Cardiology Lecture 6: Valvular Cardiopathy

Valvular Cardiopathy

Mitral Valve

• Mitral Stenosis (MS)
  • Definition: Obstruction to left ventricular inflow at the level of the mitral valve due to structural abnormality
  • Causes: Rheumatic fever, congenital mitral stenosis, malignant carcinoid disease, systemic lupus erythematosus
  • Symptoms: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hoarseness, persistent cough, dysphagia, hemoptysis
  • Physical examination: Mitral face, jugular vein distension, palpable first heart sound, diastolic thrill, loud S1, opening snap (OS), diastolic rumble
• Mitral Regurgitation (MR)
  • Definition: Abnormal reversal of blood flow from the left ventricle to the left atrium
  • Causes: Mitral valve prolapse, ischemic heart disease, rheumatic heart disease, infective endocarditis, annular calcification, cardiomyopathy
  • Symptoms: Acute: sudden development of left heart failure, fatigue, dyspnea; Chronic: asymptomatic, then symptoms of congestive heart failure
  • Physical examination: Wide splitting of S2, palpable first heart sound, S3, murmur
• Mitral Valve Prolapse (MVP)
  • Definition: One or both mitral valve leaflets prolapse into the left atrium during systole
  • Causes: Inherited, associated with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome)
  • Symptoms: Most patients asymptomatic, symptoms related to autonomic dysfunction, progression of mitral regurgitation, or complications

Aortic Valve

• Aortic Stenosis (AS)
  • Definition: Narrowing or obstruction of the aortic valve
  • Causes: Congenital valvular aortic stenosis, acquired valvular aortic stenosis (senile degenerative calcification, rheumatic heart disease)
  • Symptoms: Classic symptom triad: angina pectoris, syncope, heart failure
  • Physical examination: Pulsations of apical impulse, carotid arterial pulse is typically diminished and rises slowly, sustained and powerful apex beat, systolic thrill, harsh crescendo-decrescendo systolic murmur
• Aortic Regurgitation (AR)
  • Definition: Abnormal retrograde flow of blood through the aortic valve during cardiac diastole
  • Causes: Valvular abnormalities (bicuspid aortic valve, rheumatic fever), abnormalities of the ascending aorta (longstanding uncontrolled hypertension, Marfan syndrome)
  • Symptoms: Acute: sudden, severe shortness of breath, rapidly developing heart failure; Chronic: palpitations, shortness of breath, chest pain, sudden cardiac death
  • Physical examination: Diastolic pressures often lower than 60 mm Hg, Corrigan pulse, Musset sign, Hill sign, Duroziez sign, Müller sign, Quincke sign, Traube sign, apical beat, soft S2, S3 gallop if LV dysfunction is present

Tricuspid Valve

• Tricuspid Stenosis
  • Definition: Obstruction to right ventricular inflow at the level of the tricuspid valve
  • Causes: Rheumatic heart disease, carcinoid heart disease, congenital tricuspid stenosis or tricuspid atresia, infective endocarditis, systemic lupus erythematosus
  • Symptoms: Fatigue, peripheral edema, abdominal discomfort and swelling, hepatomegaly, dyspnea
  • Physical examination: Clinical signs can be masked by those of combined valvular lesions### Tricuspid Valve
• Tricuspid regurgitation: abnormal reversal of blood flow from the right ventricle to the right atrium due to structural alterations of the tricuspid valve apparatus or right ventricular dilatation
• Causes:
  • Primary causes: structural valve deformity (rheumatic heart disease, endocarditis, Ebstein anomaly, prolapse, papillary muscle dysfunction, trauma, connective tissue diseases)
  • Secondary causes: dilatation of the RV cavity (pulmonary hypertension, chronic obstructive airway disease, intracardiac shunts, mitral stenosis, pulmonary stenosis, regurgitation, dilated cardiomyopathy)
• Clinical manifestations:
  • Symptoms and signs of right heart failure (peripheral edema, abdominal swelling, effort hepatalgia, angina, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea)
  • Physical examination:
    • Jugular venous distention
    • Diminished peripheral pulse volume
    • RV heave
    • S3 gallop
    • S4 gallop (increases with inspiration)
    • High-pitched pansystolic murmur (along lower left sternal border with inspiratory accentuation)
    • Short, early diastolic flow rumble (due to increased flow across the TV)

Pulmonary Valve

• Pulmonary stenosis:
  • Definition: dynamic or fixed anatomic obstruction to flow from the right ventricle to the pulmonary arterial vasculature
  • Causes:
    • Congenital (isolated valvular, subvalvular, or peripheral obstruction)
    • Acquired (rheumatic heart disease, myxomatous plaques, cardiac tumors)
• Clinical manifestations:
  • Symptoms:
    • Asymptomatic (most children and adults with mild-to-moderately severe pulmonic stenosis)
    • Exertional dyspnea and fatigue (severe PS)
    • Exertional angina, syncope, or sudden death (extremely rare cases)
    • Symptoms of right-sided heart failure (occasionally)
  • Physical examination:
    • Inspection:
      • Cyanosis (in those with significant right-to-left shunt)
      • Epigastrial pulsation (due to right ventricular hypertrophy)
    • Palpation:
      • Right ventricular heave
      • Systolic thrill (may be palpable in the pulmonic area)
    • Auscultation:
      • Normal S1
      • Widely split S2
      • Systolic crescendo-decrescendo ejection murmur (in the pulmonic area, increases with inspiration and radiates to the base of the heart)
      • Systolic ejection click (may precede the murmur)

Pulmonary Regurgitation

• Definition: retrograde flow from the pulmonary artery into the right ventricle during diastole
• Causes:
  • Dilatation of the pulmonic valve ring:
    • Primary pulmonary hypertension
    • Secondary pulmonary hypertension (multiple causes)
    • Marfan syndrome
    • Tetralogy of Fallot
  • Acquired alteration of pulmonic valve leaflet morphology:
    • Infective endocarditis
    • Rheumatic heart disease
    • Carcinoid heart disease
    • Syphilis infection
  • Congenital absence or malformation of the valve:
    • Complete absence of the pulmonic valve
    • Valvular abnormalities
• Clinical manifestations:
  • Symptoms:
    • Dyspnea on exertion (most common complaint)
    • Easy fatigability
    • Light-headedness
    • Chest pain
    • Palpitations
    • Syncope
    • Peripheral edema
  • Physical examination:
    • Palpation:
      • Jugular venous pressure (usually increased)
      • Right ventricular heave (at the left lower sternal border)
      • Palpable pulmonary artery pulsation (at the left upper sternal border, significant pulmonary artery dilatation)
      • Palpable P2 (with significant pulmonary hypertension)
    • Auscultation:
      • P2 (accentuated, pulmonary hypertension)
      • S2 split (widened, increased right ventricular end-diastolic volume, increased ejection time, and delayed P2)
      • S3 or S4 (right ventricular hypertrophy or failure)
      • Decrescendo early diastolic murmur (at the pulmonic area, louder in inspiration)
      • Graham Steel murmur (high-pitched, early diastolic decrescendo, heard over the left upper-to-left midsternal area)
      • Holosystolic murmur (at the lower left sternal border, louder with inspiration, caused by tricuspid regurgitation)