Valvular heart diseases

Last updated: July 20, 2023

Summarytoggle arrow icon

Valvular heart disease (VHD) comprises a group of conditions that affect the heart valves. Valvular defects are either acquired or congenital and manifest as stenosis and/or insufficiency (regurgitation) of the valves. Acquired defects, which are primarily found in the left heart, are the most common form of VHD and often occur secondary to infections (postinflammatory), degenerative processes, or underlying heart disease. 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 medical therapy for symptoms (e.g., due to heart failure) as well as interventional or surgical procedures to repair, reconstruct, or replace valves.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

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.

Etiology of valvular heart conditions [2][3]
Valve stenosis Valve regurgitation
Left heart Mitral valve
Aortic valve
  • Degenerative calcification (most common)
  • Rheumatic endocarditis
  • Congenital (e.g., unicuspid, bicuspid, or hypoplastic valve)
Right heart Tricuspid valve
Pulmonary valve

Clinical featurestoggle arrow icon

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)
  • Late-systolic crescendo
  • Midsystolic high-frequency click (due to the tensing of the chordae tendinae)
  • Loudest before S2
Mitral regurgitation
  • Blowing
  • Radiation into the axilla

Pulmonary stenosis

  • Crescendo-decrescendo ejection systolic murmur
  • Possible radiation into the back

  • Possible early systolic pulmonary ejection click and/or widely split 2ndheart sound

Pulmonary regurgitation
Tricuspid stenosis (extremely rare)
  • Delayed diastolic murmur with a decrescendo
  • Possible pre-systolic crescendo
Tricuspid regurgitation
  • Augmentation of the murmur's intensity with inspiration (Carvallo sign)


Managementtoggle arrow icon

This section provides a general overview of various management strategies for valvular heart diseases (VHDs). See the respective articles on aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation for the management of acutely decompensated VHD, and for further details on the management of chronic VHD.

Approach [6]

  • Perform a thorough initial evaluation, including TTE and assessment of symptoms and comorbidities.
  • Consider the need for advanced studies to identify symptom etiology and further characterize valvular lesions.
  • Classify the disease according to severity.
  • Refer patients with indications for interventional treatment (e.g., those with severe and/or symptomatic VHD):
  • Refer patients without indications for valve intervention at diagnosis to a cardiologist for monitoring.
  • Offer supportive care to all patients.

Acutely decompensated VHD (e.g., presenting as cardiogenic shock, acute heart failure, or acute arrhythmia symptoms) requires urgent management and cardiology consultation.

The approach to management depends on the type and severity of VHD, the patient's individual risk profile (e.g., comorbidities, age, and fitness level), evaluation of risks and benefits of each procedure, and shared decision-making.

Diagnosticstoggle arrow icon

Minimum diagnostic workup [6]

Advanced studies [6]

Classification [6]

Medical treatmenttoggle arrow icon

Supportive care [6]

Monitoring for disease progression [6]

Monitor all patients without indications for intervention at diagnosis.

  • Repeat patient history and physical examination annually.
  • Obtain TTE follow-up at fixed intervals depending on the type and severity of valve defect.
  • Consider advanced studies and/or referral for valve intervention depending on findings.

Interventional treatmenttoggle arrow icon

Valve repair [6]

  • Valve reconstruction
    • Annuloplasty [7]
      • A ring-shaped device is attached to the outside of the valve opening to reestablish the shape and function of the valve.
      • Commonly used to treat mitral valve regurgitation [8]
    • Leaflet repair: involves the use of a clip device; may be performed in patients with mitral valve regurgitation
  • Valvuloplasty
    • A procedure performed in patients with valvular stenosis (e.g., aortic valve stenosis or mitral stenosis) to separate fused or calcified valve leaflets.
    • Approach
      • Percutaneous balloon valvuloplasty: A balloon is advanced into the target valve (either transfemorally or transapically) and inflated, opening the stenotic valve.
      • Open commissurotomy: open surgical procedure to separate fused and/or calcified leaflets

Prosthetic heart valve replacement [6]

Overview of prosthetic heart valve replacement options [6]
Mechanical prosthetic valve Biological prosthetic valve
  • Older patients (≥ 65 years of age), [6]
  • Patients with a high risk of bleeding
  • Patients who are currently pregnant or have a desire to carry a pregnancy in the future
  • Valve has a long lifespan.
  • Anticoagulation is only necessary for 3 months after surgery.

The choice of mechanical vs. bioprosthetic valve replacement should be based on shared-decision making, patient age and preference, presence of comorbidities (e.g., conditions that increase the patient's surgical risk), and ability to take anticoagulation.

Replacement route

The approach depends on the type of valve (e.g., mechanical vs. bioprosthetic) and the patient's surgical risk.

  • Surgical heart valve replacement: may be done in conjunction with a CABG in suitable patients who require both procedures
  • Transcatheter aortic valve replacement (TAVR)
    • A minimally invasive, percutaneous procedure that utilizes an endovascular technique to replace the aortic valve.
    • A collapsible replacement valve is inserted via a catheter and placed over the native valve.
    • Once the replacement valve is expanded, it displaces the old valve and assumes its function.
  • Transcatheter mitral valve replacement

Complications of heart valve intervention [6][9]

Preoperative risk assessment [6]

Post-procedure follow-up [6]

  • Monitor patients for recurrent or persistent symptoms and complications of heart valve intervention.
  • Obtain TTE to evaluate valve and cardiac function.
    • 1–3 months after valve procedure [6]
    • At fixed intervals thereafter depending on type of valve replacement

Anticoagulant therapy after heart valve replacement [6]

Insufficient anticoagulation increases the risk of thromboembolism, while excessive anticoagulation with VKA increases bleeding risk significantly. In patients with a mechanical valve and uncontrollable hemorrhage, anticoagulation reversal may be indicated.

Referencestoggle arrow icon

  1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2020; 143 (5).doi: 10.1161/cir.0000000000000923 . | Open in Read by QxMD
  2. 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
  3. Mazine A, Badiwala M, Cohen G. Year in review. Curr Opin Cardiol. 2016; 31 (2): p.154-161.doi: 10.1097/hco.0000000000000268 . | Open in Read by QxMD
  4. Vesey JM, Otto CM. Complications of prosthetic heart valves. Curr Cardiol Rep. 2004; 6 (2): p.106-111.doi: 10.1007/s11886-004-0007-x . | Open in Read by QxMD
  5. Dürrleman N, Pellerin M, Bouchard D, et al. Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute.. J Thorac Cardiovasc Surg. 2004; 127 (5): p.1388-92.doi: 10.1016/j.jtcvs.2003.12.013 . | Open in Read by QxMD
  6. Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic Heart Valve Thrombosis. J Am Coll Cardiol. 2016; 68 (24): p.2670-2689.doi: 10.1016/j.jacc.2016.09.958 . | Open in Read by QxMD
  7. Iung B, Vahanian A. Epidemiology of Acquired Valvular Heart Disease. Can J Cardiol. 2014; 30 (9): p.962-970.doi: 10.1016/j.cjca.2014.03.022 . | Open in Read by QxMD
  8. 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
  9. Waller BF. Etiology of pure tricuspid regurgitation.. Cardiovasc Clin. 1987; 17 (2): p.53-95.
  10. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  11. 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

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