1. Valvular Heart Disease
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The four valves (tricuspid, pulmonary, mitral, and aortic) of the human heart work in concert to ensure unidirectional flow of blood through the chambers of the heart and the pulmonary and systemic circuits. The valves themselves are avascular, thin fibrous structures that open and close completely and passively with changes in pressure during the cardiac cycle.
The tricuspid and mitral valves, which sit between the atria and the ventricles, open when ventricular pressure is lower than atrial pressure during diastole and allow ventricular filling. These close immediately with the onset of ventricular systole as ventricular pressure exceeds that in the atria; and the pulmonary and aortic valves, which regulate the outflow of the right and left ventricles, open once ventricular pressure exceeds arterial pressure.
Following the ejection of blood from the ventricle, chamber pressure falls again, causing the pulmonary and aortic valves to close. This cycle repeats with every heartbeat.

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Common causes of heart valve disease include :
congenital defects,
connective tissue disorders,
infective endocarditis,
rheumatic heart disease, and
calcific disease of aging
Disease or damage to the valve(s) can cause stenosis—obstruction of forward flow, or regurgitation—inadequate closure, resulting in backward flow of blood.
Abnormal flow across the diseased valve can often be heard as a murmur:
mild—generally not clinically significant,
moderate—may cause symptoms, especially in active individuals, or
severe—typically associated with symptoms.

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Symptoms of heart valve disease may include:
fatigue;
decreased exercise capacity;
dyspnea (especially with exertion);
palpitations, angina pectoris, or both;
Pre-syncope, syncope;
heart failure with nonproductive cough; and
lower-extremity swelling (advanced cases
Mitral Valve Disease
A variety of mitral valve disorders can cause incomplete closure during systole, which allows blood to flow back (regurgitate) into the left atrium. Symptoms from the ensuing pulmonary congestion include exertional dyspnea or, in advancing cases, dyspnea at rest. Eventually pulmonary hypertension with left heart dilation and failure develops.
Mitral stenosis refers to any narrowing of the mitral orifice. The increased resistance to ventricular filling causes an inability to augment cardiac output during exertion. In advanced cases, high left atrial pressure mimics the signs and symptoms of left ventricular failure, with dyspnea, pulmonary hypertension, marked fatigue, and lower-extremity edema.

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Mitral Valve Disease
Rheumatic heart disease is the most common cause (60% of cases). Streptococcal infection (i.e., strep throat) can cause an inflammatory reaction in the heart, including the mitral valve, and result in thickening of the valve and mitral stenosis after 10 years or more. Rheumatic heart disease is commonly associated with atrial fibrillation and has a high risk of thromboembolism from atrial fibrillation
Aortic Valve Disease
Aortic regurgitation results when the aortic valve cusps fail to close securely during diastole, allowing blood in the aorta to flow back into the left ventricle.
Aortic stenosis is failure of the aortic valve cusps to freely open during systole, leading to high left ventricular pressures and limited cardiac output. High ventricular pressures are necessary to maintain arterial blood pressures downstream of the narrowing, and these high pressures cause left ventricular hypertrophy.

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Right-Sided Valvular Heart Disease
Valvular conditions on the right side of the heart, involving the tricuspid and pulmonic valves, have multiple origins but cause fewer clinical problems than aortic and mitral valve disease
Tricuspid regurgitation is often a functional lesion caused by either pulmonary hypertension or dilation of the right ventricle, and in these situations it is rarely severe. Edema and fatigue are potential symptoms, although tricuspid regurgitation is often asymptomatic.
Tricuspid stenosis is a rare condition involving obstruction to flow from the right atrium to the right ventricle. It is almost always due to rheumatic heart disease and seen in association with mitral stenosis. Lower-extremity edema and ascites are common manifestations of the high sustained right atrial pressure.

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Right-Sided Valvular Heart Disease
Pulmonic regurgitation is also rare and can be due to pulmonary hypertension.
Pulmonic stenosis is a narrowing of the pulmonary valve causing fixed blood flow to the lungs and increased pressures in the right ventricle.
Management and Medications
Treatment decisions for valvular heart disease are primarily based on symptoms. Valvular heart disease is essentially a mechanical disorder, and definitive treatment requires surgery.
In aortic regurgitation, echocardiography can quantify the regurgitation, but transesophageal echocardiography and sometimes computed tomography or magnetic resonance angiography may be needed to visualize the entire aortic root.
Surgical repair of the native valve is possible in some instances, depending on the specific anatomic defect. Mitral valve prolapse and bicuspid aortic valve disease can be repaired (bioprosthetic or metallic valves)

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Effects on the Exercise Response
Valvular heart disease affects the exercise response in proportion to the severity of the lesion.
Severe Mitral Regurgitation
Hemodynamic response is altered.
Exercise capacity and peak O2 are reduced.
High static loads (weightlifting, downhill skiing) may provoke symptoms by markedly increasing afterload and the regurgitated fraction of cardiac output
Severe Mitral Stenosis
Cardiac output may be blunted or fixed.
Flow limitation may cause exercise-induced hypotension.
Exertional tachycardia can increase left atrial and pulmonary pressures, so high heart rate activities (cycling, running, swimming) are contraindicated.

