Valvular heart disease is any

cardiovascular disease Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina, heart attack), heart failure, hypertensive heart disease, rheumati ...

process involving one or more of the four

valves of the heart A heart valve is a biological one-way valve that allows blood to flow in one direction through the chambers of the heart. A mammalian heart usually has four valves. Together, the valves determine the direction of blood flow through the heart. Hear ...

(the

aortic The aorta ( ; : aortas or aortae) is the main and largest artery in the human body, originating from the left ventricle of the heart, branching upwards immediately after, and extending down to the abdomen, where it splits at the aortic bifurc ...

and

mitral valve The mitral valve ( ), also known as the bicuspid valve or left atrioventricular valve, is one of the four heart valves. It has two Cusps of heart valves, cusps or flaps and lies between the atrium (heart), left atrium and the ventricle (heart), ...

s on the left side of heart and the

pulmonic In phonetics, the airstream mechanism is the method by which airflow is created in the vocal tract. Along with phonation and articulation, it is one of three main components of speech production. The airstream mechanism is mandatory for most sou ...

and

tricuspid valves The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, at the superior portion of the right ventricle. The function of the valve is to allow blood to flow from the right atrium to the right vent ...

on the right side of heart). These conditions occur largely as a consequence of aging,Burden of valvular heart diseases: a population-based study. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano. Lancet. 2006 Sep;368(9540):1005-11. but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including

rheumatic heart disease Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). The ...

and pregnancy. Anatomically, the valves are part of the dense connective tissue of the heart known as the

cardiac skeleton In cardiology, the cardiac skeleton, also known as the fibrous skeleton of the heart, is a high-density homogeneous structure of connective tissue that forms and anchors the valves of the heart, and influences the forces exerted by and through the ...

and are responsible for the regulation of blood flow through the heart and

great vessels Great vessels are the large vessels that bring blood to and from the heart. These are: * Superior vena cava * Inferior vena cava * Pulmonary arteries * Pulmonary veins * Aorta Transposition of the great vessels is a group of congenital A b ...

. Valve failure or dysfunction can result in diminished heart functionality, though the particular consequences are dependent on the type and severity of valvular disease. Treatment of damaged valves may involve medication alone, but often involves surgical

valve repair Heart valve repair is a cardiac surgery procedure, carried out to repair one or more faulty heart valves. In some valvular heart diseases repair where possible is preferable to valve replacement. A mechanical heart valve is a replacement valve t ...

valve replacement Valve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis ( homograft from human tissue or xenograft e.g. from pig). It is an alternative to valve repair. __TOC__ ...

Classification

Stenosis and insufficiency/regurgitation represent the dominant functional and anatomic consequences associated with valvular heart disease. Irrespective of disease process, alterations to the valve occur that produce one or a combination of these conditions. Insufficiency and regurgitation are synonymous terms that describe an inability of the valve to prevent backflow of blood as leaflets of the valve fail to join (coapt) correctly. Stenosis is characterized by a narrowing of the valvular orifice that prevents adequate outflow of blood. Stenosis can also result in insufficiency if thickening of the annulus or leaflets results in inappropriate leaf closure.

Aortic and mitral valve disorders

Aortic and mitral valve disorders are

left heart The heart is a muscular organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrients to the tissue ...

diseases that are more prevalent than diseases of the pulmonary or tricuspid valve in the

right heart The heart is a muscular organ found in humans and other animals. This organ pumps blood through the blood vessels. The heart and blood vessels together make the circulatory system. The pumped blood carries oxygen and nutrients to the tiss ...

due to the higher pressures in the left heart. Stenosis of the aortic valve is characterized by a thickening of the valvular annulus or leaflets that limits the ability of blood to be ejected from the left ventricle into the aorta. Stenosis is typically the result of valvular calcification but may be the result of a congenitally malformed

bicuspid aortic valve Bicuspid aortic valve (BAV) is a form of heart disease in which two of the leaflets of the aortic valve fuse during development in the womb resulting in a two-leaflet (bicuspid) valve instead of the normal three-leaflet (tricuspid) valve. BAV is ...

. This defect is characterized by the presence of only two valve leaflets. It may occur in isolation or in concert with other cardiac anomalies. Aortic insufficiency, or regurgitation, is characterized by an inability of the valve leaflets to appropriately close at the end

systole Systole ( ) is the part of the cardiac cycle during which some chambers of the heart contract after refilling with blood. Its contrasting phase is diastole, the relaxed phase of the cardiac cycle when the chambers of the heart are refilling ...

, thus allowing blood to flow inappropriately backward into the left ventricle. Causes of aortic insufficiency in the majority of cases are unknown, or

idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. For some medical conditions, one or more causes are somewhat understood, but in a certain percentage of people with the condition, the cause ...

. It may be the result of connective tissue or immune disorders, such as

Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with dolichostenomelia, long arms, legs, Arachnodactyly, fingers, and toes. They also typically ha ...

systemic lupus erythematosus Lupus, formally called systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Common ...

, respectively. Processes that lead to aortic insufficiency usually involve dilation of the valve annulus, thus displacing the valve leaflets, which are anchored in the annulus. Mitral stenosis is caused largely by

, though is rarely the result of calcification. In some cases, vegetations form on the mitral leaflets as a result of endocarditis, an inflammation of the heart tissue. Mitral stenosis is uncommon and not as age-dependent as other types of valvular disease. Mitral insufficiency can be caused by dilation of the left heart, often a consequence of

heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to Cardiac cycle, fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF ...

