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Valvular Heart Disease: Diagnosis and Management
SympoSIUm on cARDIoVAScULAR DISEASES
From the Division o Cardiology, Department o Medicine, Northwestern Uni-
versity Feinberg School o Medicine, Chicago, IL (K.M., V.H.R., R.O.B.); and
Division o Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.E.S.).
Address correspondence to Kameswari Maganti, MD, Division o Cardiology,
Department o Medicine, Northwestern University Feinberg School o Medicine,201 E Huron St, Ste 11-240, Chicago, IL 60611 ([email protected]).
Individual reprints o this article and a bound reprint o the entire Symposium
on Cardiovascular Diseases will be available or purchase rom our Web sitewww.mayoclinicproceedings.com.
2010 Mayo Foundation for Medical Education and Research
Dv vv h vv h h U S, hh h vv phy
vp . A h US pp , phy-
ky p h v
vv . B pp
h U S vp , h vv
y y. Th, -
h y vv pv
h pv y p .
AORTIC STENOSIS
Etiologyand PathoPhysiology
A (AS) h pv -
v h W hyp
y y . I y y h
v f vv p-
v p vv. Rh
Kameswari Maganti, MD; Vera H. Rigolin, MD; Maurice Enriquez Sarano, MD;
and Robert O. Bonow, MD
h , h y ,
h U S. A vp
pv f h
f p v . Th k h v-
p v AS, hh
h h vp v h, - , hyp, k, v v
-y pp h pp().1
O v (LV) f
h vv v ( vv ,
hypph yphy) v h vv (p-
vv ).
I p h vv AS, h vy
y v y y. Th v
p h y hk h
LV h ( hyp-
phy). Th vp hypphy py
h h LV pp
v p
p h AS. L v y -
y pv, p y
y p h p h vv.
I y p, h py h
y, y
h p v. I LV y
y p, pv vv
p (AVR). Hv, LV -
pv y y v.2
D v v LV y-
p h ppv -
y .
On completion of this article, you should be able to (1) summarize important basic and clinical concepts of valvular heart
disease, (2) recognize the full array of valvular disorders so as to provide enhanced care for patients with valvular heart
disease, and (3) treat patients in accordance with new recommendations from recent clinical trials and clinical practice
guidelines.
Valvular heart disease (VHD) encompasses a number o common
cardiovascular conditions that account or 10% to 20% o all cardi-
ac surgical procedures in the United States. A better understand-
ing o the natural history coupled with the major advances in diag-
nostic imaging, interventional cardiology, and surgical approaches
have resulted in accurate diagnosis and appropriate selection o
patients or therapeutic interventions. A thorough understanding
o the various valvular disorders is important to aid in the man-agement o patients with VHD. Appropriate work-up or patients
with VHD includes a thorough history or evaluation o causes and
symptoms, accurate assessment o the severity o the valvular
abnormality by examination, appropriate diagnostic testing, and
accurate quantifcation o the severity o valve dysunction and
therapeutic interventions, i necessary. It is also important to un-
derstand the role o the therapeutic interventions vs the natural
history o the disease in the assessment o outcomes. Prophy-
laxis or inective endocarditis is no longer recommended unless
the patient has a history o endocarditis or a prosthetic valve.
Mayo Clin Proc. 2010;85(5):483-500
AR = aortic regurgitation; AS = aortic stenosis; AVR = aortic valve re-
placement; CAD = coronary artery disease; CMR = cardiac magnetic res-
onance imaging; CT = computed tomography; ECG = electrocardiography;
LV = let ventricular; MR = mitral regurgitation; MS = mitral stenosis;MV = mitral valve; RV = right ventricular
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VALVULAR HEART DISEASE
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C hypphy pv p -
pv. A vy p-
, h v p h
LV p v hh h v-
. Th, yp x y
LV y y v p h pv y . Th
hk y y
f p y f
v, p v h p
y .
