Valvular Heart Disease: Classic Teaching and Emerging Paradigms

doi:10.1016/j.amjmed.2013.05.022

The American Journal of Medicine

Volume 126, Issue 12, December 2013, Pages 1035-1042

https://doi.org/10.1016/j.amjmed.2013.05.022 Get rights and content

Abstract

Valvular heart disease is both prevalent and increases with age. The final pathway of valvular disease is heart failure and sometimes sudden death, so clinicians must identify and treat it before these endpoints occur. Noninvasive diagnostic modalities such as echocardiography, exercise tolerance testing, and cardiac magnetic resonance provide additional quantitative, qualitative, and prognostic data. Studies have elucidated predictors of disease progression and potential medical therapies, but the niche of valvular disease has benefited relatively less from randomized controlled clinical trials than other cardiovascular disease fields. New invasive techniques like transcatheter valve replacement offer hope for high-risk operative candidates. We review classic teaching with current guidelines and emphasize recent advances in disease management.

Section snippets

Echocardiography

Traditional transthoracic echocardiography (TTE) has good spatial and excellent temporal resolution. It remains the preferred initial test for diagnosis of suspected valvular disease. A transesophageal echocardiogram may provide better definition, especially for posterior structures like the mitral valve and for prosthetic valves, where TTE views may be limited by acoustic shadowing. Three-dimensional echocardiography is now widely available and is especially valuable for assessment of complex

Aortic Stenosis

Aortic stenosis is the most common degenerative valve lesion in North America and Europe, with severe disease affecting up to 2% of older adults. Calcific degeneration of a normal trileaflet or congenitally bicuspid aortic valve results in decreased leaflet excursion and an elevated systolic gradient between the left ventricle and aorta. Compensatory left ventricular hypertrophy leads to impaired filling, systolic dysfunction, and myocardial oxygen supply–demand mismatch. These result in the

Mitral Stenosis

Mitral stenosis is a classic sequela of rheumatic fever but has become less prevalent in North America and Europe. Worldwide, rheumatic valve disease and mitral stenosis, in particular, still pose a significant public health challenge. Severe intracardiac calcification in the elderly or patients with renal disease can cause functional stenosis, but the barrier to left ventricular filling in these cases is primarily the mitral annulus, not immobile leaflets. Patients typically present with

Pulmonic Stenosis

Pulmonic stenosis is typically congenital. Severe obstruction leads to right ventricular failure, producing exertional dyspnea, syncope, and angina. Examination shows a systolic crescendo–decrescendo murmur, widely split S2, and soft P2. TTE is diagnostic. Guidelines recommend percutaneous valvuloplasty for severe disease (symptomatic with peak gradient >30 mm Hg or asymptomatic with peak gradient >40).²

Pulmonic Regurgitation

Mild pulmonic regurgitation is physiologic and requires no further evaluation. Severe

Conclusions

An increased prevalence of valvular heart disease has been accompanied by proliferation of the modalities used to diagnose and treat valvular heart disease. Nevertheless, a carefully performed history and physical examination remain the most prudent initial method of evaluating suspected disease. TTE is the principal imaging modality. The future challenge for both primary care physicians and cardiologists is to appropriately select patients who will benefit from additional diagnostic and

Acknowledgements

The authors thank Dr Warren J. Manning for his valuable suggestions on the manuscript.

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: Authorship: Both authors had access to the data and participated in writing this manuscript.

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ReviewValvular Heart Disease: Classic Teaching and Emerging Paradigms

Abstract

Section snippets

Echocardiography

Aortic Stenosis

Mitral Stenosis

Pulmonic Stenosis

Pulmonic Regurgitation

Conclusions

Acknowledgements

Lancet

Am J Cardiol

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Ann Thorac Surg

Circulation

Prospective study of asymptomatic valvular aortic stenosis

Circulation

Review
Valvular Heart Disease: Classic Teaching and Emerging Paradigms