1. Valvular Diseases Causes of valve regurgitation
congenital, senile degeneration, acute and chronic rheumatic carditis, infective endocarditis, syphilitic aortitis
traumatic valve rupture, damage to chordae and papillary muscles (e.g. in MI), dilated valve ring (e.g. dilated CMP)
Causes of valve stenosis
congenital, senile degeneration
rheumatic carditis
Common clinical scenarios
Young people: functional murmurs, MVP, AS
Old people: aortic sclerosis, aortic stenosis

2. Mitral Stenosis Symptoms Signs
pulmonary congestion: dyspnea, cough, hemoptysis (also due to PE)
chest pain (PH), edema and ascites (RVF)
fatigue (low COP), palpitation (AF), thromboembolic complications
Signs
inspection: mitral facies
palpation: tapping apex (palpable first heart sound), RV heave (PH)
auscultation: loud first heart sound, loud P2 (PH), opening snap, rumbling mid-diastolic murmur, presystolic accentuation
atrial fibrillation, raised pulmonary capillary pressure: crepitations, pulmonary edema, effusion

3. Mitral Stenosis ECG CXR Echo Doppler Cardiac catheterization
LA hypertrophy, RVH, AF
CXR
enlarged LA, pulmonary venous congestion
Echo
thick immobile cusps, reduced valve area, reduced rate of LV diastolic filling
Doppler
pressure gradient across MV, pulmonary artery pressure
Cardiac catheterization
pulomnary wedge pressure, pressure gradient between LA and LV

4. Mitral Stenosis Medical management Mitral balloon valvoplasty
digoxin for AF + BB or CA
diuretics for pulmonary congestion
anticoagulant to reduce the risk of systemic emboli
antibiotic prophylaxis against infective endocarditis
Mitral balloon valvoplasty
significant symptoms
isolated MS
no to trivial MR
mobile non-calcific valve / subvalvular apparatus on echo
LA free of thrombus
Mitral valve surgery
closed mitral valvotomy
open mitral valvotomy
mitral valve replacement: mechanical, bioprosthesis [St. Jude (bi-leaflet), Carpentier-Edwards (porcine), Medtronics (single leaflet, open)]

5. Mitral Regurgitation Causes Symptoms Signs
mitral valve prolapse (myxomatous changes) is the most common cause in developed world
damage to cusps: rheumatic valve disease, IE, congenital cleft mitral valve
damage to chordae: rheumatic valve disease, IE, trauma, degenerative
damage to papillary: ischemia, infarction, infiltrative, HCM
damage of annulus: calcification, IE (abscess)
dilation of MV ring: IHD, CMP, acute rheumatic valve
Symptoms
dyspnea, edema, ascites, fatigue, palpitations (AF, increased stroke volume), thromboembolic complications
Signs
jerky pulse (AF), displaced apex (hyperdynamic circulation)
3rd heart sound, apical pansystolic murmur with or without thrill
signs of pulmonary congestion and pulmonary hypertension

6. Mitral Regurgitation ECG CXR Echo Doppler Cardiac catheterization
LAH, LVH, AF
CXR
enlarged LA, enlarged LV, pulmonary venous congestion
Echo
dilated LA and LV, dynamic LV, structural abnormalities (e.g. MVP)
Doppler
detects and quantifies MR
Cardiac catheterization
dilated LA and LV, MR, assess PH, detect co-existing CAD

7. Mitral Regurgitation Medical (mild and moderate cases) Surgical
diuretics, vasodilators (e.g. ACEI)
digoxin and anticoagulant (for AF)
antibiotic prophylaxis (for IE)
Surgical
MV valvoplasty (repair)
MV replacement
Indications for surgery
worsening symptoms
progressive cardiomegaly
deterioration of LV function: EF < 60%, LVEDD > 55
Complications of artificial valves
IE, thromboembolic complications, hemolysis, valve dysfunction

8. Mitral Regurgitation
Emergency minor criteria for surgery in isolated severe chronic MR
any symptoms of heart failure or suboptimal exercise tolerance test
flail mitral leaflet
left atrial diameter > 45 mm
paroxysmal atrial fibrillation
abnormal exercise end-systolic volume index or ejection fraction
MVP
asymptomatic, acute MR (ruptured chordae), chronic MR, CHF
mid-systolic click, late systolic murmur or pan-systolic murmur
increased risk for IE, arrhythmias, embolic stroke and TIA (small), sudden death (rare)

9. Aortic Stenosis Causes
young patient: thick congenital bicuspid valve, unicuspid valve, supravalvular stenosis, subvalvular stenosis (discrete, diffuse)
middle age: thick bicuspid valve, rheumatic disease
old age: thick degenerative valve, calcification of bicuspid valve, rheumatic AS

10. Aortic Stenosis Symptoms Signs Severity
angina, exertional pre-syncope and dizziness, dyspnea, impaired exercise tolerance, episodes of acute pulmonary edema, sudden death
other signs of LVF (systolic and diastolic dysfunction)
Signs
slow-rising carotid pulse, narrow pulse pressure, thrusting apex beat (LV pressure overload)
ejection systolic murmur, basal crepitations
Severity
indicated by: diamond-shaped murmur, anacrotic pulse, paradoxical S2, S4 (LVH), S3 (LVF)
not indicated by: intensity, presence of thrill

11. Aortic Stenosis ECG CXR Echo Doppler Cardiac catheterization
LVH, LBBB, normal
CXR
enlarged LV, dilated ascending aorta, calcified AV, normal
Echo
calcified AV with restricted opening, thickened LV walls
Doppler
detects AR, estimates gradient
Cardiac catheterization
systolic gradient between LV and aorta, post-stenotic dilation of aorta, detects AR if present, detect presence of CAD

12. Aortic Stenosis Medical Surgical Mechanical versus bioprosthetic valve
prophylaxis against IE
anticoagulants if in AF
diuretics for pulmonary congestion (cautiously)
vasodilators are contraindicated
Surgical
mechanical AV replacement: symptomatic with normal COP and valve gradient > 50
bioprosthesis: symptomatic elderly (disk valve, caged-ball valve, bio-prosthetic valve)
aortic balloon valvoplasty: congenital AS
Mechanical versus bioprosthetic valve
mechanical: durable, large orifice, best in left side, high thromboembolic potential, chronic warfarin therapy
bioprosthetic: not durable, small orifice/functional stenosis, best in tricuspid orifice, low thromboembolic potential, consider in elderly

13. Aortic Regurgitation Congenital: Acquired
bicuspid AV, cystic medial necrosis (Marfan, Ehlers-Danlos, osteogenesis imperfecta, pseudoxanthoma elasticum)
Acquired
rheumatic heart disease, dilated aorta
degenerative, connective tissue disorders (ankylosing spondylitis, rheumatoid arthritis, Reiter, giant-cell arteritis), syphilis (chronic aortitis)
acute AR: infective endocarditis, trauma, dissecting aneurysm

14. Aortic Regurgitation Symptoms Signs (peripheral) Signs (central)
mild to moderate: asymptomatic, palpitations
severe: dyspnea, orthopnea, PND, chest pain (noctural and exertional angina) if aortic diastolic pressure < 40
Signs (peripheral)
Quincke sign: capillary pulsation
Corrigan sign: water hammer pulse
Bisferens pulse (AS/AR > AR)
DeMusset sign: systolic head bobbing
Mueller sign: systolic pulsation of uvula
Durosier sign: femoral retrograde bruits
Traube sign: pistol shot femorals
Hill sign: lower extremity BP > upper extremity BP by > 20 mmHg (mild), > 40 mmHg (moderate), > 60 mmHg (severe)
widened pulse pressure
Signs (central)
apex: enlarged, displaced, hyperdynamic (forcible nonsustained), palpable S3, Austin-Flint murmur
diastolic murmur: length correlates with severity (chronic), in acute murmur shortens as DP=LVEDP, mitral pre-closure

15. Aortic Regurgitation ECG CXR Echo Doppler Cardiac catheterization
LVH, T inversion
CXR
cardiac dilation, aortic dilation, pulmonary congestion
Echo
dilated LV, hyperdynamic LV, fluttering AML
Doppler
detects reflux
Cardiac catheterization
dilated LV, AR, dilated aortic root
Assessing severity
more severity with more peripheral signs and larger LV
S3, Austin-Flint murmur, LVH, radiological cardiomegaly

16. Aortic Regurgitation Medical Surgical Criteria for replacement
diuretics for pulmonary congestion, vasodilators (ACEI)
prophylaxis against IE, treatment of underlying cause (e.g. IE, syphilis)
Surgical
AV replacement: mechanical or bioprosthesis
aortic root replacement: for dilated aortic root (Marfan, syphilis, dissecting aneurysm) if LVEDD > 55, EF > 55%, FS > 27%
Criteria for replacement
symptoms: congestive heart failure, declining exercise tolerance on exercise testing, angina
anatomy: LV dysfunction (EF < 50%), progressive LV dilation or decline in EF on serial studies, severe dilation (LVDD > 75 mm, LVSD > 55 mm, aortic root dimension > 50)

17. Tricuspid Stenosis Causes Clinical
rheumatic: almost always have associated MS (signs of PH), isolated TS is rare, uncorrected TS worsens survival chance for patients undergoing surgery for AV or MV
carcinoid: mainly affects TV and PV
Clinical
similar to MS, JVD, edema, ascites, hepatomegaly
rumbling diastolic murmur with opening snap accentuated with respiration

18. Tricuspid Regurgitation
Causes
functional overload: pulmonary hypertension, RV dilation from infarction or myopathy
structural leaflet abnormalities: infectious endocarditis, congenital (Ebstein anomaly), acquired (carcinoid, plantain diet, ergot drugs)
Clinical
asymptomatic (tolerated for years), JVD
high-pitch blowing holosystolic murmur varying with respiration (Rivero-Carvallo sign) in xyphoid area
complications: right heart failure, renal failure
Treatment
none to treat underlying condition
diuretics, salt restriction
valve replacement, rings
Markers of severity
large pulsations in neck, pulsatile enlarged liver, widespread edema (anasarca, Michelin tire man), RV S3 (increases with respiration)

19. Pulmonary Stenosis typically congenital RVH
valvular, supravalvular, subvalvular (infundibular)
RVH
harsh systolic ejection murmur at 2nd left interspace (crescendo-decrescendo), thrill

20. Pulmonary Regurgitation
Causes
PH (most common)
IE, rheumatic disease, carcinoid heart disease
congenital defects, trauma
physiological is normal variant
Assessment
color flow doppler: right atrial enlargement, right ventricular volume overload
typical murmur: low-pitched diastolic murmur heard at left sternal border increasing with inspiration
PH murmur: high-pitched blowing diastolic murmur at left parasternal border (Graham-Steele murmur)