. In these cases, the left ventricle of the heart becomes enlarged and causes displacement of the attached

papillary muscle The papillary muscles are muscles located in the ventricles of the heart. They attach to the cusps of the atrioventricular valves (also known as the mitral and tricuspid valves) via the chordae tendineae and contract to prevent inversion or ...

s, which control the mitral.

Pulmonary and tricuspid valve disorders

Pulmonary and tricuspid valve diseases are

diseases. Pulmonary valve diseases are the least common heart valve disease in adults.Ragavendra R. Baliga, Kim A. Eagle, William F Armstrong, David S Bach, Eric R Bates, ''Practical Cardiology'', Lippincott Williams & Wilkins, 2008, page 452. Pulmonary valve stenosis is often the result of congenital malformations and is observed in isolation or as part of a larger pathologic process, as in

Tetralogy of Fallot Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect characterized by four specific cardiac defects. Classically, the four defects are: * Pulmonary stenosis, which is narrowing of the exit from the r ...

Noonan syndrome Noonan syndrome (NS) is a genetic disorder that may present with mildly unusual facial features, short height, congenital heart disease, bleeding problems, and skeletal malformations. Facial features include widely spaced eyes, light-colored ...

, and

congenital rubella syndrome Congenital rubella syndrome (CRS) occurs when a human fetus is infected with the rubella virus (German measles) via maternal-fetal transmission and develops birth defects. The most common congenital defects affect the ophthalmologic, cardiac, a ...

. Unless the degree of stenosis is severe, individuals with pulmonary stenosis usually have excellent outcomes and better treatment options. Often patients do not require intervention until later in adulthood as a consequence of calcification that occurs with aging. Pulmonary valve insufficiency occurs commonly in healthy individuals to a very mild extent and does not require intervention.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD. J Am Coll Cardiol. 2014;63(22):e57. More appreciable insufficiency is typically the result of damage to the valve due to

cardiac catheterization Cardiac catheterization (heart cath) is the insertion of a catheter into a heart chamber, chamber or Blood vessel, vessel of the heart. This is done both for diagnostic and interventional purposes. A common example of cardiac catheterization is c ...

intra-aortic balloon pump The intra-aortic balloon pump (IABP) is a mechanical device that increases myocardial oxygen perfusion and indirectly increases cardiac output through afterload reduction. It consists of a cylindrical polyurethane balloon that sits in the aorta, ...

insertion, or other surgical manipulations. Additionally, insufficiency may be the result of

carcinoid syndrome Carcinoid syndrome is a paraneoplastic syndrome comprising the signs and symptoms that occur secondary to neuroendocrine tumors (formerly known as carcinoid tumors). The syndrome is caused by neuroendocrine tumors most often found in the gut ...

, inflammatory processes such a rheumatoid disease or endocarditis, or congenital malformations. It may also be secondary to severe

pulmonary hypertension Pulmonary hypertension (PH or PHTN) is a condition of increased blood pressure in the pulmonary artery, arteries of the lungs. Symptoms include dypsnea, shortness of breath, Syncope (medicine), fainting, tiredness, chest pain, pedal edema, swell ...

. Tricuspid valve stenosis without co-occurrent regurgitation is highly uncommon and typically the result of rheumatic disease. It may also be the result of congenital abnormalities, carcinoid syndrome, obstructive right atrial tumors (typically

lipoma A lipoma is a benign tumor made of adipose tissue, fat tissue. They are generally soft to the touch, movable, and painless. They usually occur just under the skin, but occasionally may be deeper. Most are less than in size. Common locations inc ...

s or

myxoma A myxoma (New Latin from Ancient Greek, Greek 'mucus') is a myxoid tumor of primitive connective tissue. It is most commonly found in the heart (and is the most common primary tumor of the heart in adults) but can also occur in other locations ...

s), or hypereosinophilic syndromes. Minor tricuspid insufficiency is common in healthy individuals. In more severe cases it is a consequence of dilation of the right ventricle, leading to displacement of the

s which control the valve's ability to close. Dilation of the right ventricle occurs secondary to

ventricular septal defect A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. It's a common heart problem present at birth ( congenital heart defect). The extent of the opening may vary ...

s, right to left shunting of blood,

eisenmenger syndrome Eisenmenger syndrome or Eisenmenger's syndrome is defined as the process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect (typically by a ventricular septal defect, atrial septal defect, or less commonly, pa ...

hyperthyroidism Hyperthyroidism is a endocrine disease in which the thyroid gland produces excessive amounts of thyroid hormones. Thyrotoxicosis is a condition that occurs due to elevated levels of thyroid hormones of any cause and therefore includes hyperth ...

, and

pulmonary stenosis Pulmonic stenosis, is a dynamic or fixed obstruction of flow from the right ventricle of the heart to the pulmonary artery. It is usually first diagnosed in childhood. Signs and symptoms Some individuals with mild PS may not experience any sympt ...

. Tricuspid insufficiency may also be the result of congenital defects of the tricuspid valve, such as

Ebstein's anomaly Ebstein's anomaly is a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced downwards towards the apex of the right ventricle of the heart. Ebstein's anomaly has great anatomical heterogeneity tha ...

