Valvular Heart Disease

 

Valvular Heart Disease (VHD): Overview, Causes, and Management

Valvular heart diseases (VHDs) include conditions affecting the heart valves. These defects can be congenital or acquired, presenting as either stenosis (narrowing) or insufficiency/regurgitation (backflow).

• Stenosis → pressure overload → concentric hypertrophy

• Regurgitation → volume overload → eccentric hypertrophy

Diagnosis usually involves ECG, chest X-ray, and echocardiography (ECHO).
Treatment ranges from medical therapy for heart failure symptoms to surgical or interventional valve repair/replacement.

---

Epidemiology

• Aortic stenosis → most common in industrialized countries; usually degenerative and symptomatic > 75 years.

• Aortic regurgitation → onset between ages 40–60; worsens with age.

• Mitral stenosis → symptoms typically appear between ages 20–39.

• Mitral regurgitation → second most common VHD (0.6–2.4% prevalence); more common in women.

• Tricuspid valve disease → rare (<1%).

• Pulmonary valve disease → uncommon except in congenital conditions.

---

Etiology

Valvular defects may be acquired (more common) or congenital.

Causes by Valve

Valve	Stenosis	Regurgitation
Mitral	Rheumatic fever, rheumatic diseases (SLE, RA)	Mitral valve prolapse, dilated cardiomyopathy, ischemic heart disease, rheumatic fever, endocarditis
Aortic	Degenerative calcification, rheumatic endocarditis, congenital (bicuspid/unicuspid)	Endocarditis, dissection, trauma, bicuspid valve, Marfan/Ehlers-Danlos, rheumatic disease
Tricuspid	Rheumatic fever, endocarditis (IV drug use), RV dilation, pulmonary HTN	Endocarditis, rheumatic fever, carcinoid syndrome, Marfan syndrome
Pulmonary	Congenital, carcinoid syndrome, pulmonary HTN	Congenital, pulmonary HTN, dilated cardiomyopathy

---

Clinical Features

All VHDs may lead to heart failure symptoms (dyspnea, fatigue, edema).

Key Murmurs

Defect	Murmur Features
Aortic stenosis	Harsh crescendo-decrescendo systolic murmur, radiates to carotids, soft S2
Aortic regurgitation	Early diastolic decrescendo murmur, best at Erb’s point, ± Austin Flint murmur
Mitral stenosis	Delayed diastolic decrescendo murmur, opening snap, loud S1
Mitral regurgitation	Holosystolic murmur at apex, radiates to axilla, S3 present
Mitral valve prolapse	Late systolic crescendo murmur + midsystolic click
Pulmonary stenosis	Crescendo-decrescendo ejection systolic murmur, possible ejection click
Tricuspid regurgitation	Holosystolic murmur ↑ with inspiration (Carvallo sign)

 Diagnostics

Minimum workup:

• ECG → rhythm disturbances, hypertrophy

• TTE (ECHO) → structure, valve morphology, hemodynamics

• Chest X-ray → cardiac silhouette, pulmonary congestion

Advanced studies:

• TEE → precise anatomy

• Cardiac MRI → structural disease

• Catheterization → valve hemodynamics

• Stress testing → unclear symptoms

---

Management

General Approach

1. Evaluate with TTE, symptoms, comorbidities

2. Classify by severity (A–D stages)

3. Intervention indicated if severe and/or symptomatic

   • Valve repair or replacement (surgical vs. transcatheter)

4. Supportive care for all patients

5. Urgent cardiology consult if acute decompensation

---

Medical Treatment

• Lifestyle: risk factor control, low-salt diet, smoking/alcohol cessation

• Heart failure management: diuretics, afterload reduction as indicated

• Endocarditis prophylaxis if high-risk

• Anticoagulation when appropriate (prosthetic valves, AFib, thromboembolism risk)

• Annual monitoring with history, physical exam, and repeat TTE

---

Interventional Options

Valve Repair

• Annuloplasty → restores valve shape (common for mitral regurgitation)

• Leaflet repair (clips) → minimally invasive option

• Valvuloplasty → balloon or surgical commissurotomy for stenosis

Valve Replacement

• Mechanical valves: durable but require lifelong anticoagulation

• Bioprosthetic valves: limited lifespan (10–15 years) but less anticoagulation needed

• TAVR (Transcatheter Aortic Valve Replacement): minimally invasive alternative for high-risk patients

  
  
  

---

Special Considerations

VHD in Pregnancy

• Pregnancy increases hemodynamic stress → higher maternal/fetal risk.

• Pre-pregnancy counseling and risk assessment required.

• Progestin-only contraception preferred; avoid estrogen-containing methods in high thromboembolic risk.

• ACE inhibitors, ARBs, and warfarin are contraindicated in pregnancy.

---

Key Takeaway

Valvular heart disease is a progressive condition with significant morbidity if untreated. Management depends on the type of defect, severity, and patient factors. Early recognition, appropriate imaging, and timely referral for repair or replacement are critical to improving outcomes.