Evy, h p vy, yp-
(35% p), yp (15% p),
yp / h (50% p) vp.3
Th yp ypy h x. O
yp vp, pp v
h v vv y 2 3 y h
k h.4,5
Th, hy h yp . P
p h yp v AS
; hv, AS pv , p-
h v AS hv hh kh vp
yp h 3 5 y.6 A
p py p h v AS
h h p v-
p h v.
Physical Examination
Th p phy x v-
h h vy vv , h vy
, LV . I , p h v
AS h p h
pk (pulsus parvus et tardus), hh pp
y pp h p. Th y p
y p h y h v.
Th p y y h.
Th j v p y , p
a v y p, f h v-
(RV) p hypphy h v-
p. Th v v y p h
RV . Th p p y
LV y h vp
LV hypphy. Th S1
y . Th S2
y h
p vv p pp,
h vv p h
vv . A S4
y p-
p v .
P S4
y p h AS k
LV hypphy ypy h h AS
v h h h
LV hypphy.
Th h AS --
y h h
h pp h h -
. Hv, y h LV px
(h Gv ph) y k
(MR). Th y h p h vy AS. A h
vy h AS , h h
, ky pk y-
. A y h -
(AR) p, h p
h h AS. I y p h p AS,
h y y p y y j
k. Th pp h h vv
h vy AS . I h p
v h , h p p y
y p, h h y p,
h j v p y v, h y y .1,7
diagnostic tEsting
Chest Radiography. C
p h AS, h h LV px
h LV hypphy. A vv
pp h pj
fpy. Thy y p-
p pj. Th px
y , py p h -
p vv. Cy p h
AS. I p h h , h h ,
h py v. I -
v h , h h h v
y .
Electrocardiography. Th yp -
phy (ECG) p h AS LV hyp-
phy, h y p .
Th 85% p h v AS. Hv,
p AS. L
,
h h k. Th y x-
h h -
y. Th x y h h.
A vp, py p-
h h hyp. A p ECG
p h AS h F 1.
Echocardiography. Ehphy h
y h hp h -
vy AS. T- hphy -
h phy h vv
f p. Th p -
vv h-
v f v AS. A
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pp h
65 y. O hphy, h y
vv hk, ypy h f
h p f -
y. D f hk h -
; , h,
vv phy, . Wh
, vv hy h
, h vv vy h 2.5 /.8,9
Sv hv
h vv h h-
h , h v
y y.10-14
I p h AS, h vv y hk
, h x
vv (F 2). D h f
yy y p
h p vv. Th h
v -
y, hh py p
h p vv. I h h , h LV
vy y . L v
hypphy p, .
L v y y . I h
h vp, h v y
y p.
Dpp hphy x h
v h vy AS y j vy
h vv . I
h vv -
py y y p. Th
h vy AS h Dpp
hphy h T 1.8
A h vv h , h v-
y f h vv . Th hk
AS h pp h v-
y AS h hphy, hh h y v-
h h hy
. A h vy AS Dpp-
p y h vy AS
h f. I p h p,
h p h LV y, h -
vv y pv h
FIGURE 2. Parasternal short-axis echocardiographic view o a pa-tient with severe aortic stenosis due to a congenital bicuspid aorticvalve. The leaets are heavily calcifed (arrow).
FIGURE 1. Electrocardiogram o a patient with severe aortic stenosis showing marked let
ventricular hypertrophy with repolarization abnormalities.
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vy . I h -p, -
AS, h -
y y h vy AS -
p h y v AS h
h p AS.15,16 A h p
h -p, - AS pv F 3.
Computed Tomography. Bh - p phy (CT) pv
v vv hv
h h hph
.17 Th CT
y , CT h h
v h p vy -
p h
y.
Cardiac Magnetic Resonance Imaging. C -
(CMR)
y h vv . Vy-
CMR y v - vy h vv. A h
CT, h h y h
AS y ,18 h -
h v
y.
