Valvular Heart Disease

Eric J Milie, D.O.

Goals and Objectives

Recognize which cardiac murmurs warrant further evaluationUnderstand three cardinal signs of aortic stenosis and indications for surgical interventionOutline treatment plans for specific valvular heart lesions

Grading Heart Murmurs

Out of VII. Only heard with careful listeningII. Audible when stethoscope applied to chestIII. Louder than 2/6IV. Accompanied by a palpable thrillV. Audible when stethoscope partially off of chestVI. Audible to naked ear

Findings Murmur S1 S2 Other Findings

Maneuvers

Aortic Stenosis

Mid to late systolic; may be soft or absent if severe

Normal Single or paradoxically split

Carotid upstrokes diminished and delayed; S3 or S4

may be present

Murmur softer with Valsalva maneuver

Mitral Stenosis

Diastolic rumble Loud Normal Opening snap may be present

Murmur increased during brief exercise

Aortic Regurgitation

Blowing diastolic Soft Normal Wide pulse pressure, systolic hypertension, hyperdynamic circulation

Murmur increased with handgrip or squatting

Mitral Regurgitation

Holosystolic Soft Normal or split

S3 may be present; cartoid upstrokes brisk

Murmur louder with Valsalva maneuver

MVP Mid to late systolic

Normal Normal Mid-systolic click Murmur increased with standing

Recommendations by Class

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II:Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa. Weight of evidence/opinion is in favor of usefulness/efficacyIIb. Usefulness/efficacy is less well established by evidence/opinion. Class III:Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

Aortic Stenosis: Etiology

Often congenitalRheumatic AS associated with previous rheumatic diseaseIdiopathic, calcific As associated with elderly, generally milder

AS: Symptoms

DyspneaAnginaSyncope

These are cardinal symptoms, occur late in disease, and are associated with mortality (usually 2-3 year survival after onset of symptoms)

AS: Physical Exam

Weak and delayed arterial pulses with carotid thrill (pulsus parvus et tardus)Double apical impulseS4 commonDiamond shaped systolic murmurUsually >3/6

AS: Echo

LV thickeningThickening and calcification of aortic valve cuspsDilatation, reduced LVEF poor prognosis

Aortic stenosis with turbulent flow (green pixels), as seen in the five-chamber view

AS: Classification of Severity

Mild: Valve Area >1.5cm²Moderate: Valve area 1.0cm² to 1.5cm²Severe: Valve area <1.0cm²

AS: Treatment

Avoid strenuous exercise in severe ASTreat CHF in standard fashion, but avoid afterload reductionStatin therapy to slow progression of leaflet calcificationBalloon valvotomy to reduce symptoms in patients who aren’t surgical candidatesValve replacement in adults who are symptomatic or with evidence of outflow obstructionSurgery optimally performed before frank heart failure develops

Aortic Regurgitation: Etiology

Rheumatic etiology commonHypertensionInfective endocarditisDilitation due to cystic medial necrosisMyxomatous infiltrationMarfan syndromePatients ¾ male

AR: Manifestations

Exertional dyspneaCardiac awarenessAnginaLV failureWide pulse pressureCapillary pulsations (Quincke’s sign)S3Blowing, decrescendo diastolic murmur heard best along left sternal border

AR: Lab

CXR- LV enlargementEKG- LV hypertrophyEcho: LA and LV enlarged, increased excursion of LV posterior wall

AR: Treatment

Standard therapy for LV failureVasodilators to delay need for surgical interventionSurgical intervention indicated in symptomatic patients with severe AR or in asymptomatic patients with LV dysfunction on echo (LVEF <55%)

Mitral Stenosis: Etiology

Most commonly rheumatic (up to 40% of patients with rheumatic fever develop mitral stenosis, 99% of surgically removed mitral valves with rheumatic infiltration)Congenital MS rare

MS: History

Symptoms commonly begin in 4th decadeCan cause severe debility by age 20 in economically deprived areasPrincipal symptoms are dyspnea and pulmonary edema precipitated by exertion, anemia, fever, excitement pregnancy, sexual intercourse, etc.