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Effects on the Exercise Response
Aortic Regurgitation
High static loads (weightlifting, downhill skiing) may provoke symptoms by markedly increasing afterload and the regurgitated fraction of cardiac output.
If left ventricle function is normal, high dynamic loads are often well tolerated
Aortic Stenosis
Prevents augmentation of cardiac output.
Flow limitation increases risk of exertional hypotension and syncope

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Effects on the Exercise Response
Valvular heart diseases commonly cause early exertional fatigue, exertional dyspnea and a hypotensive pressor response to exercise, and symptoms of pre-syncope or syncope. Medical and surgical management improves these exertional symptoms to improve quality of life and preserve independent functioning.
Exercise management must consider how to perform exercise without provoking symptoms and whether the specific valvular condition will worsen with a particular form of exercise.
Effects of Exercise Training
There are no randomized studies of exercise training with regard to the benefit—or harm—of exercise for persons with valvular heart disease. Exercise is associated with a higher quality of life in individuals with valvular heart disease; and in those who undergo valve surgery, preoperative functional capacity is a strong predictor of postoperative functional capacity. Symptoms of valvular heart disease may well restrict activity, but development of such symptoms is usually a strong argument for surgery, not for reducing activity.

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Recommendations for Exercise Testing
Exercise tolerance testing with close attention to the electrocardiographic and blood pressure response, and is valuable for both symptom diagnosis and risk assessment before unsupervised exercise.
Need to assess symptoms such as dyspnea, chest discomfort, palpitations, or pre-syncope.
Exercise echocardiography is particularly advantageous for people with mitral valve disease:
Mitral Regurgitation : Exercise echo to evaluate for exercise-induced pulmonary hypertension and define functional capacity Mitral Stenosis: Exercise echo to evaluate the mitral pressure gradient and pulmonary pressure
Aortic Regurgitation : Exercise testing to assess exertional symptoms and the hemodynamic response to exercise, looking for systemic hypotension, pulmonary congestion, or just reduced peak O Aortic Stenosis : Exercise testing to determine the clinical severity of aortic stenosis. A drop in blood pressure during exertion is an ominous sign, and can reveal whether someone is truly asymptomatic or simply sedentary.

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Recommendations for Exercise Programming
Exercise recommendations for persons with valvular heart disease should take into consideration the type and severity of valvular heart disease, the type of exercise (i.e., dynamic or static or a mix of dynamic and static), and the life circumstances and desires of the individual.
Individuals who have moderate valvular stenosis or regurgitation should consult with a cardiologist before starting an exercise program, because guidance on the type and intensities of exercise remains a clinical judgment with an insufficient evidence base to make a general recommendation. On the following slides are general recommendations for mild or severe valvular heart conditions and after valvular surgery.

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Recommendations for Exercise Programming
Mild and Asymptomatic to Minimally Symptomatic, Any Valve:
Any exercise the person wants to do is permissible.
Regular follow-up with the cardiologist is required.
People should avoid going hard enough to cause symptoms.
If increasing symptoms develop, they should see their cardiologist.
Moderate to Severe and Symptomatic, Mitral or Aortic Valve:
Stenosis—avoid high dynamic exercises
Aortic stenosis—generally low-intensity activities only
Regurgitation—avoid high static exercise
Connective Tissue and Congenital Conditions
Mitral valve prolapse—avoid contact sports
Genetic disorders of the aortic root—avoid contact sports and high arterial pressures
Dilated aortic root—see chapter 15 on aneurysms

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Recommendations for Exercise Programming
Status Post-valve Repair or Replacement :
Cardiac rehabilitation with supervised exercise is strongly advised.
If high-intensity exercise is the goal, exercise testing up to the proposed level of exertion should be considered.
The medical home staff can coordinate interval follow-up and assessment, which is especially important for those individuals with moderate degrees of valvular heart disease. People should be periodically queried about new or progressive symptoms such as decreased exercise capacity, palpitations, angina, syncope, and dyspnea.
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