Rapid Review·Cardiovascular
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Valvular Heart Disease
T1Must knowPulmonary Regurgitation
Focus on
Mostly a consequence of fixing something else — repaired tetralogy or balloon valvuloplasty — or of pulmonary hypertension (the Graham Steell murmur). A soft decrescendo diastolic murmur at the left sternal border that gets louder on inspiration; watch the right ventricle on serial echo and replace the valve when it dilates or the patient becomes symptomatic.
Key takeaways
Causes and pathophysiology
Iatrogenic
after repair of pulmonic stenosis or right ventricular outflow obstruction.Other causes
rheumatic heart disease and infective endocarditis.Pathophysiology
progressive right ventricular volume overload, dilation, and eventual failure.Clinical features and diagnosis
Right heart failure
dyspnea, fatigue, and a prominent parasternal impulse once the ventricle dilates.The murmur
a decrescendo diastolic murmur at the left sternal border that increases with inspiration, with a soft or absent P2.Transthoracic echocardiography
confirms it.Management
Serial echocardiography
then valve replacement once symptoms or right ventricular dysfunction develop.When any valve goes to surgery
The summary rule
symptomatic disease; asymptomatic disease with a falling ejection fraction; mitral stenosis with pulmonary hypertension; and any acute regurgitation.| Lesion | Operate when |
|---|---|
| Any valve lesion | Symptomatic disease |
| Aortic stenosis, asymptomatic | Ejection fraction under 50 percent |
| Aortic regurgitation, asymptomatic | Ejection fraction under 55 percent |
| Mitral regurgitation, asymptomatic | Ejection fraction under 60 percent |
| Mitral stenosis | Pulmonary hypertension |
| Any acute regurgitation | Always |
Before non-cardiac surgery
the valve plan is on Approach to Perioperative Cardiac Management.A 27-year-old with repaired tetralogy of Fallot has worsening exercise tolerance, a decrescendo diastolic murmur at the left sternal border that increases with inspiration, and a dilated right ventricle. What is the lesion and when is the valve replaced?
Pulmonary regurgitation after repair of right ventricular outflow obstruction (iatrogenic), with right ventricular volume overload. Follow with serial echocardiography and replace the valve once symptoms or right ventricular dysfunction develop, as here.
How it's tested
A 28-year-old with repaired tetralogy of Fallot has worsening exercise tolerance, a decrescendo diastolic murmur at the left sternal border louder on inspiration, and a markedly dilated RV on MRI: severe pulmonary regurgitation — pulmonary valve replacement.
A woman with mitral stenosis and pulmonary hypertension has a high-pitched early diastolic murmur at the upper left sternal border and a loud P2: Graham Steell murmur of functional PR — treat the mitral stenosis and pulmonary hypertension.
Which right-sided murmur is diastolic: PR (decrescendo) and tricuspid stenosis (rumble); all right-sided murmurs get louder on inspiration.
Go deeper
Guidelines: 2020 ACC/AHA Valvular Heart Disease Guideline · 2018 AHA/ACC Adult Congenital Heart Disease Guideline
Related Step 2 pages: Pulmonary Stenosis, Tetralogy of Fallot, Cor Pulmonale, Aortic Regurgitation, Heart Sounds & Murmurs
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