Valvular Disease Summary

Valve Disorders

  • Stenosis: Narrowing → forward flow murmur
  • Regurgitation: Leakage → backward flow murmur
  • Timing: Systolic vs. Diastolic murmurs

Aortic Stenosis (AS)

  • Triad: Angina, syncope, heart failure
  • Murmur: Harsh systolic (RUSB → carotids)
  • Severe: Valve area ≤1 cm²
  • Emergency: Avoid vasodilators in pulmonary edema

Aortic Regurgitation (AR)

  • Murmur: Early diastolic (LUSB)
  • Signs: Wide pulse pressure, waterhammer pulse
  • Acute AR: Surgical emergency
  • Chronic: Afterload reduction (ACEi/ARB)

Mitral Stenosis (MS)

  • Murmur: Diastolic rumble (apex)
  • Signs: Loud S1, opening snap
  • Complication: AF (50% cases)
  • Anticoagulation: Warfarin for AF (NOACs not recommended)

Mitral Regurgitation (MR)

  • Murmur: Pansystolic (apex → axilla)
  • Acute MR: Surgical emergency
  • Management: Afterload reduction, diuretics
  • Chronic: Laterally displaced apex

Emergency Management

  • AS: Diuretics, avoid vasodilators
  • Acute AR/MR: Surgical emergency
  • MS with AF: Rate control, anticoagulation
  • Cardiogenic shock: Inotropes, IABP

Other Valvular Disorders

  • MVP: Mid-systolic click ± murmur
  • TR: Pansystolic murmur ↑ with inspiration
  • Pulmonary: Rare, usually secondary

Valvular Heart Disease

Disorders of cardiac valves causing stenosis (narrowing) or regurgitation (leakage)

Introduction

Valvular heart disease involves either narrowing (stenosis) or leakage (regurgitation) of the cardiac valves, leading to impaired blood flow and cardiac dysfunction.

Key concepts: Stenosis causes murmurs from forward flow through narrowed valves, while regurgitation causes murmurs from backward flow through incompetent valves.

Valvular Disorders by Type

Valve Stenosis Regurgitation
Aortic Systolic murmur Diastolic murmur
Mitral Diastolic murmur Systolic murmur
Tricuspid Diastolic murmur Systolic murmur
Pulmonary Systolic murmur Diastolic murmur

Aortic Stenosis (AS)

Definition

Restricted opening of aortic valve cusps causing LV outflow obstruction. Severe when valve area ≤1 cm² (normal 3-4 cm²).

Causes

  • Congenital (young adults)
  • Degenerative calcific (most common in UK)
  • Rheumatic (most common worldwide)

Pathophysiology

Progressive obstruction → LV pressure overload → concentric LV hypertrophy → diastolic dysfunction → eventual LV failure.

Clinical Features

Symptoms

  • Classic triad: Angina, syncope, heart failure
  • Sudden cardiac death risk

Examination

  • Pulsus parvus et tardus (slow-rising pulse)
  • Sustained, heaving apex beat
  • Harsh crescendo-decrescendo systolic murmur (RUSB radiating to carotids)
  • Soft/absent S2 in severe AS

Investigations

Test Findings
ECG LVH with strain pattern, LBBB
CXR Post-stenotic aortic dilation, calcified valve, late LV enlargement
Echo Gold standard for assessment of valve area and gradients

Emergency Management

Symptomatic severe AS requires urgent cardiology referral for valve replacement.

Presentation Management
Pulmonary edema Diuretics, CPAP. Avoid vasodilators
Atrial fibrillation Rate control with digoxin
Angina Beta-blockers if no heart failure
Cardiogenic shock Inotropes, emergency surgery

Aortic Regurgitation (AR)

Definition

Failure of aortic valve closure causing diastolic backflow into LV.

Causes

  • Acute: Endocarditis, aortic dissection, trauma
  • Chronic: Bicuspid valve, rheumatic, Marfan's, annuloaortic ectasia

Pathophysiology

Volume overload → LV eccentric hypertrophy → eventual LV failure. Acute AR causes sudden pressure overload without time for compensation.

Clinical Features

Chronic AR

  • Wide pulse pressure
  • Waterhammer pulse, Corrigan's sign
  • Early diastolic murmur (LUSB)
  • Austin Flint murmur (apical diastolic rumble)

Acute AR

  • Cardiogenic shock
  • Pulmonary edema
  • Soft murmur (low pressure gradient)

Emergency Management

Type Management
Acute AR Emergency surgery, vasodilators (nitroprusside), inotropes
Chronic AR Afterload reduction (ACEi/ARB), diuretics for CHF

Mitral Stenosis (MS)

Definition

Impaired LV filling due to narrowed mitral valve (severe when area ≤1.5 cm², normal 4-6 cm²).

Causes

  • Rheumatic fever (most common)
  • Calcific degeneration
  • Congenital (rare)

Pathophysiology

LA pressure overload → pulmonary congestion → reactive pulmonary hypertension → RV failure.

Clinical Features

Symptoms

  • Dyspnea (most common)
  • Hemoptysis
  • Atrial fibrillation (50% cases)

Examination

  • Loud S1, opening snap
  • Low-pitched diastolic rumble (apex)
  • Mitral facies (malar flush)
  • Signs of pulmonary hypertension

Emergency Management

Presentation Management
Pulmonary edema Diuretics, rate control for AF
Atrial fibrillation Rate control (β-blockers, CCBs, digoxin)
Hemoptysis May require thoracic surgery

Anticoagulation: All MS patients with AF require warfarin (NOACs not recommended).

Mitral Regurgitation (MR)

Definition

Systolic backflow from LV to LA through incompetent mitral valve.

Causes

  • Acute: Papillary muscle rupture (MI), chordal rupture (endocarditis)
  • Chronic: MVP, rheumatic, annular calcification, cardiomyopathy

Pathophysiology

Volume overload → LA/LV dilation → pulmonary congestion. Acute MR causes sudden pulmonary edema.

Clinical Features

Chronic MR

  • Fatigue, dyspnea
  • Laterally displaced hyperdynamic apex
  • Pansystolic murmur (apex → axilla)
  • S3 gallop

Acute MR

  • Cardiogenic shock
  • Pulmonary edema
  • Soft murmur (low LA-LV gradient)

Emergency Management

Acute MR is a surgical emergency with high mortality without prompt intervention.

Management Steps
  1. Oxygen, CPAP/intubation for respiratory failure
  2. Afterload reduction (nitroprusside)
  3. Diuretics for pulmonary edema
  4. IABP if cardiogenic shock
  5. Emergency surgery for papillary muscle rupture

Other Valvular Disorders

Mitral Valve Prolapse (MVP)

  • Mid-systolic click ± late systolic murmur
  • Mostly benign (2-5% population)
  • Rarely causes significant MR
  • Rule out other causes for symptoms

Tricuspid Regurgitation (TR)

  • Pansystolic murmur (LSE, ↑ with inspiration)
  • RV failure signs (JVD, hepatic congestion, edema)
  • Common causes: Pulmonary HTN, endocarditis (IVDU), Ebstein's anomaly
  • Treat underlying cause