A symptom-complex paradigm for the main chronic heart valve pathologies:
Aortic Stenosis (AS)
- asymptomatic, harsh systolic murmur at
apex radiating to sternal notch and carotids
During a long latent period with increasing outflow tract obstruction, which results in increasing left ventricular pressure load, patients remain asymptomatic and acute complications are rare. However, as soon as symptoms such as exertional dyspnoea, angina, or dizziness and syncope occur, outcome becomes dismal […] sudden death—although a common mode of death in symptomatic patients—appears to be a very rare event in asymptomatic AS (< 1%/year) … [yet is] probably the major concern when asymptomatic patients with severe AS are followed conservatively.¹
- late – angina, syncope
- ECG: left ventricular hypertrophy
- Endocarditis prophylaxis
- TAVR
Aortic Insufficiency (AI)
Volume overload of left ventricle develops gradually and appears to be well tolerated over many years until presentation with congestive heart failure.
- hyperdynamic circulation
- Echo: LV size
- surgery before LV irreversibly dilated: indicated when end-systolic LV dimension 55 mm
Aortic Regurgitation (AR)
- sudden LV pressure and volume overload result in pulmonary edema in face of normal heart size
- emergent reduction of preload and afterload
- urgent surgery
Mitral Stenosis (MS)
- dyspnoea, cough, ± haemoptysis – i.e. pulmonary oedema
- embolic phenomena (atrial thrombus)
- ECG/Echo: left atrial hypertrophy
- MVR: porcine vs prosthetic (lifelong anticoagulation)
Mitral Insufficiency (MI)
- chronic, slow LV volume overload, dilatation, and hypertrophy → fatigue and dyspnoea upon decompensation
- cardiomegaly, holosystolic precordial murmur → axilla
- acute pulmonary oedema
- reduce pre- and after-load
- ± surgery
Mitral valve prolapse (MVP)
- Usually not a serious clinically
- chest pain, palpitations, fatigue
- endocarditis prophylaxis
The tricuspid valve is organically affected in rheumatic heart disease, the infective endocarditis of intravenous drug use, or by trauma caused by pacemaker electrodes during implantation or retrieval.² The most common hemodynamic abnormality of the pulmonary valve is the congenitally narrowed domed valve of pulmonic stenosis. Pulmonary stenosis is usually well tolerated in its mild and moderate forms.³
Presentation of murmur and aetiology:
- In childhood, think congenital
- In young adults, think rheumatic or hypertrophic
- In elderly, think degenerative
Works cited
- Baumgartner, Helmut. “Aortic stenosis: medical and surgical management.” Heart (British Cardiac Society) vol. 91,11 (2005): 1483-8. doi:10.1136/hrt.2004.056176.
- Ibrahim, Bassem Sobhi.”Right ventricular failure.” e-Journal of Cardiology Practice 14(32); Dec 12, 2016.
- Fitzgerald KP, Lim MJ. The pulmonary valve. Cardiol Clin. 2011 May;29(2):223-7. doi: 10.1016/j.ccl.2011.01.006. PMID: 21459245.
- Jarolim, DR 1996, Internal Medicine, 2nd ed. 1996., Springer New York, New York, NY, doi: 10.1007/978-1-4612-2370-2.
Further
