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Valvular Heart Disease

  1. Mitral Stenosis (Ref. Hari. 18th ed., pg -1929)

Causes: Rheumatic; congenital (Rare), mucopolysaccharidoses, endocardial fibroelastosis, malignant carcinoid prosthetic valve.


RHD is the most common cause of MS. Rest all causes are extremely rare


Pathophysiology –


Mitral stenosis – LA pressure increase → Pulm venous and pulm arterial wedge pressure increases (responsible for exertional dyspnea) → Pulmonary hypertension.

Extra Edge:

  1. In normal adults, the area of the mitral valve orifice is 4–6 cm2.
  2. In the presence of significant obstruction, blood can flow from the LA to the LV only if propelled by an abnormally elevated left atrioventricular pressure gradient, the hemodynamic hallmark of MS.
  3. When the mitral valve opening is reduced to <1 cm2, often referred to as "severe" MS, a LA pressure of ~25 mmHg is required to maintain a normal cardiac output (CO).
  4. The elevated pulmonary venous and pulmonary arterial (PA) wedge pressures reduce pulmonary compliance, contributing to exertional dyspnea. (Ref. Hari. 18th ed., pg - 1929)

Presentation: Dyspnoea Q on exertion (main symptom) fatigue; palpitations; chest pain Q; hemoptysis Q , Hoarseness of voice (Autner syndrome), dysphagia.

Malar flush Q; low-volume pulse Q; Af Q; tapping apex beat. Left parasternal heave due to RVH -Palpitations – Usually due to atrial arrhythmias.


On examination


Tapping apex beat, left parasternal heave (due to right ventricular hypertrophy)

On auscultation:
loud S1Q; opening snap Q (pliable valve Q); rumbling mid-diastolic murmur Q with presystolic accentuation (LQ 2012).  Loud P2, Graham Steell murmur Q may occur.


Important Points: LVH & S3 are not feature of MS (LQ 2012)

Severity is indicated by
(LQ 2012)

  1. Longer the diastolic murmur
  2. The closer the opening snap to A2.




  1. AF
  2. P-mitrale if in sinus rhythm
  3. RVH
  4. Progressive RAD.


  1. Straitening of the left border of heart (Earliest feature Q
  2. Left atrial enlargement
  3. Pulmonary oedema                                          
  4. Mitral valve calcification.
  5. Prominent upper lobe veins (Colonel moustache sign)               
  6. Kerley B lines                                    

Echocardiography diagnostic. Significant stenosis exists if the valve orifice is <1cm2/m2 body surface area.


Reduced EF slope is characteristic Q . (AIPG 10)

Management Strategy for Patients with Mitral Stenosis (MS) and Mild Symptoms.

There is controversy as to whether patients with severe MS (MVA <1 cm2) and severe pulmonary hypertension (PH) (PASP >60 mmHg) should undergo percutaneous mitral balloon valvotomy (PMBV) or mitral valve replacement (MVR) to prevent right ventricular failure. CXR, chest x-ray; ECG, electrocardiogram; echo, echocardiography; LA, left atrial; MR, mitral regurgitation; MVA, mitral valve area; MVG, mean mitral valve pressure gradient; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; PAWP, pulmonary artery wedge pressure; 2D, 2-dimensional.


  1. Diuretics to reduce preload and pulmonary venous congestion
  2. Digoxin If in AF or in CHF. Rate control is crucial. Anticoagulated with warfarin
  3. If this fails to control symptoms, balloon valvuloplasty (if pliable, non-calcified valve), open mitral valvotomy or valve replacement
  4. Endocarditis prophylaxis for dental or surgical procedures
  5. Oral penicillin as prophylaxis against recurrent rheumatic fever if <30yrs old 


  1. Pulmonary hypertension
  2. Emboli
  3. Pressure from large LA on local structures, eg hoarseness Q (recurrent laryngeal nerve, Ortner’s syndrome Q) dysphagia Q (oesophagus), bronchial obstruction Q
  4. Infective endocarditis. 