TABLE 1. Classifcation o Aortic Stenosis Severity Using Doppler Examination
A M M Sv
A j vy (/) 2.5 2.6-2.9 3.0-4.0 >4.0M ( H) 40 (>50)
A vv (2) >1.5 1.0-1.5 0.85 0.60-0.85 0.50 0.25-0.50
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Cardiac Catheterization. B h y
hph h vy AS, -
h y y
h p y y (CAD)
h h hy . H-
v, vv hy hp p h h vv v
pv p h vy AS.
Cy phy
AVR p k CAD. Cy phy
p h h p, jv v
h, LV y y, hy CAD
y k , . Th p-
h p ppvy y
p h h R p h
h y y -
vv .
Exercise Testing. My p h AS - yp h y vp y
yp phy
. Oh p y h y p-
v yp . I ppy yp-
p h v AS, x y hv
yp p -
p x. Sh h p h
phy pv h p
p h yp.2,15
trEatmEnt
P h AS h yp h p h x,
h p y h yp. B h
p AS v y, -
-p p h v AS y ppp. A
pvy, pk j vy 4 /
p v AS.2 Ahh h p
vy y p, pk j vy -
y y v 0.3 / h vv
y v 0.1 2 p h -
AS.2
Cy,
y h p AS. B h
AS h k CAD, hpy
h pp p hp v
y h p AS. Hv, h
hpy hv v
.19
I p h vp yp, AVR h -
h. I yp
p h LV y. Ev h LV
y, vv -
. S AVR h-
y pv. Th v AS
F 4.2
P vvy h vv y
p h
y h vv. Hv,
v p , p- vvy h p h
h hh AS
pv - vv.20 Nvh, h
p y p hhy yp-
p h h
h h p y h
. Ip ph vv p-
h- v y y
x p
h v AS h -
AVR.21 Th v y ppv Ep
hh-k , h v 10,000p.
AORTIC REGURGITATION
Etiology
A h -
f, h pp h
, h. Rh h h
v AR . Hv,
vv h hv
AR h hph.
A h p h y AR f , h p,
p, p vv p -
y vv; h h
; h h h
h h vv -
; yx
h vv; ; v ; h-
; v h
M y; -v p;
fy h ; phphp
y; h . Oh y
h y h vv p y-
h, , Tky , ky-
py, J hphy, Whpp ,
Ch .1
D h py h
ph ,
h x x -
h M y y p
vv, Eh-D y, p-
, yph , h h v
h ky py,
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, h Bh y, p h, h
h h v , p-
pyh, h R y. A
AR y ,
f p p. Bp
vv y h h -
f y
h x.22 Sy, ky
py h h f
h . I p h h AR
y y pv v
.
PathoPhysiology
I h AR, p x
p h v. Th x p f
h v v h y h vy
AR. L v
h v - v LV .
I , h k v h j
h hh-p y hyp-
, hh h LV . Th
p x h v
AR y pv LV h -
y y. L v y
y h yp h , h
yp x, hp, pxy
yp.
I y, p v AR, h v
p h v v y vp
hypphy, h p
yy y. Th hy-
pphy hp h h LV vy
hk, hy h LV
v (Laplaces law: [V P R-
]/[W Thk 2]). I y
FIGURE 4. Management strategy in patients with severe aortic stenosis. Preoperative coronary angiography shouldbe perormed routinely as determined by age, symptoms, and coronary risk actors. AVA = aortic valve area; CABG =coronary artery bypass grat; LV = let ventricular; V
max= maximum velocity.
Adapted rom Circulation.2
Severe aortic stenosis
Vmax
>4 m/s
AVA
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h hypphy. Th
y h pv h -
h hypphy. Dp
h v h p
, h py h k
LV y p yp y y. Hv, h pv
LV , p v y xh,
h y -
.23-25 Th p y v, LV y
pv
y AVR. Wh , hv, y -
y y vp, hh p h
h k v LV y.
