valve to close first
  • Lower left sternal edge
  • Patient sitting forward
  • Listen in expiration
  • Low rumbling murmur
  • Apex in held expiration with patient on left side
  • Apical murmur, radiates to axilla
  • Similar intensity throughout systole (much softer sounding than stenosis)
  • Soft S1 due to incomplete closure of the mitral valve (soft sounding shwoosh-click)
  • Loud P2 if pulmonary hypertension
  • Normal S1
  • Widely split S2
  • Listen on inspiration
  • Listen on inspiration
  • Listen on inspiration
  • Listen on inspiration
  • Best heard at 4th intercostal space on right side


Investigations for valvular heart disease

ECGs often none specific, but may show evidence of some of the cardiac changes such as hypertrophy or dilatation. Again atrial fibrillation is a very important sign to detect!

Chest x-rays may show signs of cardiac enlargement, calcification of valves and signs of pulmonary oedema.

Echocardiograms can directly asses the valve structure and function. This can also be used to observe changes in the chamber size and function. This is the primary way to diagnose and quantify valvular defects.

Consequences of valvular disease

Symptoms

  • Exertional dyspnoea
  • Angina like chest discomfort
  • Fatigue
  • Palpitations
  • Exertional syncope (aortic stenosis)

Complications

  • Arrhythmias
  • Congestive cardiac failure
  • Left ventricular pressure/volume overload
  • Left ventricular failure
  • Pulmonary hypertension due to elevated left atrial pressure
  • Right ventricular failure

Treatments

  • Valve replacement/repair in severe cases
  • Metal valves require lifetime anti-coagulation
  • Prosthetic valves may eventually fail
  • Transfemoral TAVI is a minimally invasive valve replacement technique that is similar to stenting only a lot bigger!