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Valve Disease
Jason Ryan, MD, MPH
Heart Valves

Pulmonic
AfraTafreeh.com Aortic
Tricuspid

Mitral
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Valve Disease
• Stenosis
• Stiffening/thickening of valve leaflets
• Obstruction to forward blood flow
• Regurgitation
• Malcoaptation of valve leaflets
• Leakage of blood flow backwards across valve
Valve Lesions - Systole
• Occur when heart contracts/squeezes
• Aortic stenosis
• Mitral regurgitation
• Pulmonic stenosis
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• Tricuspid regurgitation
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Valve Lesions - Diastole

• Occur when heart relaxes/fills
• Aortic regurgitation
• Mitral stenosis
• Pulmonic regurgitation
• Tricuspid stenosis
Valve Disorders
Treatments

• Only severe valvular lesions treated

• Mostly surgical diseases
• Surgical repair
• Often done for mitral valve prolapse → mitral regurgitation
• Valve replacement AfraTafreeh.com

• Bioprosthetic (pig or cow)

• Mechanical (requires life-long anticoagulation)
• Valvuloplasty (stenotic lesions)
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Stenotic Valve Disorders

• Stiff valve
• “Gradient” across valve
• High pressure upstream
• Lower pressure downstream
Rheumatic Fever
• Occurs weeks after streptococcal pharyngitis
• Common in children
• Autoimmune: type II hypersensitivity reaction
• Antibodies to bacterial M proteins cross-react
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Rheumatic Fever
• Jones criteria
• Joints: Polyarthritis (>5 joints)
• ♥: Carditis (valvulitis, myocarditis, pericarditis)
• Nodules (subcutaneous)
• Erythema marginatum (rash on trunk)
• Sydenham chorea (jerking movement disorder)
Rheumatic Heart Disease
• Damage to heart valves by rheumatic fever
• Mitral valve most commonly involved
• Often presents years after acute rheumatic fever
• Many patients do not recall acute symptoms
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Carcinoid Heart Disease

• Caused by carcinoid tumors of intestines
• Secrete serotonin
• Fibrous deposits tricuspid/pulmonic valves
• Leads to stenosis and regurgitation
• Serotonin inactivated by lungs
• Left sided lesions rare
Aortic Stenosis
Pathophysiology

• Stiff aortic valve

• Systolic problem
• Increased afterload

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Aortic Stenosis
Hemodynamics
• LV pressure systolic >> aortic pressure
• LVSP = 160mmHg (normal = 120)
• SBP = 120mmHg (normal = 120)
• Gradient = 40mmHg
• ↑ LVEDP due to ↑ afterload

Normal Aortic Stenosis

Aortic Stenosis
Clinical features

• Systolic crescendo-decrescendo murmur

• Syncope: failure to ↑CO due to ↑ afterload
• Angina: ↑ LVEDP → ↓ coronary blood flow
• Left heart failure: ↑ LVEDP
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Aortic Stenosis
Causes

• Senile aortic stenosis

• “Wear and tear”
• Collagen breakdown
• Calcium deposition
• Bicuspid aortic valve
Patrick J. Lynch, medical illustrator
• Rarely rheumatic heart disease

CDC/Public Domain
Supravalvular Aortic Stenosis
• Narrowing of ascending aorta above aortic valve
• Seen in Williams syndrome
• Genetic deletion syndrome

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Wikipedia/Public Domain
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Mitral Stenosis
Pathophysiology

• Stiff mitral valve

• Diastolic problem
• LA pressure >> LV diastolic pressure
• Left atrial pressure 20mmHg (normal = 10)
• LVEDP 5mmHg (normal = 10)
• Gradient = 15mmHg
• Decreased preload
Mitral Stenosis
Clinical features

• Caused by rheumatic fever

• Most common symptom: dyspnea
• ↑ LA pressure → pulmonary congestion
• Murmur: diastolic rumble with opening snap
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Tricuspid Stenosis
• Very rare valve disorder
• Diastolic murmur at left lower sternal border
• Caused by rheumatic fever (with mitral disease)
• Tricuspid regurgitation more common
• Carcinoid heart disease
Pulmonic Stenosis
• Congenital defect in children
• Fused commissures with thickened leaflets
• Carcinoid heart disease

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Wikipedia/Public Domain
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Regurgitant Lesions
• Acute and chronic forms
• Acute regurgitation (often from endocarditis)
• May cause shock
• Activation of sympathetic nervous system
• Increased contractility
• Increased afterload
• Chronic regurgitation
• No shock
• Leads to chronic heart failure
• Sympathetic activation only if severe heart failure
Aortic Regurgitation
Pathophysiology

• Blood leaks across aortic valve

• Diastolic problem
• Increased preload, stroke volume
• Increased afterload
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• More stroke volume → aorta → ↓ compliance (stiffening)
• Blowing diastolic murmur
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Aortic Regurgitation
Causes

• Dilated aortic root → leaflets pull apart

• Often from HTN or other aortic aneurysm
• Rarely from tertiary syphilis (aortitis)
• Bicuspid aortic valve
• Turner syndrome
• Coarctation of the aorta
• Endocarditis
• Rheumatic heart disease
• Almost always with mitral disease
Aortic Regurgitation
Clinical features

• Leaking blood back into LV causes low diastolic BP

• 120/80 (normal) → 120/40
• Low diastolic pressure
• Wide pulse pressure
• High cardiac output with low diastolic pressure
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• Wide pulse pressure symptoms
• “Water hammer” pulses
• Head bobbing
• Many, many others (mostly historical)
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Mitral Regurgitation
Pathophysiology

• Blood leaks across mitral valve

• Increased LA volume → Starling mechanism
• Increased left ventricular filling from LA
• Increased preload, stroke volume
• Reduced afterload
Mitral Regurgitation
Causes

• Primary MR caused by mitral valve prolapse

• Also called degenerative or myxomatous
• Billowing of mitral valve leaflets above annulus
• Common cause of mitral regurgitation
• Causes a systolic click
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• Don’t confuse with opening snap of mitral stenosis

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Mitral Regurgitation
Secondary causes

• Ischemia → damage to papillary muscle

• Left ventricular dilation
• Dilated cardiomyopathy
• Leaflets pulled apart
• “Functional” MR
• Hypertrophic cardiomyopathy
Mitral Regurgitation
Causes

• Endocarditis
• Rheumatic heart disease
• Congenital
• Cleft mitral valve
• Endocardial cushion defect
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• Down syndrome
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Mitral Regurgitation
Clinical Features

• Holosystolic murmur at apex

S1 S2
Afterload Reduction
Aortic and Mitral Regurgitation

• In theory, ↓ afterload can improve forward flow

• For severe, acute regurgitation this helps
• For chronic disease, clinical trials with mixed results
• In general, these are surgical diseases
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• Common test scenario “Best medical option?”
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Tricuspid Regurgitation
• Small amount of TR normal (“physiologic TR”)
• Holosystolic murmur at left sternal border
• Pathologic causes
• Functional TR from RV enlargement
• Endocarditis – classically with IV substance use
• Carcinoid
• Ebstein’s anomaly
Pulmonic Regurgitation
• Most common cause: repaired Tetralogy of Fallot
• Repair of RVOT obstruction damages valve
• Endocarditis (rare)
• Rheumatic heart disease (rare)
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Tetralogy of Fallot