Signs and symptoms

Aortic stenosis

Symptoms of

aortic stenosis Aortic stenosis (AS or AoS) is the narrowing of the exit of the left ventricle of the heart (where the aorta begins), such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse o ...

may include

symptoms, such as

dyspnea on exertion Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that co ...

(most frequent symptomVOC=VITIUM ORGANICUM CORDIS, a compendium of the Department of Cardiology at Uppsala Academic Hospital. By Per Kvidal September 1999, with revision by Erik Björklund May 2008),

orthopnea Orthopnea or orthopnoea is shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. It is commonly seen as a late manifestation of heart failure, resulting from fluid ...

and

paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea or paroxysmal nocturnal dyspnoea (PND) is an attack of severe shortness of breath and coughing that generally occurs at night. It usually awakens the person from sleep, and may be quite frightening. PND, as well as sim ...

,Chapter 1: Diseases of the Cardiovascular system > Section: Valvular Heart Disease in:

angina pectoris Angina, also known as angina pectoris, is chest pain or pressure, usually caused by insufficient blood flow to the heart muscle (myocardium). It is most commonly a symptom of coronary artery disease. Angina is typically the result of part ...

, and syncope, usually exertional. Medical signs of aortic stenosis include ''pulsus'' ''parvus et tardus'', that is, diminished and delayed

carotid pulse In anatomy, the left and right common carotid arteries (carotids) () are arteries that supply the head and neck with oxygenated blood; they divide in the neck to form the external and internal carotid arteries. Structure The common carotid a ...

fourth heart sound The fourth heart sound or S4 is an extra heart sound that occurs during late diastole, immediately before the normal two "lub-dub" heart sounds (S1 and S2). It occurs just after atrial contraction and immediately before the systolic S1 and is cau ...

, decreased A₂ sound, sustained

apex beat The apex beat (lat. ''ictus cordis''), also called the apical impulse, is the pulse felt at the point of maximum impulse (PMI), which is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at wh ...

precordial thrill In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the ind ...

. Auscultation may reveal a systolic murmur of a harsh crescendo-decrescendo type, heard in 2nd right intercostal space and radiating to the carotid arteries.

Aortic regurgitation

Patients with

aortic regurgitation Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a conse ...

may experience

symptoms, such as

and

, palpitations, and

. In acute cases patients may experience

cyanosis Cyanosis is the change of Tissue (biology), tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Cyanosis is apparent usually in the Tissue (bi ...

and

circulatory shock Shock is the state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms of shock may include weakness, tachycardia, hyperventilation, sweating, anxiety, and increased thirst. ...

. Medical signs of aortic regurgitation include increased

pulse pressure Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Healthy pulse pressure is around 40 ...

by increased systolic and decreased diastolic blood pressure, but these findings may not be significant if acute. The patient may have a diastolic decrescendo murmur best heard at left sternal border, water hammer pulse,

Austin Flint murmur In cardiology, an Austin Flint murmur is a low-pitched rumbling heart murmur which is best heard at the cardiac apex. It can be a mid-diastolicEric J. TopolThe Topol Solution: Textbook of Cardiovascular Medicine Third Edition with DVD, Plus Integra ...

, and a displaced

down and to the left. A

third heart sound The third heart sound or S3 is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). S3 is associated with heart failure. Physiology It occurs at the beginning of the middle third of diastole, approxima ...

may be present

Mitral stenosis

Patients with

mitral stenosis Mitral stenosis is a valvular heart disease characterized by the Stenosis, narrowing of the opening of the mitral valve of the heart. It is almost always caused by Rheumatic Heart Disease, rheumatic valvular heart disease. Normally, the mitral va ...

may present with

symptoms, such as

and

palpitations Palpitations occur when a person becomes aware of their heartbeat. The heartbeat may feel hard, fast, or uneven in their chest. Symptoms include a very fast or irregular heartbeat. Palpitations are a sensory symptom. They are often described as ...

chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...

hemoptysis Hemoptysis or haemoptysis is the discharge of blood or blood-stained sputum, mucus through the mouth coming from the bronchi, larynx, vertebrate trachea, trachea, or lungs. It does not necessarily involve coughing. In other words, it is the airw ...

, thromboembolism, or

ascites Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...

and

edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...

(if right-sided

develops). Symptoms of mitral stenosis increase with exercise and pregnancy On

auscultation Auscultation (based on the Latin verb ''auscultare'' "to listen") is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory system, circulatory and resp ...

of a patient with mitral stenosis, typically the most prominent sign is a loud S₁. Another finding is an

opening snap With newer, non-invasive imaging techniques, the origin of other, so-called ''adventitial sounds'' or heart clicks has been appreciated. These are short, high-pitched sounds. * The mitral valve in cases of mitral stenosis may open with an ''opening ...

followed by a low-pitched diastolic rumble with presystolic accentuation. The opening snap follows closer to the S₂ heart tone with worsening stenosis. The murmur is heard best with the bell of the stethoscope lying on the left side and its duration increases with worsening disease. Advanced disease may present with signs of right-sided heart failure such as

parasternal heave A parasternal heave, lift, or thrust is a precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which originate on the heart or the ...

jugular venous distension The jugular venous pressure (JVP, sometimes referred to as ''jugular venous pulse'') is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different ...

hepatomegaly Hepatomegaly is enlargement of the liver. It is a non-specific sign (medicine), medical sign, having many causes, which can broadly be broken down into infection, hepatic tumours, and metabolic disorder. Often, hepatomegaly presents as an abdomin ...

and/or

(presenting with a loud P₂). Signs increase with exercise and pregnancy.

