SYMPOSIUM ON CARDIOVASCULAR DISEASES
Valvular Heart Disease: Diagnosis and Management

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Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.

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

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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.

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