1. Valvular Heart Disease
Eric J Milie, D.O.

2. Goals and Objectives
Recognize which cardiac murmurs warrant further evaluation
Understand three cardinal signs of aortic stenosis and indications for surgical intervention
Outline treatment plans for specific valvular heart lesions

5. Grading Heart Murmurs Out of VI Only heard with careful listening
Audible when stethoscope applied to chest
Louder than 2/6
Accompanied by a palpable thrill
Audible when stethoscope partially off of chest
Audible to naked ear

8. Findings Murmur S1 S2 Other Findings Maneuvers Aortic Stenosis
Mid to late systolic; may be soft or absent if severe
Normal
Single or paradoxically split
Carotid upstrokes diminished and delayed; S3 or S4 may be present
Murmur softer with Valsalva maneuver
Mitral Stenosis
Diastolic rumble
Loud
Opening snap may be present
Murmur increased during brief exercise
Aortic Regurgitation
Blowing diastolic
Soft
Wide pulse pressure, systolic hypertension, hyperdynamic circulation
Murmur increased with handgrip or squatting
Mitral Regurgitation
Holosystolic
Normal or split
S3 may be present; cartoid upstrokes brisk
Murmur louder with Valsalva maneuver
MVP
Mid to late systolic
Mid-systolic click
Murmur increased with standing

11. Recommendations by Class
Class I:    Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
Class II:Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.  
IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb. Usefulness/efficacy is less well established by evidence/opinion.
Class III:Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

14. Aortic Stenosis: Etiology
Often congenital
Rheumatic AS associated with previous rheumatic disease
Idiopathic, calcific As associated with elderly, generally milder

15. AS: Symptoms Dyspnea Angina Syncope
These are cardinal symptoms, occur late in disease, and are associated with mortality (usually 2-3 year survival after onset of symptoms)

17. AS: Physical Exam
Weak and delayed arterial pulses with carotid thrill (pulsus parvus et tardus)
Double apical impulse
S4 common
Diamond shaped systolic murmur
Usually >3/6

19. AS: Echo
LV thickening
Thickening and calcification of aortic valve cusps
Dilatation, reduced LVEF poor prognosis

21. Aortic stenosis with turbulent flow (green pixels), as seen in the five-chamber view

22. AS: Classification of Severity
Mild: Valve Area >1.5cm²
Moderate: Valve area 1.0cm² to 1.5cm²
Severe: Valve area <1.0cm²

23. AS: Treatment Avoid strenuous exercise in severe AS
Treat CHF in standard fashion, but avoid afterload reduction
Statin therapy to slow progression of leaflet calcification
Balloon valvotomy to reduce symptoms in patients who aren’t surgical candidates
Valve replacement in adults who are symptomatic or with evidence of outflow obstruction
Surgery optimally performed before frank heart failure develops

27. Aortic Regurgitation: Etiology
Rheumatic etiology common
Hypertension
Infective endocarditis
Dilitation due to cystic medial necrosis
Myxomatous infiltration
Marfan syndrome
Patients ¾ male

28. AR: Manifestations Exertional dyspnea Cardiac awareness Angina
LV failure
Wide pulse pressure
Capillary pulsations (Quincke’s sign) S3
Blowing, decrescendo diastolic murmur heard best along left sternal border

30. AR: Lab CXR- LV enlargement EKG- LV hypertrophy
Echo: LA and LV enlarged, increased excursion of LV posterior wall

33. AR: Treatment Standard therapy for LV failure
Vasodilators to delay need for surgical intervention
Surgical intervention indicated in symptomatic patients with severe AR or in asymptomatic patients with LV dysfunction on echo (LVEF <55%)

38. Mitral Stenosis: Etiology
Most commonly rheumatic (up to 40% of patients with rheumatic fever develop mitral stenosis, 99% of surgically removed mitral valves with rheumatic infiltration)
Congenital MS rare

40. MS: History Symptoms commonly begin in 4th decade
Can cause severe debility by age 20 in economically deprived areas
Principal symptoms are dyspnea and pulmonary edema precipitated by exertion, anemia, fever, excitement pregnancy, sexual intercourse, etc.