Mitral regurgitation

Patients with

mitral regurgitation Mitral regurgitation (MR), also known as mitral insufficiency or mitral incompetence, is a form of valvular heart disease in which the mitral valve is insufficient and does not close properly when the heart pumps out blood. Section: Valvular He ...

may present with

symptoms, such as

and

, palpitations, or

pulmonary edema Pulmonary edema (British English: oedema), also known as pulmonary congestion, is excessive fluid accumulation in the tissue or air spaces (usually alveoli) of the lungs. This leads to impaired gas exchange, most often leading to shortness ...

. On auscultation of a patient with mitral stenosis, there may be a

holosystolic murmur Systolic heart murmurs are heart murmurs heard during systole, i.e. they begin and end between S1 and S2. Many involve stenosis of the semilunar valves or regurgitation of the atrioventricular valves. Types * Mid-systolic ejection murmurs are ...

at the apex, radiating to the back or clavicular area, a

, and a loud, palpable P₂, heard best when lying on the left side. Patients also commonly have

atrial fibrillation Atrial fibrillation (AF, AFib or A-fib) is an Heart arrhythmia, abnormal heart rhythm (arrhythmia) characterized by fibrillation, rapid and irregular beating of the Atrium (heart), atrial chambers of the heart. It often begins as short periods ...

. Patients may have a laterally displaced apex beat, often with heave In acute cases, the murmur and

tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...

may be only distinctive signs.

Tricuspid regurgitation

Patients with

tricuspid regurgitation Tricuspid regurgitation (TR), also called tricuspid insufficiency, is a type of valvular heart disease in which the tricuspid valve of the heart, located between the right atrium and right ventricle, does not close completely when the right ventr ...

may experience symptoms of right-sided heart failure, such as

and

. Signs of tricuspid regurgitation include

pulsatile liver In fluid dynamics, a flow with periodic variations is known as pulsatile flow, or as Womersley flow. The flow profiles was first derived by John R. Womersley (1907–1958) in his work with blood flow in arteries. The cardiovascular system of chord ...

, prominent V waves and rapid y descents in

jugular venous pressure The jugular venous pressure (JVP, sometimes referred to as ''jugular venous pulse'') is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different f ...

. Auscultatory findings include inspiratory

left lower sternal border Surface anatomy (also called superficial anatomy and visual anatomy) is the study of the external features of the body of an animal.Seeley (2003) chap.1 p.2 In birds, this is termed ''topography''. Surface anatomy deals with anatomical features t ...

(LLSB) and a blowing holosystolic murmur at LLSB, intensifying with inspiration, and decreasing with expiration and

Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air, as if blowing up a balloon. Variations of the maneuver can be ...

. Patients may have a

along LLSB. Atrial fibrillation is usually present in patients with tricuspid regurgitation

Causes

Calcific disease

Calcification Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature M ...

of the leaflets of the aortic valve is a common with increasing age, but the mechanism is likely to be more related to increased

lipoprotein A lipoprotein is a biochemical assembly whose primary function is to transport hydrophobic lipid (also known as fat) molecules in water, as in blood plasma or other extracellular fluids. They consist of a triglyceride and cholesterol center, sur ...

deposits and inflammation than the "wear and tear" of advance age.Owens DS, O'Brien KD. Clinical and Genetic Risk Factors for Calcific Valve Disease. In: Valvular Heart Disease, 4th, Otto CM, Bonow RO. (Eds), Saunders/Elsevier, Philadelphia 2013. pp.53-62. Aortic stenosis due to calcification of tricuspid aortic valve with age comprises >50% of the disease. Aortic stenosis due to calcification of a

comprises about 30–40% of the disease.

Hypertension Hypertension, also known as high blood pressure, is a Chronic condition, long-term Disease, medical condition in which the blood pressure in the artery, arteries is persistently elevated. High blood pressure usually does not cause symptoms i ...

diabetes mellitus Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained hyperglycemia, high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or th ...

hyperlipoproteinemia Hyperlipidemia is abnormally high levels of any or all lipids (e.g. fats, triglycerides, cholesterol, phospholipids) or lipoproteins in the blood. citing: and The term ''hyperlipidemia'' refers to the laboratory finding itself and is also use ...

and

uremia Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess in the blood of amino acid and protein metabolism end products, such as urea and creatinine, which ...

may speed up the process of valvular calcification.

Dysplasia

Heart valve dysplasia Heart valve dysplasia is a congenital heart defect which affects the aortic, pulmonary, mitral, and tricuspid heart valves. Dysplasia of the mitral and tricuspid valves can cause leakage of blood or stenosis. Dysplasia of the mitral and tricuspid ...

