Definition
Valvular heart disease comprises a group of congenital or acquired conditions characterized by damage to the heart valve(s), resulting in deranged blood flow through the heart chambers.
Key Points
- Valve replacements are uncommon but prognosis is very good.
- Biological valves tend to degenerate after 10–15 years.
Epidemiology
Rheumatic fever is still a major problem in developing countries, while congenital heart disease occurs in 8–10 cases per 1000 live births worldwide.
Aetiology
- Congenital valve abnormalities.
- Rheumatic fever.
- Infective endocarditis.
- Degenerative valve disease.
- Drug induced (ergot, dopamine agonists).
Pathology
- Rheumatic fever: immune-mediated acute inflammation of heart valves due to a cross-reaction between group A α-haemolytic Streptococcus antigens and cardiac proteins.
- Disease may narrow valve orifice (stenosis) or make it incompetent (regurgitation) or both.
- Stenosis causes a pressure load while regurgitation causes a volume load on the heart chamber immediately proximal to it with upstream and downstream effects.
Clinical Features
Aortic Stenosis
(Senile degeneration most common cause.)
- Angina pectoris.
- Dizziness, syncope.
- Left heart failure.
- Slow upstroke arterial pulse.
- Precordial systolic thrill (second right ICS).
- Harsh midsystolic ejection murmur (second right ICS).
Aortic Regurgitation
(Congenital, rheumatic, infective endocarditis most common causes.)
- Dyspnoea, palpitations.
- Congestive cardiac failure.
- Wide pulse pressure.
- Water-hammer pulse.
- Decrescendo diastolic murmur (lower LSE).
Mitral Stenosis
(Rheumatic and congenital most common causes.)
- Pulmonary hypertension.
- Paroxysmal nocturnal dyspnoea.
- Atrial fibrillation.
- Malar flush
- Loud first heart sound and opening snap.
- Low-pitched diastolic murmur with presystolic accentuation at the apex.
Mitral Regurgitation
(Functional, degenerative, rheumatic, infective carditis most common causes.)
- Dyspnoea, chronic fatigue, palpitations.
- Pulmonary oedema.
- Apex laterally displaced, hyperdynamic praecordium.
- Apical pansystolic murmur radiating to axilla.
Tricuspid Stenosis
(Rheumatic most common cause – usually aortic or mitral disease as well.)
- Fatigue.
- Peripheral oedema.
- Liver enlargement/ascites.
- Prominent JVP with large a waves.
- Lung fields are clear.
- Rumbling diastolic murmur (lower left sternal border).
Tricuspid Regurgitation
(Functional, rheumatic, infective carditis most common causes.)
- Chronic fatigue.
- Hepatomegaly/ascites.
- Peripheral oedema.
- Right ventricular heave.
- Prominent JVP with large v waves.
- Pansystolic murmur (subxiphoid area).
Investigations
- ECG.
- Chest X-ray.
- Echocardiography and colour Doppler techniques.
- Cardiac catheterization with measurement of transvalvular gradients.
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