Wh p LV y, LV -
p , v p-
y y py p. P xp-
yp, y h x h y h . A
y f v.
Physical Examination
Th phy x p h
h AR py h k
v p p. Th pph p-
p h pk k
p (-h C p). A
p y pp. P h y h
v h . Cpy p p-
p h p, p, . Sy
p y v p
h p p. Th p p -
, hypy, p y y.
A p v pp h px. A
y h y h h h h, h
p h, h
h k v. A , h
pp.
Th y h S2
y
p h y h AR. A
h S2
h
y hk f. A j-
h y p h p
vv.24 A S3
y p LV
y
v.25
Th AR hh-y, -
, , y h
h h h h
p h . Th
h h h ph h hp h h
p p p xp-
. Th y v h
pph v , h -
x. Th h v h
p, h , y -
h, h ph h Vv v. M
AR y y . Ah vy AR , h
h. Hv, h h v p-
, h h v h
h, h h .25,26
Th A-F ,
h h px, h h
(MS) p h
vv (MV) . Th -ph
h p p phy MS
y h p LV p y h
hh-p j AR p h p h MV.26
Oh hv h h v y h ARj h f h LV
ky pp
.24
diagnostic tEstingfor acutE ar
A AR ph . B h v-
h h p,
. I h p, hyp hy
py p. Wh
k v, p
y py hy. Th p y
p hk. Th p y. Th S1
h y h
MV h . Ey h MV
hphy p p
h pp p . Rp
pp v AR -
pv hpy (, hp h
h ) hy. A
p y .27
Chest Radiography. I p h AR, h
phy v . Th -
h . Py v -
. I p h h AR, h -
phy h h LV
. Th y h
y p. P-
y h h h vp.
A h ph p h v AR h
F 5.
Electrocardiography. F ECG y -
y h h LV hypphy h
h p . L x
v y p. Wh y LV v v-
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, h p Q v I, VL, V3
hh V6. A h p, h p
, h QRS p .1
Echocardiography. Ehphy h
y LV , v-
, j . I h ph-
h vv, , ,
hy hp h y AR (F 6).
C-f p Dpp hphy h
h y h vy AR (F 7)
y h h vv.24 N h
pv y v h
vy vv , h px
hy v h
p .
Ahh ph h pv
p p h AR, phy-
p h h h
y h h
v phy. A
p y
h vy AR h pv h
y v .
I p h p , -
v h y ky. I h p-
, v h ph-
hphy y .
Th vp - 3-
hphy h p
LV v j . Ahh p-
y p h AR, LV-v
- 3- hphy h
h , p, p 2-
hph h, py
y hp h. Th j h
h h y p h p
.
Cardiac Catheterization. C h
py y y y
p h h ppp k p.Ivv LV AR vy -
v p h vv
v.
FIGURE 5. Chest radiograph o a patient with severe aortic regurgi-
tation showing cardiomegaly and bilateral pleural eusions.
FIGURE 7. Transesophageal echocardiographic long-axis view
with color-ow Doppler imaging in a patient with a bicuspid aorticvalve with severe aortic regurgitation (arrow). Ao = aorta; LV = letventricle.
FIGURE 6. Transesophageal echocardiographic short-axis view o apatient with a bicuspid aortic valve. Note that there are 2 leaets
instead o 3 (arrows).