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 Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect characterized by four specific cardiac defects. Classically, the four defects are: * Pulmonary stenosis, which is narrowing of the exit from the r ...

is a congenital heart defect with four abnormalities, one of which is stenosis of the pulmonary valve.

is an abnormality of the tricuspid valve, and its presence can lead to tricuspid valve regurgitation. * * A

is an aortic valve with only 2 cusps as opposed to the normal 3. It is present in about 0.5% to 2% of the general population and causes increased calcification due to higher turbulent flow through the valve.

Connective tissue disorders

Marfan's Syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with long arms, legs, fingers, and toes. They also typically have exceptionally flexible joints ...

is a connective tissue disorder that can lead to chronic aortic or mitral regurgitation.

Osteogenesis imperfecta Osteogenesis imperfecta (; OI), colloquially known as brittle bone disease, is a group of genetic disorders that all result in bones that bone fracture, break easily. The range of symptoms—on the skeleton as well as on the body's other Or ...

is a disorder in formation of type I collagen and can also lead to chronic aortic regurgitation.

Inflammatory disorders

Inflammation of the heart valves due to any cause is called valvular

endocarditis Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, o ...

; this is usually due to bacterial infection but may also be due to

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

(

marantic endocarditis Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis in which small sterile vegetations are deposited on the valve leaflets. Formerly known as marantic endocarditis, which comes from the Greek , meaning "wasting away". The term ...

), certain autoimmune conditions ( Libman-Sacks endocarditis, seen in

) and

hypereosinophilic syndrome Hypereosinophilic syndrome is a disease characterized by a persistently elevated eosinophil count (≥ 1500 eosinophils/mm³) in the blood for at least six months without any recognizable cause, with involvement of either the heart, nervous sys ...

(

Loeffler endocarditis Loeffler endocarditis is a form of heart disease characterized by a stiffened, poorly-functioning heart caused by infiltration of the heart by white blood cells known as eosinophils. Restrictive cardiomyopathy is a disease of the heart muscle whic ...

). Endocarditis of the valves can lead to regurgitation through that valve, which is seen in the tricuspid, mitral, and aortic valves. Certain medications have been associated with valvular heart disease, most prominently

ergotamine Ergotamine, sold under the brand name Ergomar among others, is an ergopeptine and part of the ergot family of alkaloids; it is structurally and biochemically closely related to ergoline. It is structurally similar to several neurotransmitter ...

derivatives

pergolide Pergolide, sold under the brand name Permax and Prascend (veterinary) among others, is an ergoline-based dopamine receptor agonist used in some countries for the treatment of Parkinson's disease. Parkinson's disease is associated with reduced do ...

and

cabergoline Cabergoline, sold under the brand name Dostinex among others, is a dopaminergic medication used in the treatment of high prolactin levels, prolactinomas, Parkinson's disease, and for other indications. It is taken by mouth. Cabergoline is an ...

. Valvular heart disease resulting from

rheumatic fever Rheumatic fever (RF) is an inflammation#Disorders, inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a Streptococcal pharyngitis, streptococcal throat infection. Si ...

is referred to as rheumatic heart disease. Acute rheumatic fever, which frequently manifests with carditis and valvulitis, is a late sequela of Group A beta-hemolytic streptococcus infection in the throat, often lagging the initial infection by weeks to months. Cardiac involvement is dependent on the cross-reaction of antibodies directed against M proteins produced by bacteria with human proteins present in the

myocardium Cardiac muscle (also called heart muscle or myocardium) is one of three types of vertebrate muscle tissues, the others being skeletal muscle and smooth muscle. It is an involuntary, striated muscle that constitutes the main tissue of the wall o ...

endocardium The endocardium (: endocardia) is the innermost layer of tissue that lines the chambers of the heart. Its cells are embryologically and biologically similar to the endothelial cells that line blood vessels. The endocardium also provides prot ...

(although acute rheumatic fever may present as pancarditis with additional involvement of the

pericardium The pericardium (: pericardia), also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue (fibrous pericardium), ...

). This results in generalized inflammation in the heart, producing acute erosions and vegetations with fibrin deposition in the mitral valve that may be followed by chronic changes over years to decades, including shortening of the

chordae tendinae The chordae tendineae (: chorda tendinea) or tendinous cords, colloquially known as the heart strings, are inelastic cords of fibrous connective tissue that connect the papillary muscles to the tricuspid valve and the mitral valve in the heart. ...

and thickening or fusion of the mitral leaflets, leading to a severely compromised "buttonhole" or "fish mouth" valve. In 70% of cases rheumatic heart disease involves only the mitral valve, while 25% of cases involve both the aortic and mitral valves. Involvement of other heart valves without damage to the mitral is exceedingly rare. Mitral stenosis is almost always caused by rheumatic heart disease. Less than 10% of aortic stenosis is caused by rheumatic heart disease. Rheumatic fever can also cause chronic mitral and aortic regurgitation. 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. Among persons who have experienced rheumatic fever, long-term intramuscular antibiotic therapy is used as secondary prophylaxis against additional streptococcal infections, which can contribute to progression of rheumatic heart disease. In people with severe valvular disease, however, short-term risks of cardiovascular compromise after intramuscular injections may outweigh the benefits, and oral therapy may be considered instead of IM injections in this subset of patients. Diseases of the aortic root can cause chronic aortic regurgitation. These diseases include

syphilitic aortitis Syphilitic aortitis is inflammation of the aorta associated with the tertiary stage of syphilis infection. SA begins as inflammation of the outermost layer of the blood vessel, including the blood vessels that supply the aorta itself with blood ...