MS: Physical

Right ventricular liftPalpable S1Opening snap follows A2 by 0.06 to 0.12 secondsOS-A interval inversely proportional to severity of diseaseDiastolic rumbling murmur

MS: Complications

HemoptysisPulmonary embolismPulmonary infectionSystemic embolization

Endocarditis uncommon in pure MS

MS: Labs

EKG: Typically A. Fib or LA enlargement when sinus rhythm presentCXR: LA and RV enlargement, Kerley B linesEcho: calcification and thickening of valve leaflets and LA enlargement

MS: Treatment

Prophylaxis for rheumatic feverHeart failure treatment if presentDig, beta blockers to control ventricular rateValvotomy in presence of symptoms and mitral orifice <1.7cm²Anticoagulation if indicated

Mitral Regurgitation: Causes

Rheumatic heart disease in 33% of casesMVPIschemic heart disease with papillary muscle dysfunctionLV dilitationMitral annular calcificationHypertrophic cardiomyopathyInfective endocarditiscongenital

MR: Clinical Manifestations

FatigueWeaknessExertional dyspnea

MR: Physical Exam

Sharp upstoke of arterial pulseLV liftS1 diminishedWide splitting of S2Loud holosystolic murmur

MR: Echo

Enlarged LAHyperdynamic LVDoppler echocardiogram useful in diagnosing and assessing severity of MR

MR: Treatment

For severe/ decompensated MR, treat as heart failureEndocarditis prophylaxis is indicatedSurgical intervention warranted in symptomatic individuals or in evidence of progressive LV dysfunctionSurgery before decompensated heart failureAnticoagulation in face of atrial fibrillation

Mitral Valve Prolapse: Etiology

Most commonly idiopathic? FamilialIschemic heart diseaseAtrial septal defectMarfan syndromeMore common female>male

Normal mitral valve

MVP

MVP: Clinical Manifestations

Most patients asymptomatic and remain soChest pain (atypical)Supraventricular and ventricular arrhythmias

Most important complication of severe MR is LV failureSudden death is very rare

MVP: PE

Mid or late systolic click followed by late systolic murmurMurmur exaggerated by valsalva, reduced with squatting

Echo shows displacement of one or both leaflets late in systole

MVP: Treatment

Asymptomatic patient: reassuranceProphylaxis for endocarditis indicatedValve repair for patients with severe MRASA or anticoagulation for patients with TIA or embolization

Question 1

A new patient comes to you for evaluation. He’s a 45 year old male whose only complaint is that of some dyspnea on exertion, which he attributes to old age. He doesn’t smoke or drink alcohol. He does admit to being “very ill as a child,” but has been relatively healthy since. On physical exam, a diastolic murmur is noted, but the remainder of the exam is within normal limits.

Question 1 continued

Which of the following is the next best step in this patient’s management?

a) Only routine preventative careb) Trial of beta blocker therapy to see if his shortness of

breath resolvesc) Echocardiogram for assessment of the diastolic

murmur, with further recommendations to followd) Cranial OMT for assessment of his CRI

Question 2

A 73 year old white male presents to the emergency department after a syncopal episode. He’s dyspnic, with air hunger at the bedside, and is complaining of chest discomfort radiating to his jaw and down his left arm. On exam, a III/VI crescendo-decrescendo murmur is appreciated.

Question 2 continued

Which of the following valvular pathologies is most likely responsible for this man’s presentation?

a) Aortic Stenosisb) Aortic Regurgitationc) Mitral Stenosisd) Mitral Regurgitatione) Mitral valve prolapse

Question 3

The most common cause of mitral stenosis is:a) Familialb) Idiopathicc) Sauerkraut ingestiond) Rheumatice) Alcohol induced