Valvular Heart disease: Types, Causes, Symptoms and Diagnosis

Primary Valvular Heart disease can cause significant morbidity and lead to premature death. Rheumatic fever is the main cause of valvular heart disease in low and middle- income countries. Prevalence and mortality rates vary among different communities in the same country as well depending upon availability of medical resources and population - wide programs for detection and treatment of group A streptococcal pharyngitis. In low economy countries, valvular disease progresses rapidly than in developed countries causing serious symptoms in patients aged < 20 years due to repeated infections with more virulent strains of streptococci. Valve disease in high-income countries is mainly by degenerative or inflammatory processes that lead to valve thickening, fibrosis, calcifications and dysfunctions. Prevalence increases with age.

Valvular Heart Disease Types

1. Mitral Stenosis
2. Mitral Regurgitation
3. Mitral Valve Prolapse
4. Aortic Stenosis
5. Aortic Regurgitation
6. Tricuspid Stenosis
7. Tricuspid Regurgitation
8. Pulmonary Stenosis
9. Pulmonary regurgitation

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Valvular Heart disease Causes/ Etiology

Aortic Stenosis

• Congenital ( bicuspid aortic valve )
• Degenerative calcific disease
• Rheumatic fever

Aortic Regurgitation

• Congenital 
• Endocarditis
• Rheumatic fever
• Myxomatous ( prolapse)
• Radiation
• Trauma
• Syphilis
• Ankylosing Spondylitis
• Aortic Dissection
• Medial degeneration
• MArfan Syndrome

Mitral Stenosis

• Rheumatic Disease
• Congenital ( Parachute valve)
• Severe mitral annular calcification with leaflet involvement
• SLE, RA
• Myxoma
• Infectious endocarditis with large vegetations

Mitral Regurgitation

• Infectious endocarditis
• Papillary muscle rupture ( Post MI)
• Chordal rupture
• Blunt Trauma
• Chronic Rheumatic fever
• Radiation
• Calcification

Mitral valve Prolapse

• Marfan syndrome
• Danlos syndrome
• Acute rheumatic fever
• Ischemic heart disease
• Cardiomyopathy

Tricuspid Stenosis

• Rheumatic Fever
• Congenital

Tricuspid Regurgitation

• Rheumatic
• Endocarditis
• Myxomatous
• Carcinoid
• RV and tricuspid annular dilation
• Cardiomyopathy
• Atrial fibrillation

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Valvular Heart Disease Signs and Symptoms

Aortic Stenosis

• Exertional dyspnea
• Angina Pectoris
• Syncope
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Pulmonary edema occur in advanced stages of diseases.
• Pulsus parvus at tardus - Acrotid arterial pulse rises slowly to a delayed peak.
• Double apical impulse ( palpable S4)
• Ejection ( mid) systolic murmur that commenses shorlty after the S1 , that increases in intensity towards the middle of ejection  and ends just before aortic valve closure.

Aortic Regurgitation

• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Excessive diaphoresis
• Anginal chest pain in absence of CAD
• A rapidly water-hammer arterial pulse.
• A booming pistol-shot sound can be heard over the femoral arteries ( Traube’s sign)
• S4 maybe heard

Mitral Stenosis

• Dyspnea
• Orthopnea
• Paroxysmal Nocturnal dyspnea
• Hemoptysis
• Atrial Fibrillation

Mitral Regurgitation

• Acute: Cardiogenic shock or Pulmonary edema
• Chronic : Atrial Fibrillation or CHF
• Holosystolic murmur at the apex, increases with increases VR.

Tricuspid Stenosis

• Dyspnea
• Fatigue due to low Cardiac output and discomfort
• Opening Snap of the tricuspid valve after pulmonic valve closure
• Diastolic murmur heard along the left lower sternal border and over the xiphoid process.

Tricuspid Regurgitation

• Fatigue
• Exertional dyspnea
• Cervical pulsations, abdominal fullness/bloating, swelling of lower extremity.
• Neck veins distended in severe Tricuspid Regurgitation.

Also Read: Ramsay Hunt Syndrome: Causes, Symptoms, Risk Factors, Diagnosis, Treatment, Prevention and Complications

Valvular Heart Disorders Diagnosis

Mitral stenosis

• Chest Xray- Pulmonary blood flow redistribution in upper lobes, dilated pulmonary vessels, left atrial enlargement and flattened heart border.
• ECG- P mitrale( Broad and notched P waves) , RVH ( tall R waves in V1 and V2)
• TTE- Mitral valve thickening/ calcifications

Aortic Regurgitation

• Diastolic decrescendo murmur , widened pulse pressure, collapsing/ water hammer pulses
• Pulsus biferens

Aortic stenosis

• Crescendo decrescendo murmur of 2^nd right Intercostal space, increases with increased venous return.
• Late - peaking if severe aortic stenosis

Mitral Regurgitation

• Holosystolic murmur at the apex increases with increased venous return.

Mitral Valve Prolapse

• There will be regurgitation but intensifies with valsalva
• Echo to confirm the diagnosis.

Also Read: Development of Heart Tube

Valvular Heart Disorders Treatment

Mitral Stenosis

• Percutaneous Mitral balloon commissurotomy, Valve replacement can also be done
• Anticoagulants are given as AF in this setting is highly thrombogenic.

Aortic Regurgitation

• Consider CABG
• Acutely - Emergent Replacement 
• Chronic- Urgent Replacement

Aortic Stenosis

• Valve replacement
• Consider CABG - indications include Severe AS with one or more of following- LVEF<50%, other cardiac surgery.

Mitral Regurgitation Valve replacement

• In primary MR- Surgery if LVEF is 30-60% regardless of symptoms.
• Consider surgery if successful valve repair is highly likely - Asymptomatic and LVEF >60%, Symptomatic and LVEF < 30%.
• Secondary MR- Medical management is Beta blocker or ACE inhibitor.

Mitral valve prolapse

• Avoid dehydration and beta blockers.

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