Behçet's disease Behçet's disease (BD) is a type of inflammatory disorder which affects multiple parts of the body. The most common symptoms include painful sores on the mucous membranes of the mouth and other parts of the body, inflammation of parts of the ...

, and

reactive arthritis Reactive arthritis, previously known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infect ...

Heart disease

Tricuspid regurgitation is usually secondary to right ventricular dilation which may be due to left ventricular failure (the most common cause), right ventricular infarction,

inferior myocardial infarction Inferior may refer to: * Inferiority complex * An anatomical term of location * Inferior angle of the scapula, in the human skeleton * ''Inferior'' (book), by Angela Saini * ''The Inferior'', a 2007 novel by Peadar Ó Guilín * Inferior good: eco ...

, or

cor pulmonale Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs. Chroni ...

Other causes of tricuspid regurgitation include

and

myxomatous degeneration A myxoma (New Latin from Greek 'mucus') is a myxoid tumor of primitive connective tissue. It is most commonly found in the heart (and is the most common primary tumor of the heart in adults) but can also occur in other locations. Types Table ...

Diagnosis

Aortic stenosis

Patients with

can have

chest X-ray A chest radiograph, chest X-ray (CXR), or chest film is a Projectional radiography, projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common fi ...

findings showing dilation of the ascending aorta, but they may also have a completely normal chest X-ray.Rosenhek R, Baumgartner H. Aortic Stenosis. In: Valvular Heart Disease, 4th, Otto CM, Bonow RO. (Eds), Saunders/Elsevier, Philadelphia 2013. pp 139-162. Direct visualization of calcifications on chest X-ray is uncommon. Other findings include dilation of the left ventricle.

ECG Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of ...

typically shows left ventricular hypertrophy in patients with severe stenosis, but it may also show signs of left heart strain. Echocardiography is the diagnostic gold standard, which shows left ventricular hypertrophy, leaflet calcification, and abnormal leaflet closure.

Aortic regurgitation

Chest X-ray A chest radiograph, chest X-ray (CXR), or chest film is a Projectional radiography, projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common fi ...

is not as sensitive as other tests, but it may show

aortic root The ascending aorta (AAo) is a portion of the aorta commencing at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum. Structure It passes obliqu ...

dilation (especially in causes involving the

) and

apex The apex is the highest point of something. The word may also refer to: Arts and media Fictional entities * Apex (comics) A-Bomb Abomination Absorbing Man Abraxas Abyss Abyss is the name of two characters appearing in Ameri ...

displacement.O'Gara, Patrick T.; Loscalzo, Joseph. "Aortic Regurgitation". ''Harrison's principles of internal medicine''. Jameson, J. Larry,, Kasper, Dennis L.,, Longo, Dan L. (Dan Louis), 1949-, Fauci, Anthony S., 1940-, Hauser, Stephen L., Loscalzo, Joseph, (20th edition ed.). New York. .

OCLC OCLC, Inc. See also: is an American nonprofit cooperative organization "that provides shared technology services, original research, and community programs for its membership and the library community at large". It was founded in 1967 as the ...

1029074059. An

may show left ventricular hypertrophy and signs of left heart strain. Left axis deviation can be a sign of advanced disease. An

echocardiogram Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an echo ...

can be helpful in determining the root cause of the disease, as it will clearly show aortic root dilation or dissection if it exists. Typically the pump function of the heart during

is normal, but an echocardiogram will show flow reversal during

diastole Diastole ( ) is the relaxed phase of the cardiac cycle when the chambers of the heart are refilling with blood. The contrasting phase is systole when the heart chambers are contracting. Atrial diastole is the relaxing of the atria, and ventricul ...

. This disease is classified using regurgitant fraction (RF), or the amount of volume that flows back through the valve divided by the total forward flow through the valve during systole. Severe disease has an RF of >50%, while progressive aortic regurgitation has an RF of 30–49%.

Mitral stenosis

Chest x-ray A chest radiograph, chest X-ray (CXR), or chest film is a Projectional radiography, projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common fi ...

will typically show an enlarged left atrium, and may show dilation of the pulmonary veins.O'Gara, Patrick T.; Loscalzo, Joseph. "Mitral Stenosis". ''Harrison's principles of internal medicine''. Jameson, J. Larry,, Kasper, Dennis L.,, Longo, Dan L. (Dan Louis), 1949-, Fauci, Anthony S., 1940-, Hauser, Stephen L.,, Loscalzo, Joseph, (20th edition ed.). New York. .

1029074059. ECG can show left atrial enlargement, due to increased pressures in the left atrium.

Echocardiography Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an ec ...

is helpful in determining the severity of the disease by estimating the pulmonary artery

systolic Systolic is an adjective describing something pertaining to a systole, part of the cardiac cycle. Systolic may also refer to: Physiology and medical *Systolic hypertension *Systolic heart murmur Mathematics *Systolic geometry Technology *Systoli ...

pressure. This test can also show leaflet calcification and the

pressure gradient In hydrodynamics and hydrostatics, the pressure gradient (typically of air but more generally of any fluid) is a physical quantity that describes in which direction and at what rate the pressure increases the most rapidly around a particular locat ...

over the mitral valve. Severe mitral stenosis is defined as a mitral valve area <1.5 cm². Progressive mitral stenosis has a normal valve area but will have increased flow velocity across the mitral valve.