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Cardiac Magnetic Resonance Imaging. C -
pv hhy -
LV v, , j ;
pv x v h
. I pv p
, CMR - v f. Ahh
CMR v hphy,
pv LV
p h y yp p
h v AR. Vy- h -
h h h
f.28
Exercise Testing. Ex
py h hh yp-
p. Hv, x LV j
yp p h v AR
h h pv p h LV y
k.2
trEatmEnt
P h h AR y yp
y y. I p h LV y -
, ph h h p
yp LV y y h 3.5%
p y; h vp yp LV y,
h 6% p y; h k h, h
0.2% p y.2,29 Hv, h y h
p h 50 y h v AR, h
hh y h p p -
h AVR.30 Wh p vp LV
y y h yp,
yp AVR h 2 3 y. I yp-
p h LV y y, p
yp h 25% p y.2 Ayp
p h LV y hv v
p.30 A pv LV
j -p
y y hh-k p h -
. P h v yp v
v LV hh k h -
y v. Th ph h
p -p p h h AR,
h h yp.2
Ayp p h v AR LV
h x
hphy yy yp h.
P h LV (- -
>60 ) v vy 6 h
hph vy 6 12 h. P
h vy v LV (- >70
-y >50 ) y
AVR (N Yk H A II
AVR).2 Hv, y h
h h LV h vy LV
y v h .
Th - v hpy yp- p h v AR j -
v, h v pv
pv . V y hp p-
h hv yp / LV y
p
. Thy y hp-
pv h hy p p h
v h hy AVR. Ly, hy
hv - hpy p h
p ph yp p h p-
v j h LV 2;
v h - v- hpy k. Th v hpy
h y p. V
h hy, p, -v
y h p.31-33 -Bk
hv pv , hy, h
v h y-
p h - v. V
hpy p h -
AR LV h y-
hyp h p h p
x h . P h
AVR h yp vp, LV v,
h j .2,29,30 Th
p h h v AR F 8.2
MITRAL REGURGITATION
Etiologyand PathoPhysiology
M y h vv
f hv y h -
h p h pp. Th
MR h h vp h
v MV (yx
y) h U S
h vp . L -
h MV; h MR y-
, h h-- h-
, xy, hpy, y p
yh, - xy. Th
MR vp MR,
hh h MV
y . I p, vv
h h p ppy
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p h h f h ph -
p, MR v hh
h vv f hv .34
P h vp v MR y p
h yp h h v
pp p h v .
Hv, h p vv h p h
y pv MR, h v
vp py h. Syp
h h y pv v y
y. Th pv h h v h v
v LV hypphy.
FIGURE 8. Management strategy or patients with chronic severe aortic regurgitation. AVR = aortic valve replacement; DD =diastolic diameter; echo = echocardiography; EF = ejection raction; LV = let ventricular; MRI = magnetic resonance imaging;RVG = radionuclide ventriculography; SD = systolic diameter.
Adapted rom Circulation.2
Chronic severe aortic regurgitation
Clinical evaluation + echo
Symptoms?
Reevaluation
No YesEquivocal
Exercise test
Symptoms
No symptoms
LV function?
Normal EF
AVR
Subnormal EF
Abnormal
Normal
Stable?Stable?Stable?
EF borderline or uncertain
RVG or MRI
SD 75 mm
SD 45-50 mm or
DD 60-70 mm
SD 50-55 mm or
DD 70-75 mm
LV dimensions?
Yes Yes YesNo, or
initial study
No, or
initial study
Clinical
evaluation
every
6-12 mo
Echo every
12 mo
Consider hemodynamic
response to exercise
Reevaluate
and echo
at 3 mo
Clinical
evaluation
every 6 mo
Echo every
6 mo
Clinical
evaluation
every 6 mo
Echo every
12 mo
Class I
Class I
Class IIb
Class I
Class IIa
Reevaluate
and echo
at 3 mo
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Th , h -
h v p.29
Ahh p h p h MR y
yp y y, p
y vy vp h y
v. Th LV j h MR y
h h p
h - j h --
p . Th, LV j
h -
. Av y y y h
LV j h h .35
Th, MV y p p h
ppv j h 60% h
h h hh j .35,36
Physical Examination
Th x h p h h v MR
v h p. Th -
pk hp p h p MR,
h v h p h p-
v h .1 Th p p -
y k hypy; h h v MR
y p y. Th S1
y
, y p S2
. A
S3
y p y LV
y.2 Th y MR v
h y h . Th y
h h px h p.