4 types of surgery (Ref. Hari. 18th ed., pg - 1932) 

  1. Percutaneous Balloon valvuloplasty –
  2. Closed mitral valvotomy
  3. Open mitral valvotomy
  4. Valve replacement

Two types of prosthetic valves –

  1. Mechanical prosthesis – Life long anticoagulation is indicated for patient receiving mechanical prosthesis. But its life is more than bio prosthesis valve hence preferred in young individuals
  2. Bio prosthesis – useful in older individuals (>70yrs) and in pregnancy when risk of anticoagulation is significant. 
  1. Mitral Regurgitation


  1. Functional (LV dilatation)                          
  2. Annular calcification (elderly)
  3. Rheumatic fever & RHD                                   
  4. Infective endocarditis
  5. Mitral valve prolapse                                
  6. Rupture chordae tendinea
  7. Papillary muscle dysfunction/rupture                
  8. Connective tissue disorder\ (Ehlers-Danlos, Marfan’s)
  9. Congenital (may be associated with other defects. eg ASD, AV canal) 

Pathophysiology –


In acute MR – There is normal/ reduced compliance of LA leading to marked increase in


LA pressure – pulmonary edema

In chronic MR – There is increase in LA compliance – normal / only slightly elevated LA pressure – decrease CO.


Hence in chronic MR fatigue/ exhaustion are common while symptoms resulting from pulmonary congestion are less common.



  1. Easy fatigability Q;(commonest symptom), palpitations, Dyspnea.

Signs: - displaced, hyperdynamic apex; RV heave; soft S1Q; loud P2 Q (pulmonary hypertension) pansystolic murmur Q at apex radiating to axilla.



ECG:  Af +, P-mitrale if in sinus rhythm (It means left atrial enlarge size); LVH


CXR: big LA & LV; mitral valve calcification; pulmonary oedema.


assess LV function (trans-oesophageal to assess severity and suitability for repair rather than replacement). Doppler echo to assess size and site of regurgitant jet.

Complication –

  1. Atrial fibrillation
  2. Infective endocarditis – More common than in MS 


  1. Diuretics improve symptoms.
  2. Antibiotics to prevent endocarditis
  3. Digoxin if in heart failure or Af. Control rate if fast AF.
  4. ACEI
  5. Anticoagulated if: AF; history of embolism prosthetic valve; additional mitral stenosis. 

Surgical –  Surgery for deteriorating symptoms; aim to repair or replace the valve before LV irreversible impaired.


Mitral valve replacement – Done in

  1. Severe, symptomatic MR (class II, III, IV)
  2. Asymptomatic MR with LV dysfunction, i.e. LVEF <55%

It is most common valvular lesion in India & the world because it is there in 7% of young female. It can be familial (AD) 


Management Strategy for Patients with Chronic Severe Nonischemic Mitral Regurgitation.
*Mitral valve (MV) repair may be performed in asymptomatic patients with normal left ventricular (LV) function if performed by an experienced surgical team and if the likelihood of successful MV repair is >90%. AF, atrial fibrillation; Echo, echocardiography; EF, ejection fraction; ESD, end-systolic dimension; eval, evaluation; HT, hypertension; MVR, mitral valve replacement.

  1. Mitral valve prolapse

It is the commonest valvular lesion in the world. It is seen in 5-7% Q of the young girls.

Occurs alone or with: ASD, PDA, cardiomyopathy, Turner's syndrome. Marfan's syndrome Q osteogenesis imperfecta, pseudoxanthoma elasticum, WPW syndrome

  1. Symptoms:
    1. Asymptomatic
    2. Atypical chest pain        
    3. Palpitations.  
    4. Embolic phenomena
  2. Signs:
    1. Non ejection Mid-systolic click Q
    2. A late systolic murmur Q. (Intensity of the murmur increases on standing and Valsalva Q)
  3. Complications
    1. Mitral regurgitation          
    2. Cerebral emboli    
    3. Arrhythmias    
    4. Sudden death Q



Echocardiography is diagnostic.  ECG may show inferior T wave inversion




B blockers may help palpitations and chest pain. Give endocarditis prophylaxis if co-existing mitral regurgitation. 