Mitral regurgitation

can show an enlarged

left atrium The atrium (; : atria) is one of the two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular mitral and tricuspid heart valves. ...

, as well as pulmonary venous congestion.O'Gara, Patrick T.; Loscalzo, Joseph. "Mitral Regurgitation". ''Harrison's principles of internal medicine''. Jameson, J. Larry,, Kasper, Dennis L.,, Longo, Dan L. (Dan Louis), 1949-, Fauci, Anthony S., 1940-, Hauser, Stephen L.,, Loscalzo, Joseph, (20th edition ed.). New York. .

1029074059. It may also show valvular

calcification Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature M ...

s specifically in combined mitral regurgitation and stenosis due to

. ECG typically shows left atrial enlargement, but can also show right atrial enlargement if the disease is severe enough to cause

is useful in visualizing the regurgitant flow and calculating the RF. It can also be used to determine the degree of calcification, and the function and closure of the valve leaflets. Severe disease has an RF of >50%, while progressive mitral regurgitation has an RF of <50%.

Treatment

Some of the most common treatments of valvular heart disease are avoiding smoking and excessive alcohol consumption, antibiotics, antithrombotic medications such as aspirin, anticoagulants, balloon dilation, and water pills. In some cases, surgery may be necessary.

Aortic stenosis

Treatment of aortic stenosis is not necessary in asymptomatic patients, unless the stenosis is classified as severe based on valve hemodynamics. Both asymptomatic severe and symptomatic aortic stenosis are treated with aortic valve replacement (AVR) surgery. AVR surgery can be performed using mechanical or tissue valves depending on age and other relevant factors. Trans-catheter Aortic Valve Implantation (TAVI) is an alternative to AVR and is recommended in high risk patients who may not be suitable for surgical AVR. Any angina is treated with short-acting

nitrovasodilator A nitrovasodilator is a pharmaceutical agent that causes vasodilation (widening of blood vessels) by donation of nitric oxide (NO), and is mostly used for the treatment and prevention of angina pectoris. This group of drugs includes nitrates (es ...

beta-blocker Beta blockers, also spelled β-blockers, are a class of medications that are predominantly used to manage abnormal heart rhythms ( arrhythmia), and to protect the heart from a second heart attack after a first heart attack (secondary prevention) ...

s and/or calcium blockers, although nitrates can drastically decrease blood pressure in patients with severe aortic stenosis and are therefore contraindicated. Any

hypertension Hypertension, also known as high blood pressure, is a Chronic condition, long-term Disease, medical condition in which the blood pressure in the artery, arteries is persistently elevated. High blood pressure usually does not cause symptoms i ...

is treated aggressively, but caution must be taken in administering

s. Any

is treated with

digoxin Digoxin (better known as digitalis), sold under the brand name Lanoxin among others, is a medication used to treat various heart disease, heart conditions. Most frequently it is used for atrial fibrillation, atrial flutter, and heart failure. ...

diuretic A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics ...

s and, if not contraindicated, cautious inpatient administration of

ACE inhibitor Angiotensin-converting-enzyme inhibitors (ACE inhibitors) are a class of medication used primarily for the treatment of high blood pressure and heart failure. This class of medicine works by causing relaxation of blood vessels as well as a decr ...

s. Moderate stenosis is monitored with

echocardiography Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an ec ...

every 1–2 years, possibly with supplementary

cardiac stress test A cardiac stress test is a cardiological examination that evaluates the cardiovascular system's response to external stress within a controlled clinical setting. This stress response can be induced through physical exercise (usually a treadmill) o ...

. Severe stenosis should be monitored with echocardiography every 3–6 months. In patients with non-severe asymptomatic aortic valve stenosis, increased age- and sex adjusted N-terminal pro-brain natriuretic peptide ( NT-proBNP) levels alone and combined with a 50% or greater increase from baseline had been found associated with increased event rates of aortic valve stenosis related events (

cardiovascular death In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...

, hospitalization with

due to progression of aortic valve stenosis, or

aortic valve replacement Aortic valve replacement is a cardiac surgery procedure whereby a failing aortic valve is replaced with an artificial heart valve. The aortic valve may need to be replaced because of aortic regurgitation (back flow), or if the valve is narro ...

surgery). In patients with non-severe asymptomatic aortic valve stenosis and no overt

coronary artery disease Coronary artery disease (CAD), also called coronary heart disease (CHD), or ischemic heart disease (IHD), is a type of cardiovascular disease, heart disease involving Ischemia, the reduction of blood flow to the cardiac muscle due to a build-up ...

, the increased

troponin T Troponin T (shortened TnT or TropT) is a part of the troponin complex, which are proteins integral to the contraction of skeletal and heart muscles. They are expressed in skeletal and cardiac myocytes. Troponin T binds to tropomyosin and help ...

(above 14 pg/mL) was found associated with an increased 5-year event rate of ischemic cardiac events (

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...

percutaneous coronary intervention Percutaneous coronary intervention (PCI) is a minimally invasive non-surgical procedure used to treat stenosis, narrowing of the coronary artery, coronary arteries of the heart found in coronary artery disease. The procedure is used to place and ...

