Valvular Disorders

Front 1

Aortic regurgitation

Back 1

is incompetency of the aortic valve causing flow from the aorta into the left ventricle during diastole. Causes include idiopathic valvular degeneration, rheumatic fever, endocarditis, myxomatous degeneration, congenital bicuspid aortic valve, syphilitic aortitis, and connective tissue or rheumatologic disorders. Symptoms include exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, and chest pain. Signs include widened pulse pressure and a holodiastolic murmur. Diagnosis is by physical examination and echocardiography. Treatment is aortic valve replacement and, in some cases, vasodilating drugs.

Front 2

Aortic stenosis (AS)

Back 2

is narrowing of the aortic valve obstructing blood flow from the left ventricle to the ascending aorta during systole. Causes include a congenital bicuspid valve, idiopathic degenerative sclerosis with calcification, and rheumatic fever. Progressive untreated AS ultimately results in the classic triad of syncope, angina, and exertional dyspnea; heart failure and arrhythmias may develop. A carotid pulse with small amplitude and delayed upstroke and a crescendo-decrescendo ejection murmur are characteristic. Diagnosis is by physical examination and echocardiography. Asymptomatic AS often requires no treatment. For progressive severe or symptomatic AS in children, balloon valvotomy is used; adults require valve replacement.

Front 3

Mitral regurgitation (MR)

Back 3

is incompetency of the mitral valve causing flow from the left ventricle (LV) into the left atrium during systole. Common causes include mitral valve prolapse, ischemic papillary muscle dysfunction, rheumatic fever, and annular dilation secondary to LV systolic dysfunction and dilation. Complications include progressive heart failure, arrhythmias, and endocarditis. Symptoms and signs include palpitations, dyspnea, and a holosystolic apical murmur. Diagnosis is by physical examination and echocardiography. Prognosis depends on LV function and severity and duration of MR. Patients with mild, asymptomatic MR may be monitored, but progressive or symptomatic MR requires mitral valve repair or replacement.

Front 4

Mitral stenosis (MS)

Back 4

is narrowing of the mitral orifice impeding blood flow from the left atrium to the left ventricle. The most common cause is rheumatic fever. Common complications are pulmonary hypertension, atrial fibrillation, and thromboembolism. Symptoms are those of heart failure; signs include an opening snap and a diastolic murmur. Diagnosis is by physical examination and echocardiography. Prognosis is good. Medical treatment includes diuretics, β-blockers or rate-limiting Ca channel blockers, and anticoagulants; surgical treatment for more severe disease consists of balloon valvotomy, commissurotomy, or valve replacement.

Front 5

Mitral valve prolapse (MVP)

Back 5

is a billowing of mitral valve leaflets into the left atrium during systole. The most common cause is idiopathic myxomatous degeneration. MVP is usually benign, but complications include mitral regurgitation, endocarditis, valve rupture, and possibly thromboembolism. MVP is usually asymptomatic, although some patients experience chest pain, dyspnea, and symptoms of sympathetic excess (eg, palpitations, dizziness, near syncope, migraines, anxiety). Signs include a crisp mid-systolic click, followed by a late systolic murmur if regurgitation is present. Diagnosis is by physical examination and echocardiography. Prognosis is excellent. No specific treatment is necessary unless mitral regurgitation is present, although patients with sympathetic symptoms may benefit from β-blockers.

Front 6

Pulmonic (pulmonary) regurgitation (PR)

Back 6

is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole. The most common cause is pulmonary hypertension. PR is usually asymptomatic. Signs include a decrescendo diastolic murmur. Diagnosis is by echocardiography. Usually, no specific treatment is necessary except for management of conditions causing pulmonary hypertension.

Front 7

Pulmonic stenosis

Back 7

is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole.

Pulmonic stenosis (PS) is most often congenital and affects predominantly children; stenosis may be valvular or just below the valve in the outflow tract (infundibular). Less common causes are Noonan's syndrome (a familial syndrome similar to Turner's syndrome but with no chromosomal defect) and carcinoid syndrome in adults.

Front 8

Tricuspid regurgitation (TR)

Back 8

is insufficiency of the tricuspid valve causing blood flow from the right ventricle to the right atrium during systole. The most common cause is dilation of the right ventricle. Symptoms and signs are usually absent, but severe TR can cause neck pulsations, a holosystolic murmur, and right ventricular–induced heart failure or atrial fibrillation. Diagnosis is by physical examination and echocardiography. TR is usually benign and does not require treatment, but some patients require annuloplasty, valve repair or replacement, or excision.

Front 9

Tricuspid stenosis (TS)

Back 9

is narrowing of the tricuspid orifice that obstructs blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms include a fluttering discomfort in the neck, fatigue, cold skin, and right upper quadrant abdominal discomfort. Jugular pulsations are prominent, and a presystolic murmur is often heard at the left sternal edge in the 4th intercostal space and is increased during inspiration. Diagnosis is by echocardiography. TS is usually benign, requiring no specific treatment, but symptomatic patients may benefit from surgery.