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Valvular heart diseases

Last updated: July 20, 2021

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Valvular heart diseases can take the form of stenosis, insufficiency (regurgitation), or a combination of the two. These defects are typically acquired as the result of infections, underlying heart disease, or degenerative processes. However, certain congenital conditions can also cause valvular heart diseases. Acquired defects are found primarily in the left heart as a result of higher pressure and mechanical strain on the left ventricle. The type of valvular disease determines the type of cardiac stress and subsequent symptoms. Valvular stenosis leads to a greater pressure load and concentric hypertrophy, while insufficiencies are characterized by volume overload and eccentric hypertrophy of the preceding heart cavities. Diagnostic procedures typically include ECGs, chest x-ray, and echocardiograms. Management consists of interventional or surgical procedures to reconstruct or replace valves, as well as medical treatment of possible heart failure.

Epidemiological data refers to the US, unless otherwise specified.

Valvular heart defects may either be acquired or congenital. Acquired defects are more common and typically occur secondary to infections (postinflammatory), degenerative processes, or heart disease.

All valvular defects can eventually lead to symptoms of heart failure as a result of excessive strain on the ventricles.

Physical examination

Auscultation in valvular defects
Maximum point Murmur Characteristics
Aortic stenosis
Aortic regurgitation
Mitral stenosis
  • Heart apex (midclavicular 5th left ICS)
Mitral valve prolapse
  • Heart apex (midclavicular 5th left ICS)
  • Midsystolic high-frequency click (due to the tensing of the chordae tendinae)
  • Loudest before S2
Mitral regurgitation
  • Blowing
  • Radiation into the axilla

Pulmonary stenosis

Pulmonary regurgitation
Tricuspid stenosis (extremely rare)
Tricuspid regurgitation (extremely rare)
  • Augmentation of the murmur's intensity with inspiration (Carvallo sign)

References:[4][5][6][7]

Symptomatic

Causal

  • Surgery: The choice of procedure is based on the patient's individual risk profile and an evaluation of benefits.
    • Valve reconstruction (annuloplasty)
      • Procedure: ring-shaped device attached to the outside of the valve opening to re-establish shape and function of valve
      • Reduced thromboembolic risk compared to mechanical prosthetic valve; but high risk of recurring stenosis
      • Lower mortality rate than valve replacements, though replacements are more durable
    • Prosthetic valve replacement
Prosthetic heart valve
Mechanical prosthetic valve Biological prosthetic valve
Pros
  • Valve has a long lifespan
  • Anticoagulation only necessary for 3 months post operation
Cons
  • Short lifespan due to sclerotic degeneration
    • May need to be replaced every ten years
Indications
  • Younger patients
  • Previously anticoagulated patients (e.g., with pre-existing atrial fibrillation)
  • Older patients
  • Patients with a high risk of bleeding
  • Women with a desire to have children
  • Interventional valve replacement via catheter
    • Transcatheter aortic valve replacement (TAVR)
    • Transcatheter mitral valve replacement (TMVR)
  • Percutaneous balloon valvuloplasty for stenoses

References:[7][8]

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  2. Lincoln J, Garg V. Etiology of Valvular Heart Disease. Circulation Journal. 2014; 78 (8): p.1801-1807. doi: 10.1253/circj.cj-14-0510 . | Open in Read by QxMD
  3. Waller BF. Etiology of pure tricuspid regurgitation.. Cardiovasc Clin. 1987; 17 (2): p.53-95.
  4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  5. Otto CM. Etiology, clinical features, and evaluation of tricuspid regurgitation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/etiology-clinical-features-and-evaluation-of-tricuspid-regurgitation.Last updated: August 11, 2015. Accessed: February 26, 2017.
  6. Gaasch WH. Tricuspid stenosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/tricuspid-stenosis.Last updated: June 8, 2015. Accessed: February 26, 2017.
  7. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol. 2017; 70 (2): p.252-289. doi: 10.1016/j.jacc.2017.03.011 . | Open in Read by QxMD
  8. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014; 370 (1): p.23-32. doi: 10.1056/NEJMoa1312808 . | Open in Read by QxMD
  9. Herold G. Internal Medicine. Herold G ; 2014