Wh v v MR, h hy,
h x. Ey y yp
MR. L y yp MV p-
p ppy y. S py
hyp, h P2, y
p v .
diagnostic tEsting
Chest Radiography. Cy LV
p h h MR.
I p h py hyp, h- h-
. Ky B
p h
MR pv LV .1
Electrocardiography. L
h ECG p
h MR. L v ppx-
y -h p, RV hypphy -
v 15%.1 A p ECG p h v MR
p F 9.
Echocardiography. Ehphy h
y v h p h p
MR. I pv h h -
vy MR, h h h v-
, h h , h py
hyp, h p h vv -
.36 Dpp v pv v
h vy MR h hv h p
p .35,36 Ehph xp
p h MV pp p h v MR
p F 10 11, pvy.
FIGURE 9. Electrocardiogram rom a patient with severe mitral regurgitation showing bothlet ventricular hypertrophy and let atrial enlargement.
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Exercise Testing. Ex -
py, py h yp
. M MR vy py y
y p x Dpp-
hphy pv -
, py v -
p.2 Th h py yp
p h h py yp
LV py y
p.
Cardiac Catheterization. C h
y p h hy vy
MR h vv v -
py x vv .
Cy phy p h
p y k CAD.1
trEatmEntP h h MR yp
y. Hv, v vv
y LV y vp
h yp. P h MR
h h y p h -
x, hphy
y h h (, h y h
h). I p h v MR,
x hphy h p-
yy yp vp. I v
h h h LV h -
v MR, LV y y v MR j 60% -y
40 .2 Sh h
pp .
Sy, yp p h v MR
h , py
h vv p, h
y y. I h p
y, hy h p h x-
hphy vy 6 12 h
h y ppy hy vp
yp, , py hyp,
LV y y.2 R hv h h h
h pph vy -
vv p y .37
Th p
hh h p MV p -
MV p. I h h p
h v MR h y y
xp, hh-v , h h
h p hh.2,38 Nh
p MV pp v MV
p h y p. I-
vv h f h h f
h kh p -
py v, h h h
h . Th, k xp
h py p p . I -
, h vv
h MV h h kh p, v xp-
h.2 Th p h v MR
F 12.2
F p h yp v MR, -
p hpy h h y h
v. I yp p h v
FIGURE 11. Apical 4-chamber echocardiographic view with color-owDoppler imaging in a patient with mitral valve prolapse and severe
mitral regurgitation (arrow). LA = let atrium; LV = let ventricle; RA =right atrium; RV = right ventricle.
FIGURE 10. Parasternal long-axis echocardiographic view o a pa-tient with bileaet mitral valve prolapse (arrows). LA = let atrium;
LV = let ventricle.
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Mayo Clin Proc. May 2010;85(5):483-500 doi:10.4065/mcp.2009.0706 www.mayoclinicproceedings.com495
For personal use. Mass reproduce only with pe mission from o Clinic Proceedings.
MR LV , p vy
vv y p pv h
v MR. Th h y h h k-
h vv p h 90% x-
p .2 I p h MR
h LV y, -v y h-
, -k, v p hv h
p v , h
LV - -y v h h
hp h vy MR.39-41
FIGURE 12. Management strategy or patients with chronic severe mitral regurgitation. AF = atrial fbrillation; EF =ejection raction; ESD = end-systolic dimension; HT = hypertension; LV = let ventricular; MV = mitral valve; MVR =
MV replacement.* Mitral valve repair may be perormed in asymptomatic patients with normal LV unction i perormed by an experi-
enced surgical team and i the likelihood o successul MV repair is >90%.
Adapted rom Circulation.2
Chronic severe mitral regurgitation
Reevaluation
Clinical evaluation + echocardiography
Symptoms?
LV function?LV function?
