Valvular Heart Disease: Difference between revisions

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 Acute mitral regurgitation is associated with dyspnea and orthopnea, caused by sudden pulmonary congestion and edema. Acute papillary muscle rupture may mimic the presentation of a patient with a postinfarction ventricular septal defect.(Harrison et al. 697-701)
 On physical examination no signs of cardiac compensatory mechanisms are present. The increase in left atrial pressure diminishes the pressure gradient between the left ventricle and left atrium by midsystole. The murmur of mitral regurgitation is shortened and of decreased intensity, it may be soft, short of even inaudible. an S3 gallop usually is present. The volume overload is increasing the severity of MR over time leads to a greater percentage of the LV stroke volume being ejected in a retrograde fashion.
+=== Diagnostic Options ===
+==== Treatment ====
+===== Surgical =====
+The hemodynamic overload on the heart caused by mitral regurgitation can ultimately only be corrected by surgically restoring valve competence. For all valve surgery timing of  surgery is essential. Irreversible left ventricular dysfunction will result in suboptimal results of delayed surgery. Due to the operative risk and risk of valve prosthesis surgery should however be delayed as long as possible.
+Mitral valve regurgitation is surgically corrected by mitral valve replacement or repair.  Mitral valve repair is generally found to be superior to replacement, with preservation of left ventricular function and part of the mitral valve apparatus.<cite>EnriquezSarano</cite> <cite>Gillinov</cite> <cite>Grossi</cite> <cite>Zalaquett</cite> and without the use of a prosthesis. In mitral valve regurgitation indication for valve surgery is affected by symptomatic status, ventricular functional status, and the procedure to be performed. Repair might be considered in asymptomatic patients with normal left ventricular function or patients with severe impairment of left ventricular function who might not be candidates for mitral valve replacement.
+For most patients, mitral valve surgery is performed for the relief of symptoms or to prevent worsening of asymptomatic left ventricular dysfunction.
+== Tricuspid stenosis ==
+Tricuspid stenosis (TS) is most commonly of rheumatic origin. The anatomical characteristics are similar to those of mitral stenosis including fibrous leaflet thickening and fusion and shortening of the subvalvular apparatus. The preponderance of cases are in young women. Other etiologies of right atrial obstructiuon are rare and include congenital tricuspid atresia right atrial tumors and carcinoid syndrome.
+=== Clinical presentation ===
+The reduced cardiac output in tricuspid valve stenosis causes symptoms of fatigue and malaise. On physical examination right upper quadrant tenderness with a palpable liver with a presystolic pulse may be noted. Significant peripheral edema and ascites can develop.  A tricuspid opening snap and a characteristic murmur may be audible on auscultation at the left sternal border.
+==== Diagnostic Options ====
+===== Chest radiography =====
+Cardiomegaly with increased the right atria and pulmonary artery size may be demonstrated on chest x-ray.
+===== Echocardiography =====
+Echocardiographyi is used to evaluate the valvular anatomy. It can reveal thickened tricuspid valve leaflets, reduced leaflet mobility, and a reduced orifice of flow.
+===== Treatment =====
+Tricuspid balloon valvotomy can be used to treat tricuspid stenosis; however, there is the potential for inducing severe tricuspid regurgitation.
+== Tricuspid insufficiency ==
+Functional tricuspid regurgitation results from distortion of the architecture and coordinated actions of the tricuspid leaﬂets, annulus, chords, papillary muscles, and right ventricular (RV) wall. This distortion is most commonly caused by right ventricular dilation and dysfunction from left sided heart disease with pressure/volume overload conditions. The tricuspid annulus enlarges and the shaddle shape becomes more circular. The normal annular excursion can be reduced by 50% in severe TR. <cite>Fukuda</cite> Functional tricuspid regurgitation is a marker of poor prognosis in patients with left ventricular cardiomyopathy.  Pure tricuspid regurgitation may result from rheumatic fever, infective endocarditis, carcinoid causes, rheumatoid arthritis, radiation therapy, anorectic drugs, trauma, Marfan’s syndrome, tricuspid valve prolapse, papillary muscle dysfunction, or congenital disorders.
+=== Clinical presentation ===
+A reduction in cardiac output related to tricuspid regurgitation, may cause symptoms of fatigue and weakness. Right-sided heart failure may cause ascites, congestive hepatosplenomegaly, pulsatile liver, pleural effusions, and peripheral edema.
+With progression of the disease, patients become cachexic, cyanotic and jaundice may be present. A parasternal pansytolic murmur increasing on inspiration may be appreciated on auscultation(Carvallo’s sign).  An S3, increasing with inspiration and decreasing with a Valsalva maneuve may be audible, as well as an increased P2 if pulmonary hypertension has developed.
+=== Diagnostic options ===
+==== Chest Radiography ====
+Cardiomegaly, increased right atrial and ventricular size and a prominent azygous vein can be demonstrated on chest x-ray. Chest Radiography may reveal pleural effusion, and ascites by upward diaphragmatic displacement.
+==== Echocardiography ====
+The tricuspid valve structure and function can be assessed echocardiographically, as well as the annular size. This imaging modality is used to evaluate the degree of regurgitation,  pressures and ventricular function.