• Clinical science

Valvular heart diseases (Valvular heart defects)

Summary

Valvular heart diseases can take the form of stenosis, insufficiency (regurgitation), or a combination of the two. These defects are typically acquired as the result of infections, underlying heart disease, or degenerative processes. However, certain congenital conditions can also cause valvular heart diseases. Acquired defects are found primarily in the left heart as a result of higher pressure and mechanical strain on the left ventricle. The type of valvular disease determines the type of cardiac stress and subsequent symptoms. Valvular stenosis leads to a greater pressure load and concentric hypertrophy, while insufficiencies are characterized by volume overload and eccentric hypertrophy of the preceding heart cavities. Diagnostic procedures typically include ECGs, chest x-ray, and echocardiograms. Management consists of interventional or surgical procedures to reconstruct or replace valves, as well as medical treatment of possible heart failure.

Epidemiology

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Valvular heart defects may either be acquired or congenital. Acquired defects are more common and typically occur secondary to infections (postinflammatory), degenerative processes, or heart disease.

Valve stenosis Valve regurgitation
Left heart Mitral valve
Aortic valve
  • Degenerative calcification (most common)
  • Rheumatic endocarditis
  • Congenital (e.g., unicuspid, bicuspid, or hypoplastic valve)
Right heart Tricuspid valve
Pulmonary valve
  • Congenital

References:[3][1][4][5][2][6]

Clinical features

All valvular defects can eventually lead to symptoms of heart failure as a result of excessive strain on the ventricles.

Physical examination

Auscultation in valvular defects
Maximum point Murmur Characteristics
Aortic stenosis
  • Radiation to the carotids
  • Soft S2
  • Possibly ejection click
Aortic regurgitation
Mitral stenosis
  • Heart apex (midclavicular 5th left ICS)
Mitral valve prolapse
  • Heart apex (midclavicular 5th left ICS)
  • Midsystolic high-frequency click (due to the tensing of the chordae tendinae)
  • Loudest before S2
Mitral regurgitation
  • Holosystolic murmur
  • 3rd heart sound audible
  • Quiet 1st heart sound
  • Blowing
  • Radiation into the axilla

Pulmonary stenosis

  • Possible radiation into the back

  • Possible early systolic pulmonary ejection click and/or widely split 2nd heart sound

Pulmonary regurgitation
Tricuspid stenosis (extremely rare)
Tricuspid regurgitation (extremely rare)
  • Holosystolic murmur

References:[2][4][5][7]

Treatment

Symptomatic

Causal

  • Surgery: The choice of procedure is based on the patient's individual risk profile and an evaluation of benefits.
Prosthetic heart valve
Mechanical prosthetic valve Biological prosthetic valve
Pros
  • Valve has a long lifespan
  • Anticoagulation only necessary for 3 months post operation
Cons
  • Short lifespan due to sclerotic degeneration
    • May need to be replaced every ten years
Indications
  • Younger patients
  • Previously anticoagulated patients (e.g., with pre-existing atrial fibrillation)
  • Older patients
  • Patients with a high risk of bleeding
  • Women with a desire to have children

References:[8][7]