Valvular Heart disease

Aortic stenosis
  • Slow rising pulse with Narrow pulse pressure
  • Ejection systolic murmur decrease with Valsalva manoeuvre
  • Soft/absent S2
  • present S4 (sign of severity)
  • Thrill
  • Shift of apex — LV hypertrophy or failure

Causes:

  1. Bicuspid aortic valve (young patients < 65 y)‎
  2. Degenerative calcification (old patients > 65 years)‎

Indications of AV Replacement:

  1. if symptomatic
  2. If asymptomatic severe AS with LV-EF < 50 %
  3. If asymptomatic but valvular gradient > 50 mmHg and LVSD.
  4. If there is indication for other surgery e.g., CABG
Aortic Regurgitation

Collapsing pulse (sign of severity) usually with one of the following signs: –

  1. Corrigan’s sign (visible neck arterial pulsations)
  2. Quinke’s sign (Nail-bed pulsation)
  3. De Musset’s sign (Head bobbing)
  4. Duroziez Sign (Diastolic murmur proximal to femoral artery)

Wide pulse pressure (Sign of severity)

Early diastolic murmur best heard on the Lt sternal edge Mid-diastolic Austin-Flint murmur in severe AR 

Mitral regurgitation

It is the 2nd most common valve disease after aortic stenosis.

  • Pansystolic murmur – best heard at the apex and radiating into the axilla.
  • quiet S1
  • Severe MR may cause a widely split S2
  • ECG may show a broad P wave (atrial enlargement)

Treatment options

  1. Acute cases — nitrates, diuretics, inotropes & an intra-aortic balloon pump to increase CO
  2. If patients are in heart failure — ACE inhibitors may be considered with beta-blockers & spironolactone
  3. In acute, severe MR — surgery is indicated
Mitral Stenosis
  • Low volume pulse
  • Loud S1, opening snap
  • Mid-diastolic murmur best heard in expiration
Mitral prolapse
  • Mid-systolic click (Later if patient squatting)
  • Late systolic murmur (Longer if patient standing)
  • Patients may complain of atypical chest pain or palpitations
Tricuspid regurgitation
  1. Pan-systolic murmur
  2. Prominent / giant V waves in JVP
  3. Pulsatile hepatomegaly
  4. left parasternal heave

Causes:

  • Infective endocarditis (especially IVDU)
  • Rheumatic heart disease
  • Pulmonary hypertension e.g., COPD