  1. Aortic stenosis (AS)
    1. Causes:
      1. Senile calcification
      2. RHD
      3. Congenital (bicuspid valve, William's syndrome.) Q
    2. Presentation May be asymptomatic Q or Classical triad Q:
      1. Angina
      2. Dyspnea
      3. Syncope

        ​​Others symptoms
        1. Dizziness
        2. CCF
        3. Sudden death Q.
    3. Signs:
      1. Slow rising pulse (diminished and delayed carotid upstroke-'parvus et tardus' Q)
      2. Narrow pulse pressure
      3. Heaving apex beat;
      4. Aortic thrill
      5. Ejection systolic murmur Q heard at i) apex ii) left sternal edge iii) the aortic area, radiates to the carotids.  Gallavardin phenomena is seen AS.
      6. Reversed splitting of S2.
      7. There may be an ejection click (pliable valve)
      8. S4
      9. S3



ECG: LVH with strain pattern.


CXR: calcified aortic valve; post-stenotic dilatation of ascending aorta.


Echo: diagnostic


Doppler echo can estimate the gradient across valves: severe stenosis if gradient 40mmHg or valve area <0.1 sq cm.

Criteria of severe Aortic stenosis

  1. Duration of murmur
  2. Presence of reverse splitting of S2
  3. Presence of S4
  4. Pulsus parvus et tardus

Management: If symptomatic, prognosis is poor: ( 2-3yr survival if angina/syncope, 2yr Q if cardiac failure Q). 

  1. Prompt valve replacement is recommended.
  2. Asymptomatic patients with severe AS and a deteriorating ECG, valve replacement also recommended.
  3. If the patient is not medically fit for surgery, percutaneous valvuloplasty may be attempted.

Prognosis –


Average time to death after onset of symptoms –

  1. CHF – 1yrs
  2. Angina – 2yrs
  3. Syncope – 3yrs

Extra Edge  Heyde syndrome (Ref. Hari. 18th ed., pg -972)


Heyde's syndrome (aortic stenosis with gastrointestinal bleeding) is attributed to the presence of angiodysplasia of the gastrointestinal tract in patients with aortic stenosis.


Management Strategy for Patients with Severe Aortic Stenosis.
Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is a discrepancy between clinical findings and echocardiography. AVA, aortic valve area; BP, blood pressure; CABG, coronary artery bypass graft surgery; echo, echocardiography; LV, left ventricle; Vmax, maximal velocity across aortic valve by Doppler echocardiography. 

  1. Aortic Regurgitation (AR)


  1. Congenital:
  2. RHD: c. Infective endocarditis
  3. Rheumatoid arthritis
  4. SLE; pseudoxanthoma elasticum
  5. Hypertension
  6. Aortic dissection
  7. Seronegative arthritides (ankylosing spondylitis Reiter's syndrome, psoriatic arthropathy)
  8. Marfan's syndrome
  9. Syphilitic aortitis.


  1. Palpitations most common symptom Q              
  2. Dyspnea              
  3. Cardiac failure. 

Peripheral Signs:

  1. Collapsing (water hammer pulse Q , Corrigan pulse )
  2. Wide pulse pressure Q
  3. Corrigan's sign Q (Prominent carotid pulsation, Dancing carotid)
  4. de Musset's sign Q (head nodding)
  5. Duroziez's sign Q (femoral diastolic murmur as blood flows backwards in diastole)
  6. Traube's sign Q (Pistol shot sound over femoral arteries)
  7. Quincke's sign Q (capillary pulsations in nail beds)
  8. Hill sign – BP difference in upper and lower limb. (Lower Limb BP is much higher than UL)

Precordial sign:

  1. Displaced, hyperdynamic apex beat (ill sustain heave Q)
  2. High pitched early diastolic murmur Q (heard best in expiration, with patient leaning forward).
  3. In severe AR, an Austin Flint murmur Q may be heard
  4. Soft systolic functional murmur at the aortic valve area. 





CXR: cardiomegaly; dilated ascending aorta; pulmonary edema.


Echocardiography is diagnostic.

