This is a brief overview of aortic stenosis, mitral stenosis, aortic regurgitation (aka aortic insufficiency), and mitral regurgitation (mitral insufficiency).
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Valvular diseases
of the left heart
Aortic and mitral valve stenosis and regurgitation (insufficiency)
Failure of aortic valve to open (during systole)
Etiology: Congenital, such as bicuspid aortic valve (least common); rheumatic fever; age-related calcification (most common, similar mechanism to coronary atherosclerosis)
Demographic: 60+ y/o, males
Physical exam:
Murmur: Crescendo-decrescendo, harsh, high-pitch in right upper border (peak is later with worse murmur)
Paradoxical S2 split
Parvus et tardus carotid pulse
Might hear rales in lungs
ECG: LVH
Clinical presentation:
angina
increased O2 demand due to increased tension (Laplace's law T=PV/(2h), increased afterload)
decreased O2 supply bc worse coronary perfusion with diastolic dysfunction
dyspnea - pressure backup in LV, then LA, then pulmonary circulation, which causes pulmonary edema
syncope - with exertion → low cardiac output, exercise leads to vasodilation of muscular vasculature → both decrease MAP → less blood to brain
Treatment: Aortic valve replacement if area is 1 cm^2, percutaneous balloon valvuloplasty (temporary palliative treatment)
Aortic valve regurgitation
Failure of aortic valve to close (during diastole)
Etiology: aortic root (aortic aneurysm, dissection, syphilis); leaflets of valve (congenital, IE, rheumatic fever)
Physical exam:
Murmur: diastolic decrescendo high-pitched murmur, best heard at 4th left intercostal space
Widened pulse pressure
diastolic pressure decreases (LV dilates with volume overload, LV compliance increases)
systolic pressure increases (increased volume with each beat)
Large, hypertrophic, global heart on CXR
Clinical presentation:
angina - increased demand from increased LV size; decreased supply from decreased diastolic filling of coronary arteries (due to low diastolic pressure)
heart failure - LV dilation and subsequent remodeling decreases systolic function
Treatment:
If LV function is normal, give vasodilators to lower SVR, promote blood going forward
If LV function is impaired (EF 50%), aortic valve replacement sx
Mitral valve stenosis
Failure of mitral valve to open (during diastole)
Valve area less than 2 sq cm (normally 4-6 sq cm)
Etiology: Most commonly caused by rheumatic fever; can also be congenital, infective endocarditis, calcific disease
Physical exam:
Murmur: opening snap (chordae tendinae tense) followed by diastolic decrescendo rumble, perhaps increase in intensity at end with atrial contraction, heard best at apex
Might hear rales in lungs
ECG: RVH and LAH
Clinical presentation:
dyspnea - high LA pressure transmitted to lungs, which causes pulmonary edema
hemoptysis - high pressure in lungs compensated by collateral channels from pul veins to bronchial veins; collaterals rupture
Right heart failure → JVP, leg edema, ascites, large liver
afib - high pressure in LA causes enlargement, disrupts conduction system
stagnant blood can embolize, cause clots → stroke
Treatment: Diuretics for pulmonary and systemic congestions; percutaneous balloon mitral valvuloplasty, mitral commissurotomy, and
Failure of mitral valve to close (during systole)
Etiology:
Primary: Acute MR can be caused by papillary muscle rupture (inferior MI from RCA block); disorder of valves (ie, mitral prolapse)
Secondary: result of underlying myocardial problem
Physical exam:
Murmur: Holosystolic high-pitched murmur during systole, heard best at apex
Might hear rales in lungs
ECG: acute inferoposterior MI if papillary muscle is ruptured
Clinical presentation:
Acute MR causes dyspnea - sudden increase if LA pressure from backflow of blood, which is transmitted to lungs → pulmonary edema
Chronic MR
Low CO (LA dilates → more backflow) → weakness, fatigue
Right heart failure (result of left heart failure) → leg edema, ascites
LV contractile dysfunction (lower forward output) → dyspnea
Treatment:
Primary: surgical correction of papillary muscle or mitral repair/replacement, diuretics for pul edema, vasodilator to promote forward CO
Secondary: treat underlying myocardial problem, treat LV contractile dysfunction