SYMPOSIUM ON CARDIOVASCULAR DISEASESValvular Heart Disease: Diagnosis and Management
Section snippets
Etiology and Pathophysiology
Aortic stenosis (AS) is the most prevalent form of cardiovascular disease in the Western world after hypertension and coronary artery disease. It is usually caused by either degenerative calcification of a trileaflet valve or progressive stenosis of a congenital bicuspid valve. Rheumatic heart disease, the most common etiology worldwide, is less common in the United States. Aortic stenosis develops from progressive calcification of leaflets with restriction of leaflet opening over time. The
Etiology
Aortic regurgitation results from abnormalities of the aortic leaflets, their supporting structures in the aortic root and annulus, or both. Rheumatic heart disease remains the most common cause of severe AR worldwide. However, diseases involving the aortic root and ascending aorta have become more frequent causes of AR in the western hemisphere.
Abnormalities of the aortic cusps that may result in AR include congenital leaflet abnormalities, such as bicuspid, unicuspid, or quadricuspid valves
Etiology and Pathophysiology
Mitral regurgitation may result from disorders of the valve leaflets themselves or from any of the surrounding structures that comprise the mitral apparatus. The leading cause of MR is rheumatic heart disease in developing areas of the world and degenerative forms of MV disease (myxomatous disease and fibroelastic deficiency) in the United States and other developed countries. Less common conditions include mitral annular calcification and congenital anomalies such as cleft MVs; other rare
Etiology and Pathophysiology
The most common cause of MS worldwide is rheumatic fever. Isolated MS is twice as common in women as in men.2 Other causes of MS are very rare and include congenital anomalies, prior exposure to chest radiation, mucopolysaccharidosis, severe mitral annular calcification, and left atrial myxoma.
Rheumatic disease is associated with fibrosis, calcification and fusion of commissures, leaflet thickening, and chordal fusion resulting in MS. A normal MV area is 4.0 to 5.0 cm2. Symptoms usually develop
Pregnancy
Important hemodynamic changes occur during pregnancy. Plasma volume increases during the first trimester and can reach as high as 50% above baseline by the second trimester. Plasma volume then plateaus for the rest of the pregnancy. The heart rate increases 10 to 20 beats/min above baseline. Uterine contraction and endogenous hormones result in a decline in peripheral vascular resistance and a widening of the pulse pressure. The gravid uterus can obstruct the inferior vena cava, potentially
CONCLUSION
Degenerative valve disorders will likely increase in frequency as the population ages. Rheumatic heart disease is common worldwide and is seen with increasing frequency in the United States as a result of the globalization of our society. Appropriate diagnosis, management, and follow-up of these patients are imperative to reduce long-term morbidity and mortality. A fundamental knowledge of valve disease is important for the primary care physician because the initial presentation of such
REFERENCES (46)
- et al.
Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice
J Am Soc Echocardiogr
(2009) - et al.
Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample
J Am Coll Cardiol
(1993) - et al.
Clinical factors associated with calcific aortic valve disease
J Am Coll Cardiol
(1997) - et al.
Correlation of serum lipids, calcium, and phosphorus, diabetes mellitus and history of systemic hypertension with presence or absence of calcified or thickened aortic cusps or root in elderly patients
Am J Cardiol
(1987) - et al.
The emerging role of exercise testing and stress echocardiography in valvular heart disease
J Am Coll Cardiol
(2009) - et al.
Balloon aortic valvuloplasty in adults: failure of procedure to improve long term survival
J Am Coll Cardiol
(1995) - et al.
Outcomes and safety of percutaneous aortic valve replacement
J Am Coll Cardiol
(2009) - et al.
Hemodynamic characteristics and progression to heart failure in regurgitant lesions
Heart Fail Clin
(2006) Progress in mitral and aortic regurgitation
Prog Cardiovasc Dis
(2001)- et al.
Noninvasive assessment of acute effects of nifedipine on rest and exercise hemodynamics and cardiac function in patients with aortic regurgitation
J Am Coll Cardiol
(1984)
Vasodilator therapy in chronic asymptomatic aortic regurgitation: enalapril versus hydralazine therapy
J Am Coll Cardiol
Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography
J Am Soc Echocardiogr
Beta blockade in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol
Am Heart J
Long term benefits of biventricular pacing in congestive heart failure: results from the MUltisite STimulation In Cardiomyopathy (MUSTIC) study
J Am Coll Cardiol
Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure
J Am Coll Cardiol
Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis
Ann Thorac Surg
Valvular heart disease
2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease)
Circulation
Aortic stenosis
Circulation
To operate or not in elderly patients with aortic stenosis: the decision and its consequences
Heart
Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk
Circ Cardiovasc Qual Outcomes
Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up
Circulation
Aortic valve disease
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Prevalence of valvular heart disease in cardiac amyloidosis and impact on survival
2024, Current Problems in CardiologyCardiac Computed Tomography of Native Cardiac Valves
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On completion of this article, you should be able to (1) summarize important basic and clinical concepts of valvular heart disease, (2) recognize the full array of valvular disorders so as to provide enhanced care for patients with valvular heart disease, and (3) treat patients in accordance with new recommendations from recent clinical trials and clinical practice guidelines.