1. Valvular heart disease
Stenosis- narrowing
or
Regurgitation- leak

2. Mitral stenosis
 Cause- RHD, degenerative, congenital
 Consequences-
 Increased LA pressure, transmitted to pulmonary vasculature
causing pulmonary HT
 Increased LA size, prone to develop A-fib in ~50-80%
 Reduced cardiac output
 Symptoms precipitated by A-fib or pregnancy
 Clinical-
 Symptoms- DOE, orthopnea/PND, palpitation, fatigue
 Signs- loud S1-tapping apex beat, opening snap after A2,
mid-diastolic low-pitched rumbling
murmur at apex

3. Management
 Ix-
 CxR- LAE causes straightening of left heart border,
prominent PA, peripheral pruning of pulmonary
vasculature
 ECG- P-mitrale, RVH, ± A-fib
 ECHO- Dx-thickening, mobility, calcification & severity;
severe MS- area <1.0 square cm.
& gradient >10 mm Hg
 Rx-
 Diuretics
 A-fib- rate control + anticoagulation
 Balloon valvotomy
 MVR- calcified valve, LA clot, associated MR, restenosis

4. Mitral regurgitation
 Cause- MVP, RHD, IHD, functional-dilated LV
 Consequences-
 Acute- volume & pressure overload of LA
 Chronic- LV hypertrophydilatation, LAE, ± A-fib,
low cardiac output, pulmonary venous
congestion
 Clinical-
 Symptoms- DOE, ortopnea/PND, pulmonary edema/CHF
 Signs- soft S1, hyperdynamic apex, high-pitched pansystolic
murmur at apex radiating to axilla, ± S3
(MVP- mid/late systolic click with late systolic
murmur)

5. Management
 Ix-
 CxR- LAE & LVH, ± pulmonary edema
 ECG- P-mitrale, LVH, ± A-fib
 ECHO- Dx & severity-regurgitant fraction
severe MR- regurgitant fraction >60%
 Rx-
 Vasodilators- reduce afterload- ACEI
 Diuretics
 Surgery- MV repair or replacement
indication- NYHA class III/IV, LVEF <60%,
LV end-systolic dimension >45 mm

6. Aortic stenosis
 Cause- RHD, bicuspid AV, degenerative
 Consequences-
 LV hypertrophydilatation with reduced CO
 Clinical-
 Symptoms- DOE, angina-A, syncope-S, heart failure-H
50% mortality at 5, 3, 2 years for A, S, H
 Signs- pulsus parvus et tardus, narrow pulse pressure,
sustained apex beat, ejection click after S1, soft S2,
ejection systolic murmur in aortic area radiating to carotids

7. Management
 Ix-
 CxR- LVH
 ECG- LVH
 ECHO- Dx & severity
severe- valve area <1 square cm or
gradient >40 mm Hg
 Rx-
 AV replacement- surgical or percutaneous

8. Aortic regurgitation
 Cause- RHD, bicuspid AV, CAD, HT, ankylosing spondylitis,
aortic root dilatation-due to aging,
Marfan’s, aneurysm, IE
 Consequence-
 Acute- pulmonary edema
 Chronic- pressure overload due to elevated pulse pressure
& peripheral vasoconstriction LVH,
volume overloadLV dilatationfailure
 Clinical-
 Symptoms- DOE, fatigue, CHF-acute or chronic
 Signs- hyperdynamic apex, early diastolic murmur in aortic area,
± S3, flow murmurs- ESM-AS, MDM-MS-Austin Flint murmur

9. AR- peripheral signs
 Rapid upstroke & collapse of carotid pulse- Corrigan’s
 Large volume, collapsing waterhammer pulse- Watson’s
 Low diastolic & increased pulse pressure
 >20 mm Hg difference in UL & LL systolic pressure- Hill’s
 Head nodding with heartbeat- de Musset’s
 Retinal vessel pulsation- Becker’s
 Pulsation of uvula- Muller’s
 Nailbed capillary pulsation- Quinke’s
 Pistol-shot sounds over femoral artery- Traube’s
 To & fro murmur over femoral artery- Duroziez’s
 Alternating constriction & dilatation of pupils- Landolfi’s
 Pulsatile liver- Rosenbach’s

10. Management
 Ix-
 CxR- cardiomegaly, pulmonary edema
 ECG- LVH
 ECHO- Dx & severity
severe- low LVEF, regurgitant fraction >50%/volume >60
ml
 Rx-
 Vasodilators- reduce afterload- ACEI, CCB
 Diuretics
 AV replacement- before LV dilatation/reduced LVEF

11. Tricuspid stenosis
 Causes- RHD (with mitral valve involved),
carcinoid syndrome, IE, RA myxoma,
congenital tricuspid atresia
 Symptoms of RHF
 JVP elevated, with giant a wave
 Murmur- mid-diastolic rumble, best heard in
tricuspid area, increasing with inspiration
 Dx- ECHO, severe- diastolic pressure gradient >5 mm Hg
 Rx- diuretics, balloon valvuloplasty or TVR-
bioprosthetic valve, if required

12. Tricuspid regurgitation
 Causes- RV dilatation, IE, RHD,
Ebstein’s anomaly, carcinoid, Marfan’s
 Clinical-
 Symptoms- due to RVF, if present
 Signs- elevated JVP-cv wave with absent x descent,
pulsatile liver, edema,
pansystolic murmur in tricuspid area, ± S3
 Dx-ECHO
 Rx- symptomatic- diuretics, vasodilators,
TV repair/replacement-rarely required

13. Pulmonary stenosis
 Cause- congenital, RHD, carcinoid
 Clinical-
 Fatigue, syncope, cyanosis, RVH,
s/o RV failure- raised JVP,
edema, hepatomegaly
 Dx- ECHO, severe-gradient >50 mm Hg
 Rx- balloon valvuloplasty or
valve replacement

14. Pulmonary regurgitation
 Causes- pulmonary HT, idiopathic dilated
pulmonary annulus, carcinoid
 Hyperdynamic RV, palpable P2,
widely split S2, right sided S3
 Graham Steel murmur- short diastolic murmur
along lower L sternal border- 2° to pulmonary
HT, increases with inspiration
 Dx- ECHO or MRI
 Rx- underlying cause

15. Common
 ECHO for Dx & severity
 Coronary angiography before valve replacement if-
 h/o CAD
 Symptoms of CAD
 Risk factors for CAD
 Male >40 years
 Postmenopausal female
 Valve- bioprosthetic or mechanical,
choice based on age & willingness for anticoagulation
 Bioprosthetic valve- lifelong aspirin,
Mechanical valve- lifelong aspirin + warfarin
 Target INR- 2.5-3.5