Yes
Yes
Yes*
Yes
No
No
No
No
Normal LV function LV dysfunction
EF >60%
ESD 30%
ESD 55 mm
EF 55 mm
New-onset AF?
Pulmonary HT?
Chordal preservation
likely?
MV repair
likely?* Medical therapy
MV repair
Clinical evaluation
every 6 mo
Echocardiography
every 6 mo
MV repair
If not possible,
MVRClass IIa
Class IIa
Class IIa
Class I Class I
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For personal use. Mass reproduce only with pe mission from yo Clinic Proceedings.
P h MV p -
vp, v y
.42 Th pph ky v
MV p p xp .
Hv, p pph MV p
ky p k p h p h y,
hy y v h hh-
k pp, h y p h p - p h v LV y.
MITRAL STENOSIS
Etiologyand PathoPhysiology
Th MS h -
v. I MS .2
Oh MS vy
, p xp h , py-
h, v ,
yx.
Rh h ,
, f hk, h
MS. A MV 4.0 5.0 2.
Syp y vp h h vv
1.5 2 2.5 2, py h h
h v, x.2
I ph h v MS, py y
v hk-
py v py.
Th py y h v,
hypp, hypphy, -
py hyp. I p,
y y vp h v h
py v.
R yp y vp h h vv
h 1.0 2. Hv, yp p-
h vv h
/ f , h h x, , py, ,
.
Th yp MS y x yp-
. Hv, p y p h
py , , v.
Ry, p y p h h, hpy,
yph. Svv (80% 10 y) p
h yp y yp. O
v yp vp, hv, vv
0% 15% 10 y. I v py hyp
vp, v vv h 3 y.2 T 2 -
h h vy MS.8
Physical Examination
C phy x p h MS -
p LV p, S1,
p p y h py
h h px h -
p. Th , hv, y p
p h v py hyp,
p, hvy vv. Th -
MS h h h
hp h h p h p-
. A p h v p p.
diagnostic tEsting
Chest Radiography. Th h -
ph p h v MS -
(F 13). E h h , h
v, py y p h
v MS h py hyp.
Electrocardiography. Th ECG
p h MS (P-v -
II 0.12 / P-v x +45
TABLE 2. Classifcation o Mitral Stenosis Severity
M M Sv
Sp Vv (2) >1.5 1.0-1.5
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VALVULAR HEART DISEASE
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For personal use. Mass reproduce only with pe mission from o Clinic Proceedings.
30).1 A .
Eph v RV hypphy
v h py hyp.
Echocardiography. Ehphy h py
p h MS. Th
f y h hky k y h h vv y vv
h f p. Th p f
h y . Ehphy pv
h h h
h v h h- h-
(F 14). Dpp x pv
h vy MS, h p h
vv , h py hyp.23
Th MV h j v-
y h MV.
Cardiac Catheterization. R
h p p h MS hy y
hphy. D
h y y h hphy
h
. Ch- hy
p , , p
vvy.43 Cy phy p
p h vv p y
h k CAD.
Exercise Testing. Ex h -
p y
py, py h h p-
yp y hy. Dpp hphy
h x pv p
hy h vy h MV
py y p x
yp p hh
h .2
trEatmEnt
P h MS y h h h
v p pphyx -hy p-
pv h v.2 A-
hpy pv y
p h (p
pxy), y p v (v
hyh), h.2
I yp p h h-
MV , phy x, h -
phy, ECG h p yy. N p
hpy . Ehphy h
p h v MS -
p. A p h v MS h v
v p x.2
Syp p h v MS h h p-
y hyp (>50 H ) h -
p vvy. P h
v MR, vy hk hhy MV -
, / vv pp p
h p. Syp y
p h y. I h p, x
h h h MV py y
p x y -
h p y yp.2 S vv
p h p h
p v. Th
y MS F 15.2
SPECIAL POPULATIONS
PrEgnancy
Ip hy h py.
