Valvular heart disease
|Valvular heart disease|
|Classification and external resources|
|ICD-10||I34-I37, I05-I08, Q22-Q23|
|ICD-9||394-396, 424, 746|
Valvular heart disease is any disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left and the pulmonary and tricuspid valves on the right). These conditions occur largely as a result of ageing. Most people are in their late 50s when diagnosed, and more than one in ten people over 75 have it. According to Professor Ben Bridgewater, consultant cardiac surgeon at University Hospital of South Manchester, ‘If the disease is picked up early, the outcomes from surgery are very good. Life expectancy goes back to match that of healthy people the same age.
Collectively and anatomically, the valves are part of the dense connective tissue makeup of the heart known as the cardiac skeleton. Valve problems may be congenital (inborn) or acquired (due to another cause later in life). Treatment may be with medication but often (depending on the severity) involves valve repair or replacement (insertion of an artificial heart valve). Specific situations include those where additional demands are made on the circulation, such as in pregnancy.
|Valve involved||Stenotic disease||Insufficiency/regurgitation disease|
|Aortic valve||Aortic valve stenosis||Aortic insufficiency/regurgitation|
|Mitral valve||Mitral valve stenosis||Mitral insufficiency/regurgitation|
|Tricuspid valve||Tricuspid valve stenosis||Tricuspid insufficiency/regurgitation|
|Pulmonary valve||Pulmonary valve stenosis||Pulmonary insufficiency/regurgitation|
Aortic and mitral valve disorders
These are termed left heart diseases.
Pulmonary and tricuspid valve disorders
The most common types of pulmonary valve diseases are:
- pulmonary valve stenosis
- pulmonary valve insufficiency
- pulmonary valve incompetence
- pulmonary valve regurgitation
The International Statistical Classification of Diseases classifies non rheumatic pulmonary valve diseases as I37.
Heart valve dysplasia is an error in the development of any of the heart valves, and a common cause of congenital heart defects in humans as well as animals; tetralogy of Fallot is a congenital heart defect with four abnormalities, one of which is stenosis of the pulmonary valve. Ebstein's anomaly is an abnormality of the tricuspid valve.
Valvular heart disease resulting from rheumatic fever is referred to as "rheumatic heart disease". While developed countries once had a significant burden of rheumatic fever and rheumatic heart disease, medical advances and improved social conditions have dramatically reduced their incidence. Many developing countries, as well as indigenous populations within developed countries, still carry a significant burden of rheumatic fever and rheumatic heart disease and there has been a resurgence in efforts to eradicate the diseases in these populations. Inflammation of the heart valves due to any cause is called endocarditis; this is usually due to bacterial infection but may also be due to cancer (marantic endocarditis), certain autoimmune conditions (Libman-Sacks endocarditis) and hypereosinophilic syndrome (Loeffler endocarditis). Certain medications have been associated with valvular heart disease, most prominently ergotamine derivatives pergolide and cabergoline.
The evaluation of individuals with valvular heart disease who are or wish to become pregnant is a difficult issue. Issues that have to be addressed include the risks during pregnancy to the mother and the developing fetus by the presence of maternal valvular heart disease as an intercurrent disease in pregnancy. Normal physiological changes during pregnancy require, on average, a 50% increase in circulating blood volume that is accompanied by an increase in cardiac output that usually peaks between the midportion of the second and third trimesters. The increased cardiac output is due to an increase in the stroke volume, and a small increase in heart rate, averaging 10 to 20 beats per minute. Additionally uterine circulation and endogenous hormones cause systemic vascular resistance to decrease and a disproportionately lowering of diastolic blood pressure causes a wide pulse pressure. Inferior vena caval obstruction from a gravid uterus in the supine position can result in an abrupt decrease in cardiac preload, which leads to hypotension with weakness and lightheadedness. During labor and delivery cardiac output increases more in part due to the associated anxiety and pain, as well as due to uterine contractions which will cause an increases in systolic and diastolic blood pressure.
Valvular heart lesions associated with high maternal and fetal risk during pregnancy include:
- Severe aortic stenosis with or without symptoms
- Aortic regurgitation with NYHA functional class III-IV symptoms
- Mitral stenosis with NYHA functional class II-IV symptoms
- Mitral regurgitation with NYHA functional class III-IV symptoms
- Aortic and/or mitral valve disease resulting in severe pulmonary hypertension (pulmonary pressure greater than 75% of systemic pressures)
- Aortic and/or mitral valve disease with severe LV dysfunction (EF less than 0.40)
- Mechanical prosthetic valve requiring anticoagulation
- Marfan syndrome with or without aortic regurgitation
In individuals who require an artificial heart valve, consideration must be made for deterioration of the valve over time (for bioprosthetic valves) versus the risks of blood clotting in pregnancy with mechanical valves with the resultant need of drugs in pregnancy in the form of anticoagulation.
The following table includes the main types of valvular stenosis and regurgitation. Major types of valvular heart disease not included in the table include mitral valve prolapse, rheumatic heart disease and endocarditis.
|Valvular disease||Mitral stenosis||Aortic stenosis||Aortic regurgitation||Mitral regurgitation||Tricuspid regurgitation|
|Prevalence||Most common valvular heart disease in pregnancy||Approximately 2% of people over the age of 65, 3% of people over age 75, and 4% percent of people over age 85||2% of the population, equally in males and females.|
|Main causes and risk factors||Almost always caused by rheumatic heart disease||
|Progressive obstruction of the mitral ostium causes increased pressure in the left atrium and the pulmonary circulation. Congestion may cause thromboembolism, and atrial hypertension may cause atrial fibrillation.||Obstruction through the aortic ostium causes increased pressure in the left ventricle and impaired flow through the aorta||Insufficiency of the aortic valve causes backflow of blood into the left ventricle during diastole.||Insufficiency of the mitral valve causes backflow of blood into the left atrium during systole.||Insufficiency of the tricuspid valve causes backflow of blood into the right atrium during systole.|
Symptoms increase with exercise and pregnancy
Signs increase with exercise and pregnancy
No therapy is required for asymptomatic patients. Diuretics for any pulmonary congestion or edema. If stenosis is severe, surgery is recommended. Any atrial fibrillation is treated accordingly.
No treatment in asymptomatic patients.
Medical therapy and percutaneous balloon valvuloplasty have relatively poor effect.
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