Valvular insufficiency (regurgitation): Clinical sciences

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Introduction0:00–0:38

Valvular insufficiency refers to heart valves that are incompetent or leaky. Mild forms of valvular insufficiency can occur from natural aging, while moderate and severe forms can result from disease processes like long-standing hypertension, myocardial infarction, or infections such as rheumatic heart disease.
Valvular insufficiency is divided into 4 types: aortic, mitral, pulmonic, and tricuspid regurgitation. If left untreated, these conditions can lead to arrhythmias, or heart chamber failure depending on the valve involved.

Acute Management/Unstable patient0:38–2:12

If a patient presents with a chief concern suggestive of valvular insufficiency, first perform the ABCDE assessment to determine if they are stable or unstable.
If unstable, immediately stabilize the airway, breathing, and circulation. Always have a low threshold for endotracheal intubation in these patients.
Next, establish IV access with two large bore IVs and start appropriate fluid resuscitative measures. Be careful not to give too much fluids as it can lead to fluid overload and worsen the patient’s symptoms.
Make sure to continuously monitor vitals as these patients can be at a high risk for sudden cardiovascular collapse. Once the acute management is initiated, your next step is to perform a quick focused history and physical exam.
Unstable patients with valvular insufficiency might have a history of recent myocardial infarction, respiratory infection, or GI infection.
Physical exam might reveal a murmur; and signs of acute heart failure like tachycardia, hypotension, diaphoresis, or peripheral edema.
With these findings, suspect decompensated heart failure due to valvular insufficiency. Unstable patients should undergo emergent transthoracic echocardiogram, or transesophageal echocardiogram to confirm the diagnosis; often followed by surgical intervention to either repair or replace the valve.
Keep in mind that diagnostic workup in unstable patients should not delay therapeutic intervention. Okay, now that the unstable patients are taken care of, let’s talk about stable ones.

Stable Patient2:12–2:37

Generally speaking, most patients with valvular insufficiency are stable. Your next step here is to perform a focused history and physical exam.
Remember there are four types of valvular insufficiency; aortic regurgitation, mitral regurgitation, pulmonic regurgitation, and tricuspid regurgitation.
Alright, let’s start with our first type of valvular insufficiency, which is aortic regurgitation. History typically reveals episodes of syncope and angina.

Aortic regurgitation2:37–5:24

In addition, patients usually report episodic palpitations, with or without dyspnea, or orthopnea. You might also find previously diagnosed infective endocarditis or an aortic dissection.
The physical exam can reveal an S3 heart sound, which is produced by a sudden deceleration of blood flow from the left atrium into the left ventricle; as well as a blowing decresendo early diastolic murmur heard best in the parasternal area at the second right intercostal space.
Additionally, you might also hear a rumbling diastolic murmur heard best at the apex, which is commonly referred to as an Austin Flint murmur.
This is created by the regurgitant jet hitting the left ventricular free wall. Lastly, you might find increased pulse pressure like a water hammer pulse, which describes the rapid upstroke of the distal arterial pulse followed by prompt collapse of the vessel.
With these findings, you should suspect aortic regurgitation. Here is a clinical pearl!
If similar increased pulse pressure is felt in the carotid artery, it is referred to as a Corrigan pulse. On the other hand, if a pistol shot-like sounds are auscultated over the femoral artery, it’s called Traube sign.
Sometimes, the pulse pressure difference can be so severe, there might be visible pulsation of the capillaries within the fingertips especially when pressure is applied to the tip of the finger.
This is called a Quincke sign. Once you suspect aortic regurgitation, get an ECG and an echocardiogram.
In most cases, the ECG will be normal. On echo, you can expect to see abnormal aortic valve leaflets, a regurgitant aortic jet, a dilated aortic root, and fluttering of the anterior mitral valve leaflet, with or without an increased left ventricular volume and size.
These findings confirm your diagnosis of aortic regurgitation. Treatment includes medical optimization to reduce afterload and maximize heart function like cardiac output with diuretic and antihypertensive medications.
You should also consult the surgical team to evaluate for repair or replacement of the aortic valve. Don’t forget that patients with valve replacement will need anticoagulation postoperatively.
The duration of anticoagulation depends on the type of valve, mechanical or bioprosthetic, they receive. Okay, let’s turn to another type of valvular insufficiency, mitral regurgitation.

Mitral regurgitation5:24–7:02

History might reveal previous myocardial infarction, rheumatic fever, or infective endocarditis, as well as palpitations, dyspnea, and dry cough.
On exam, at the fifth intercostal space, in the midclavicular line, you will likely hear an S3 heart sound and a holosystolic blowing, high-pitched murmur.
The combination of these findings should lead you to suspect a mitral regurgitation. As before, order an ECG and an echocardiogram, The ECG typically shows the presence of P mitrale, which looks like a biphasic or double-humped P wave.
P mitrale is a sign of left atrial enlargement. On echo, you can expect to see a regurgitant mitral jet, left ventricular hypertrophy, and abnormal mitral valve leaflets.
These findings confirm the diagnosis of mitral regurgitation. When it comes to treatment, it involves medical optimization with diuresis and blood pressure control.
Similar to aortic stenosis, the goal is to reduce afterload and maximize the heart function. You should also consult the surgical team for evaluation of repair or replacement of the mitral valve.
Here is a clinical pearl! MitraClip, which is a catheter-based device to palliate the symptoms of mitral regurgitation, can be used in patients who are at high surgical risk.
However, it is not considered a durable repair. Let’s switch gears and talk about pulmonic regurgitation.

Pulmonic regurgitation7:02–7:58

These patients usually have a history of pulmonary hypertension or dilated cardiomyopathy, and often report dyspnea. On exam, at the second left intercostal space, along the sternal border, you will likely hear a high-frequency decrescendo diastolic murmur, that gets louder with inspiration.
With these findings, suspect pulmonic regurgitation. Next, order an ECG and an echocardiogram to confirm.
ECG is typically normal. However, on echo, you will see a regurgitant pulmonic jet which confirms the diagnosis of pulmonic regurgitation.
Just like other valvular insufficiencies, treatment includes medical optimization and surgical consultation for the evaluation of repair or replacement of the pulmonic valve.

Tricuspid regurgitation7:58–9:04

Finally, we’ve arrived at our last type, tricuspid regurgitation. In this case, patients often report a history of infective endocarditis, which could be due to intravenous drug use.
History might also reveal rheumatic fever; carcinoid syndrome; pulmonary hypertension; or left heart failure. On exam, at the sternal border of the left fourth and fifth intercostal space, you can hear a holosystolic murmur.
The murmur increases with inspiration and could extend to the right of the sternum. This should lead you to suspect tricuspid regurgitation.
As before, order an ECG and an echocardiogram to confirm your diagnosis. The ECG is typically normal.
However, the echo will show a regurgitant tricuspid jet confirming the presence of tricuspid regurgitation. Again, treatment includes medical optimization and surgical evaluation for repair or replacement of the tricuspid valve.
Alright, as a quick recap… Valvular insufficiency refers to incompetent or leaking heart valves. There are 4 types classified by the affected valve: aortic, mitral, pulmonic, and tricuspid regurgitation.

Review9:04–9:41

Unstable patients present with signs and symptoms of decompensated heart failure and require urgent surgical intervention.
For stable patients, obtain an ECG and echocardiogram to confirm your diagnosis. Treatment involves medical optimization in addition to surgical evaluation for repair or replacement of the defective valve.
Valvular insufficiency (regurgitation): Video | Osmosis