Criteria of severe Aortic regurgitation

  1. Duration of murmer
  2. Presence of S3
  3. Presence of S4
  4. Austin Flint murmer
  5. Hill’s sign > 60 mm Hg


  1. Diuretic           
  2. Digoxin        
  3. ACEI                    
  4. Surgery: Valve replacement

Summary of the Medical Therapy of Valvular Heart Disease (Ref. Hari. 18th ed., pg- 1932)


Symptom Control

Natural History

Mitral stenosis

Beta blockers, nondihydropyridine calcium channel blockers, or digoxin for rate control of AF; cardioversion for new-onset AF and HF; diuretics for HF

Warfarin for AF or thromboembolism; PCN for RF prophylaxis

Mitral regurgitation

Diuretics for HF

Warfarin for AF or thromboembolism


Vasodilators for acute MR

Vasodilators for HTN

Aortic stenosis

Diuretics for HF

No proven therapy

Aortic regurgitation

Diuretics and vasodilators for HF

Vasodilators for HTN

  1. Tricuspid regurgitation


  1. Functional (Commonest cause of TR) seen in cor-pulmonale Q
  2. Pulmonary hypertension
  3. RHD
  4. Infective endocarditis (IV drug abusers) Q
  5. Carcinoid syndrome
  6. Ebstein’s Q anomaly 

Symptoms: Fatigue; hepatic pain on exertion; ascites; edema.


Giant v waves Q, prominent y descent Q in JVP, RV heave; pansystolic murmur Q, heard best at lower sternal edge in inspiration; pulsatile hepatomegaly Q; jaundice; ascites


Management: Treat underlying cause.  Drugs: Diuretics, Digoxin, ACE-inhibitors. Valve replacement (20% operative mortality).


Controversy about Carvallo’s sign: In different editions of Harrison

  1. The Pan systolic murmur of TR is loudest at the lower left sternal border, increases in intensity with inspiration (Carvallo's sign). (Ref. Hari. 18th ed., pg - 1828, 1914, 1931)
  2. Tricuspid regurgitation with normal pulmonary artery pressures, such as that caused by infective endocarditis in injection drug users, may produce an early systolic murmur. The murmur is soft, best heart at the lower left sternal edge, and may accentuate with inspiration (Carvallo's sign)(Ref. Hari. 18th ed., Pg- 1008)
  3. In Tricuspid Stenosis there is diastolic murmur . The murmur is augmented during inspiration and reduce in expiration when tricuspid blood flow is reduce this is known as (Carvallo's sign). (Ref. Hari. 18th ed., pg - 951)
  1. Tricuspid stenosis


  1. RHD; almost always occurs with mitral or aortic valve disease.
  2. Symptoms: Fatigue, ascites, oedema. 
  3. Signs: Giant a wave Q and slow y descent Q in JVP, diastolic murmur Q heard at the left sternal edge in inspiration.

Diagnosis: Doppler echo.


Treatment: Diuretics; surgical repair.

  1. Pulmonary stenosis

Causes: Usually congenital Q (Turner's syndrome, Noonan's syndrome, William's syndrome, Fallot's tetralogy, rubella).

Acquired causes:

  1. RHD
  2. Carcinoid syndrome. 

Pulmonary valve is the least common valve involved in RHD (AIIMS May’08)


Symptoms: Dyspnoea; fatigue; oedema, ascites.



  1. Dysmorphic facies Q (seen in congenital cases)
  2. Prominent a wave in JVP; heave.
  3. In mild stenosis, there is an ejection click, ejection systolic murmur (which radiates to the left shoulder);  widely split In severe stenosis, the murmur becomes longer and obscures A2
  4. P2 becomes softer and may be inaudible (single S2) Q.



: RAD, p-pulmonale, RVH, RBBB.


: post-stenotic dilatation of pulmonary artery


Oligemic lung fields


Right atrial enlargement.


: Pulmonary valvuloplasty or valvotomy. 

  1. Pulmonary Regurgitation
It is caused by any cause of pulmonary hypertension A decrescendo murmur is heard in early diastole at the left sternal edge (the Graham Steell murmur).

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