Valvular heart disease: diagnosis and management

Abstract

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.

FIGURE 1.

Electrocardiogram of a patient with severe aortic stenosis showing marked left ventricular hypertrophy with repolarization abnormalities.

FIGURE 2.

Parasternal short-axis echocardiographic view of a patient with severe aortic stenosis due to a congenital bicuspid aortic valve. The leaflets are heavily calcified (arrow).

FIGURE 3.

Algorithm for management of low-output, low-gradient aortic stenosis. AS = aortic stenosis; AVA = aortic valve area; DSE = dobutamine stress echocardiography; LV = left ventricular; LVOT = LV outflow tract.

FIGURE 4.

Management strategy in patients with severe aortic stenosis. Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. AVA = aortic valve area; CABG = coronary artery bypass graft; LV = left ventricular; V_max = maximum velocity. Adapted from Circulation.

FIGURE 5.

Chest radiograph of a patient with severe aortic regurgitation showing cardiomegaly and bilateral pleural effusions.

FIGURE 6.

Transesophageal echocardiographic short-axis view of a patient with a bicuspid aortic valve. Note that there are 2 leaflets instead of 3 (arrows).

FIGURE 7.

Transesophageal echocardiographic long-axis view with color-flow Doppler imaging in a patient with a bicuspid aortic valve with severe aortic regurgitation (arrow). Ao = aorta; LV = left ventricle.

FIGURE 8.

Management strategy for patients with chronic severe aortic regurgitation. AVR = aortic valve replacement; DD = diastolic diameter; echo = echocardiography; EF = ejection fraction; LV = left ventricular; MRI = magnetic resonance imaging; RVG = radionuclide ventriculography; SD = systolic diameter. Adapted from Circulation.

FIGURE 9.

Electrocardiogram from a patient with severe mitral regurgitation showing both left ventricular hypertrophy and left atrial enlargement.

FIGURE 10.

Parasternal long-axis echocardiographic view of a patient with bileaflet mitral valve prolapse (arrows). LA = left atrium; LV = left ventricle.

FIGURE 11.

Apical 4-chamber echocardiographic view with color-flow Doppler imaging in a patient with mitral valve prolapse and severe mitral regurgitation (arrow). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.

FIGURE 12.

Management strategy for patients with chronic severe mitral regurgitation. AF = atrial fibrillation; EF = ejection fraction; ESD = end-systolic dimension; HT = hypertension; LV = left ventricular; MV = mitral valve; MVR = MV replacement. * Mitral valve repair may be performed in asymptomatic patients with normal LV function if performed by an experienced surgical team and if the likelihood of successful MV repair is >90%. Adapted from Circulation.

FIGURE 13.

Chest radiograph of a patient with severe mitral stenosis showing left atrial enlargement and pulmonary congestion.

FIGURE 14.

Apical 4-chamber echocardiographic view of a patient with severe mitral stenosis showing severe left atrial (LA) enlargement and a calcified mitral valve with reduced excursion (arrow). LV = left ventricle; RA = right atrium; RV = right ventricle.

FIGURE 15.

Management strategy for patients with severe mitral stenosis. AF = atrial fibrillation; LA = left atrial; MR = mitral regurgitation; MV = mitral valve; MVA = MV area; PAP = pulmonary artery pressure; PMBV = percutaneous mitral balloon valvotomy. Adapted from Circulation.