41. MS: Physical Right ventricular lift Palpable S1
Opening snap follows A2 by 0.06 to 0.12 seconds
OS-A interval inversely proportional to severity of disease
Diastolic rumbling murmur

43. MS: Complications Hemoptysis Pulmonary embolism Pulmonary infection
Systemic embolization
Endocarditis uncommon in pure MS

44. MS: Labs
EKG: Typically A. Fib or LA enlargement when sinus rhythm present
CXR: LA and RV enlargement, Kerley B lines
Echo: calcification and thickening of valve leaflets and LA enlargement

45. MS: Treatment Prophylaxis for rheumatic fever
Heart failure treatment if present
Dig, beta blockers to control ventricular rate
Valvotomy in presence of symptoms and mitral orifice <1.7cm²
Anticoagulation if indicated

51. Mitral Regurgitation: Causes
Rheumatic heart disease in 33% of cases
MVP
Ischemic heart disease with papillary muscle dysfunction
LV dilitation
Mitral annular calcification
Hypertrophic cardiomyopathy
Infective endocarditis
congenital

52. MR: Clinical Manifestations
Fatigue
Weakness
Exertional dyspnea

53. MR: Physical Exam Sharp upstoke of arterial pulse LV lift
S1 diminished
Wide splitting of S2
Loud holosystolic murmur

55. MR: Echo Enlarged LA Hyperdynamic LV
Doppler echocardiogram useful in diagnosing and assessing severity of MR

58. MR: Treatment For severe/ decompensated MR, treat as heart failure
Endocarditis prophylaxis is indicated
Surgical intervention warranted in symptomatic individuals or in evidence of progressive LV dysfunction
Surgery before decompensated heart failure
Anticoagulation in face of atrial fibrillation

62. Mitral Valve Prolapse: Etiology
Most commonly idiopathic
? Familial
Ischemic heart disease
Atrial septal defect
Marfan syndrome
More common female>male

63. Normal mitral valve
MVP

65. MVP: Clinical Manifestations
Most patients asymptomatic and remain so
Chest pain (atypical)
Supraventricular and ventricular arrhythmias
Most important complication of severe MR is LV failure
Sudden death is very rare

66. MVP: PE Mid or late systolic click followed by late systolic murmur
Murmur exaggerated by valsalva, reduced with squatting
Echo shows displacement of one or both leaflets late in systole

69. MVP: Treatment Asymptomatic patient: reassurance
Prophylaxis for endocarditis indicated
Valve repair for patients with severe MR
ASA or anticoagulation for patients with TIA or embolization

73. Question 1
A new patient comes to you for evaluation. He’s a 45 year old male whose only complaint is that of some dyspnea on exertion, which he attributes to old age. He doesn’t smoke or drink alcohol. He does admit to being “very ill as a child,” but has been relatively healthy since. On physical exam, a diastolic murmur is noted, but the remainder of the exam is within normal limits.

74. Question 1 continued
Which of the following is the next best step in this patient’s management?
Only routine preventative care
Trial of beta blocker therapy to see if his shortness of breath resolves
Echocardiogram for assessment of the diastolic murmur, with further recommendations to follow
Cranial OMT for assessment of his CRI

75. Question 2
A 73 year old white male presents to the emergency department after a syncopal episode. He’s dyspnic, with air hunger at the bedside, and is complaining of chest discomfort radiating to his jaw and down his left arm. On exam, a III/VI crescendo-decrescendo murmur is appreciated.

76. Question 2 continued
Which of the following valvular pathologies is most likely responsible for this man’s presentation?
Aortic Stenosis
Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
Mitral valve prolapse

77. Question 3 The most common cause of mitral stenosis is: Familial
Idiopathic
Sauerkraut ingestion
Rheumatic
Alcohol induced