P v h
h hh 50% v y h -
. P v h p h h p-
y. Th h 10 20 / v
. U h
pph v
h p p. Th v -
h v v, py pph-
, k, hyp.
Th v y yp y-
p h h p LV
h h v. S vv
h . Th
h h py h
FIGURE 14. Apical 4-chamber echocardiographic view o a patient
with severe mitral stenosis showing severe let atrial (LA) enlarge-
ment and a calcifed mitral valve with reduced excursion (arrow). LV =let ventricle; RA = right atrium; RV = right ventricle.
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VALVULAR HEART DISEASE
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For personal use. Mass reproduce only with pe mission from yo Clinic Proceedings.
, hh xy -
y p, py h h MS.30 I
h MS
py.
D vy, p 500
L h . D
v vy, h ppxy
400 L . Th k
, v 800 L. Th
p v vy,
h h y
p h v v. I , h 24 72 h
vy. Th, h k py x
v y vy.44
Hh-k vv h py
T 3. P h v vv
h v p
h h p h py
vy. Iy, h k y h -
h h p p.
W h h ph vv p
h py. Th -
p h h p-
h vv v2; h p h
h v p, py
p.
ProsthEtic ValVEs
I p h vv p y, h -
h ph v ph
v h
h p. A, y,
h p k h -
. Ahh h y h vv
h h vv, p h h vv
h - , h h
p . Mh ph
h h h h p. Th
y ph ,45
h ph h p
h 65 y.2 My p y h 65 y
ph y , h
FIGURE 15. Management strategy or patients with severe mitral stenosis. AF = atrial fbrillation; LA = let atrial;MR = mitral regurgitation; MV = mitral valve; MVA = MV area; PAP = pulmonary artery pressure; PMBV = percu-taneous mitral balloon valvotomy.
Adapted rom Circulation.2
Mitral stenosis
Symptoms?No
No
No
No No
No
No No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MVA 50 mm Hg or
Exercise PAP >60 mm Hg or
new-onset AF
Favorable
morphology
for PMBV?
Class IIb
Class IIa
Class I Class I
New-onset
AF?
MVA 1.5 cm2
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VALVULAR HEART DISEASE
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For personal use. Mass reproduce only with pe mission from o Clinic Proceedings.
h h vv p y
h
h ph. Whh p h- vvp v p p h
ph h , h
h vv--vv h h y
p p.21
I h ph h p h MR
vp h hv vv h
p y y k , hy
h - k ph h vv.
Th, p h MR y h -
hh -
k h v p MR.2
O p vv y, ppp - -p . A p h ph
vv h v ppp pphy
h py h pphy p-
v v .46 A p h -
h vv h v ppp
. W p
p h h ph hh-k p-
h ph vv. Ap
-k p h ph vv.2 Th -
h ph vv
T 4.
Th yp, p p h - p yy. Ehphy h
p v y, hphy
y h h ph
vv p.2 P h yp
p ph vv h
p y. Th y x,
vv , p /
hpy h v h p
h p y phy.
CONCLUSION
Dv vv ky -
y h pp . Rh h
h y
h U S h
y. Appp , , -
p h p pv -
y y. A k
vv p h py phy
h p h p -
h py .
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TABLE 3. Valvular Heart Lesions Associated With HighMaternal and/or etal Risk During Pregnancy
Sv h h yp
A h NYHA III-IV yp
M h NYHA II-IV yp
M h NYHA III-IV ypA / vv v py
hyp (py p >75% y p)
A / vv h v LV y (LVEF
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C Cy, C Cv Sy Ah, h Qy C O Rh Ipy WkGp. Circulation. 2007;116:1736-1754.
The Symposium on Cardiovascular Diseases will continue in the June issue.
This activity was designated for 1 AMA PRA Category 1 Credit(s).
Th h Syp Cv D CME vy. F
CME , h k W yp..