Overview Table
| Heart Valve Disease | Mechanism | Murmur Type | Murmur Description |
|---|---|---|---|
| Aortic stenosis | Poor / obstructed flow across the aortic valve during systole (from LV to ascending aorta) | Systolic murmur |
|
| Mitral regurgitation | Blood backflow into LA from LV (via mitral valve) during systole |
|
|
| Aortic regurgitation | Blood backflow into LV from ascending aorta (via aortic valve) during diastole | Diastolic murmur |
|
| Mitral stenosis | Poor / obstructed blood flow across the mitral valve during diastole (from LA to LV) |
|
*All the above are left-sided valve diseases, they are best heard on expiration (right-sided valve diseases are best heard on inspiration).
lEft-sided heart murmurs (i.e., aortic, mitral) → increase in intensity on Expiration
rIght-sided murmurs (i.e., tricuspid, pulmonic)→ increase in intensity on Inspiration
Aortic Stenosis (AS)
Definition
Aortic stenosis is defined as an abnormal narrowing of the aortic valve orifice, resulting in increased resistance to blood flow from the left ventricle into the aorta during systole.
Aetiology
There are 3 main causes of aortic stenosis: [ref, ref]
| Cause | Description |
|---|---|
| Degenerative calcification | Leading cause in >70 y/o in developed countries
Associated risk factors:
|
| Congenital bicuspid aortic valve | Leading cause in <70 y/o
Bicuspid valves are prone to premature calcification and stenosis due to altered hemodynamics and genetic predisposition |
| Rheumatic heart disease | Significant cause in endemic regions (most commonly developing countries)
Rheumatic heart disease causes commissural fusion and leaflet thickening, often in association with mitral valve disease |
Clinical Features
Symptoms
Signs
Possible examination findings: [ref, ref]
| Examination aspect | Findings |
|---|---|
| Auscultation findings |
Additional sounds:
|
| Physical examination |
Signs of heart failure are possible |
Complications
Main complications: [ref, ref]
- Chronic heart failure (HFpEF / HFmrEF) (↑ afterload → progressive concentric remodelling → LV hypertrophy)
- Arrhythmias (esp. atrial fibrillation)
- Myocardial ischaemia (from LV hypertrophy)
- Pulmonary hypertension, secondary mitral regurgitation
- Heyde’s syndrome (triad of severe aortic stenosis + acquired type 2a von Willebrand syndrome + GI bleeding
Typically, from intestinal angiodysplasia.
)- High shear stress across the aortic valve → loss of von willebrand factor → impaired platelet-mediated haemostasis → recurrent GI bleeding and anaemia (in areas of GI angiodysplasias)
Complications associated with bicuspid valves: [ref]
- Aortic root dilation and dissection
Investigation and Diagnosis
1st line: trans-thoracic echocardiography (TTE)
Other tests (not routinely needed):
- Trans-oesophageal echocardiography – provides better resolution of the aortic valve (e.g., if there is poor acoustic window in TTE)
- Cardiac CT – to quantify valve calcification
- Cardiac MRI – assessment of ventricular function and myocardial fibrosis
Echocardiography Severity Classification
BSEBritish Society of Echocardiography recommends using the peak aortic jet velocity (Vmax) to define AS severity:
- Mild: Vmax <3 m/s
- Moderate: Vmax 3.0-3.0 m/s
- Severe: Vmax ≥4.0 m/s
The commonly seen AS severity grading system (based on 2020 ACC/AHA guidelines):
| Severity | Peak aortic jet velocity (Vmax) | Measure pressure gradient (mmHg) | Aortic valve area (cm2) |
|---|---|---|---|
| Mild | <3.0 m/s | <20 | >1.5 |
| Moderate | 3.0-3.9 m/s | 20-39 | 1.0-1.5 |
| Severe | ≥4.0 m/s | ≥40 | <1.0 |
It is more important to learn the cut-offs for severe aortic stenosis only, instead of learning all the grades and cut-offs. As exam questions tend to assess if a student is aware when to refer/offer intervention, which is mainly when aortic stenosis is severe.
Management
Pharmacological Management
This applies to ALL valvular heart diseases:
- There is no specific pharmacological management for the valve disease itself
- Pharmacological management is offered to manage heart failure if it develops (see this article)
- Optimise management of comorbidities and cardiovascular risk factors (e.g. hypertension, smoking cessation)
Surgical Management
Indications
Offer intervention if there is symptomatic, severe aortic stenosis
Consider referring asymptomatic, severe AS
for intervention if ANY of the following:
- LVEFLeft ventricular ejection fraction <55%
- Symptoms unmasked on exercise testing
- BNP/ NT-proBNP >2x upper limit of normal
- Echo measurements
- Vmax >5 m/s (very severe AS)
- Aortic valve area <0.6 cm2 (very severe AS)
Choice of Intervention
- 1st line: surgical aortic valve replacement (SAVR) (by median sternotomy or minimally invasive surgery)
- 2nd line (if high surgical risk): transcatheter aortic valve implantation (TAVI)
- If unfit for TAVI: balloon valvuloplasty
Surveilllance
Echo surveillance is recommended in AS, depending on severity:
- Mild → every 3-5 years
- Asymptomatic severe (intervention not currently needed) → every 6-12 months
Aortic Sclerosis
Definition
Aortic sclerosis is defined as focal thickening and calcification of the aortic valve with NO significant restriction of leaflet motion and NO hemodynamically significant left ventricular outflow obstruction. [Ref]
NOT the same as aortic stenosis, but it is considered a precursor to aortic stenosis.
Aetiology
Multifactorial, mainly shared risk factors with atherosclerosis: [Ref]
- Advancing age
- Male
- Hypertension
- Smoking
- Diabetes, obesity, metabolic syndrome, dyslipidaemia
Clinical Features
Aortic sclerosis is typically asymptomatic. [ref, ref]
Possible examination findings: [ref, ref]
- Soft ejection systolic murmur
- With NO radiation to the carotids
There are no symptoms attributable to valve dysfunction, distinguishing it from aortic stenosis. Key points regarding aortic sclerosis:
- Murmur does NOT radiate to the carotids
- S2 remains normal (no single S2 / soft S2 / absent S2)
- Normal pulse character (no “parvus et tardusDelayed, slow-rising, low amplitude carotid pulse“)
- Normal pulse pressure
Complications
Investigation and Diagnosis
1st line: trans-thoracic echocardiography (TTE)
Echocardiography criteria:
- Leaflet thickening and calcification
- Peak aortic jet velocity (Vmax) <2.5 m/s (no evidence of haemodynamic obstruction)
Management
There is no specific management for aortic sclerosis:
- Optimise management of comorbidities and cardiovascular risk factors (e.g. hypertension, smoking cessation)
- No routine echocardiography surveillance is needed
Aortic Regurgitation (AR)
Definition
Aortic regurgitation is defined as the backflow of blood from the aorta into the left ventricle during diastole due to incompetent closure of the aortic valve. [ref]
Aetiology
Causes of AR can be largely classified into acute vs chronic: [ref]
| Category | