Valvular heart disease: Clinical

Valvular heart disease involves damage or a defect in one or more of the four valves of the heart, so the aortic and bicuspid or mitral valves on the left side of the heart, and the pulmonary and tricuspid valves on the right side of the heart.

Normally, the valvular leaflets are very thin and when the cusps close they're perfectly apposed.

Valvular heart diseases are divided into stenosis - in which there’s narrowing of the valvular orifice that prevents adequate outflow of blood - and insufficiency or regurgitation, in which the valvular leaflets fail to close correctly and are unable to prevent backflow of blood.

These two are not mutually exclusive, which means they can both be present in the same individual and even in the same valve, for instance if thickening of the leaflets results in inappropriate closure as well as a narrow orifice.

Individuals with valvular heart disease are generally asymptomatic for a prolonged period, even for decades, and as soon as they become symptomatic, their life expectancy deteriorates very quickly.

The main symptoms are dyspnea, syncope, and angina. Both stenosis and regurgitation lead to turbulent flow when blood flows across the affected valve, which produces heart sounds called pathologic murmurs that are loud enough to be heard upon auscultation with a stethoscope.

When presentation suggests valvular heart disease, you should proceed with echocardiography to confirm the diagnosis of valvular disease and determine its severity.

A transthoracic echocardiogram is typically done, but a transesophageal echocardiogram may be needed in selected individuals, like those with a nondiagnostic transthoracic echocardiogram.

Doppler echocardiography allows determination the speed and direction of blood flow, which makes it the most sensitive noninvasive technique for detecting the regurgitant jet.

In some cases cardiovascular magnetic resonance imaging may be indicated to quantify the severity, measure left ventricular diastolic and systolic volumes, and assess left ventricular systolic function.

And as a last resort, cardiac catheterization is indicated when noninvasive tests are inconclusive or provide discrepant results, or for coronary angiography prior to valve surgery in patients at risk for coronary disease.