Chapter 29

• Valvular heart disease may remain asymptomatic until an underlying serious illness causes rapid deterioration of health.
• Patients with valvular heart disease are at increased risk of bacterial endocarditis following invasive procedures.
• Aortic stenosis significantly increases the mortality of patients requiring noncardiac surgery.
• Aortic stenosis is a common comorbidity in elderly patients.
• Heart failure in a patient with hypertrophic cardiomyopathy should be treated with rate-slowing and negative inotropic agents.
• Acute regurgitant lesions are frequently medical emergencies and are not as well tolerated as chronic regurgitant lesions.
• Once left ventricular dysfunction occurs in a patient with mitral regurgitation, the lesion is severe and unlikely to improve with surgical correction; in fact, surgery may worsen left ventricular function.

Valvular heart disease is a common cause of morbidity and mortality in the U.S. Although the incidence of rheumatic fever has declined, many patients that acquired the disease years ago are now presenting with valvular abnormalities. In addition, degenerative diseases of the valves are becoming increasingly common as the population ages. Recognition of valvular diseases is important for proper management of seriously ill patients.

The cardiac physical examination is the essential first step in making the diagnosis of valvular heart disease. Patients presenting with signs and symptoms of cardiac illness, such as shortness of breath, pulmonary edema, angina pectoris, or syncope, should have a detailed examination of the cardiovascular system to ascertain the presence of valvular lesions. Assessment of patients prior to noncardiac surgery should include an evaluation for valvular lesions. Once valvular heart disease is suspected, a diagnostic work-up can be completed to determine the severity of the abnormality and quantitate the risk to the patient.

Many patients with valvular abnormalities remain asymptomatic until the onset of an underlying medical illness precipitates heart failure. Tachycardia due to arrhythmias, pain, blood loss, or hypoxia can suddenly precipitate pulmonary edema or low-output states in patients with previously compensated valvular disease. In these instances, prompt treatment of the critical illness is essential to avoid complications of the valvular lesion.

The lesions of valvular heart disease can be broadly categorized as stenotic and regurgitant. The impact of these abnormalities on left or right ventricular function will determine the clinical presentation and risk to the patient at times of critical illness. Traditionally, cardiac catheterization has been used to diagnose and quantify valvular stenosis or regurgitation. Advances in echocardiography have made this imaging modality highly accurate in assessing valvular structure and function.

The degree of stenosis of a valve can be measured by the Gorlin formula.1 The Gorlin formula uses the principle that flow equals area times velocity. The formula for calculating aortic valve stenosis can be stated as A = F/(C × V), where A is the valve area, F is aortic valve flow (calculated as cardiac output divided by the systolic ejection period in seconds multiplied by the heart rate), C is an empiric constant accounting for valvular energy ...

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