, or

coronary artery bypass surgery Coronary artery bypass surgery, also known as coronary artery bypass graft (CABG, pronounced "cabbage"), is a surgical procedure to treat coronary artery disease (CAD), the buildup of plaques in the arteries of the heart. It can relieve chest ...

Aortic regurgitation

Aortic regurgitation Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a conse ...

is treated with aortic valve replacement, which is recommended in patients with symptomatic severe aortic regurgitation. Aortic valve replacement is also recommended in patients that are asymptomatic but have chronic severe aortic regurgitation and left ventricular ejection fraction of less than 50%. Hypertension is treated in patients with chronic aortic regurgitation, with the anti-hypersensives of choice being calcium channel blockers, ACE inhibitors, or ARBs. Also, endocarditis prophylaxis is indicated before dental, gastrointestinal or genitourinary procedures. Mild to moderate aortic regurgitation should be followed with echocardiography and a cardiac stress test once every 1–2 years. In severe moderate/severe cases, patients should be followed with echocardiography and cardiac stress test and/or

isotope perfusion imaging Perfusion is the passage of fluid through the lymphatic system or blood vessels to an organ or a tissue. The practice of perfusion scanning is the process by which this perfusion can be observed, recorded and quantified. The term perfusion scannin ...

every 3–6 months.

Mitral stenosis

For patients with symptomatic severe mitral stenosis, percutaneous balloon mitral valvuloplasty (PBMV) is recommended. If this procedure fails, then it may be necessary to undergo mitral valve surgery, which may involve valve replacement, repair, or commisurotomy. Anticoagulation is recommended for patients that have mitral stenosis in the setting of atrial fibrillation or a previous embolic event. No therapy is required for asymptomatic patients. Diuretics may be used to treat pulmonary congestion or edema.

Mitral regurgitation

Surgery is recommended for chronic severe mitral regurgitation in symptomatic patients with left ventricular ejection fraction (LVEF) of greater than 30%, and asymptomatic patients with LVEF of 30-60% or left ventricular end diastolic volume (LVEDV) > 40%. Surgical repair of the leaflets is preferred to mitral valve replacement as long as the repair is feasible. Mitral regurgitation may be treated medically with vasodilators, diuretics, digoxin, antiarrhythmics, and chronic anticoagulation. Mild to moderate mitral regurgitation should be followed with echocardiography and cardiac stress test every 1–3 years. Severe mitral regurgitation should be followed with echocardiography every 3–6 months.

Epidemiology

In the United States, about 2.5% of the population has moderate to severe valvular heart disease. The prevalence of these diseases increase with age, and 75 year-olds in the United States have a prevalence of about 13%. In industrially underdeveloped regions, rheumatic disease is the most common cause of valve diseases, and it can cause up to 65% of the valve disorders seen in these regions.

Aortic stenosis

Aortic stenosis is typically the result of aging, occurring in 12.4% of the population over 75 years of age, and represents the most common cause of outflow obstruction in the left ventricle. Bicuspid aortic valves are found in up to 1% of the population, making it one of the most common cardiac abnormalities.Braverman AC. The Bicuspid Aortic Valve and Associated Aortic Disease. In: Valvular Heart Disease, 4th, Otto CM, Bonow RO. (Eds), Saunders/Elsevier, Philadelphia 2013. p.179.

Aortic regurgitation

The prevalence of aortic regurgitation also increases with age. Moderate to severe disease has a prevalence of 13% in patients between the ages of 55 and 86. This valve disease is primarily caused by aortic root dilation, but infective endocarditis has been an increased risk factor. It has been found to be the cause of aortic regurgitation in up to 25% of surgical cases.

Mitral stenosis

Mitral stenosis Mitral stenosis is a valvular heart disease characterized by the Stenosis, narrowing of the opening of the mitral valve of the heart. It is almost always caused by Rheumatic Heart Disease, rheumatic valvular heart disease. Normally, the mitral va ...

is caused almost exclusively by

, and has a prevalence of about 0.1% in the United States. Mitral stenosis is the most common valvular heart disease in

pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...

Mitral regurgitation

Mitral regurgitation is significantly associated with normal aging, rising in prevalence with age. It is estimated to be present in over 9% of people over 75.

Special populations

Pregnancy

The evaluation of individuals with valvular heart disease who are or wish to become

pregnant Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...

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 a pre-existing 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 In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols Q, \dot Q, or \dot Q_ , edited by Catherine E. Williamson, Phillip Bennett is the volumetric flow rate of the heart's pumping output: tha ...

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

Inferior vena cava The inferior vena cava is a large vein that carries the deoxygenated blood from the lower and middle body into the right atrium of the heart. It is formed by the joining of the right and the left common iliac veins, usually at the level of the ...

l 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 increase in systolic and diastolic blood pressure. Valvular heart lesions associated with high maternal and fetal risk during pregnancy include: # Severe

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 An artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly ( valvular heart disease). Artificial heart valves can be separated into three broad classes: mechanical he ...

, 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 Women should speak to their doctor or healthcare professional before starting or stopping any medications while pregnant. Drugs taken in pregnancy including over-the counter-medications, prescription medications, nutritional supplements, recreati ...

in the form of anticoagulation.

References

{{DEFAULTSORT:Valvular Heart Disease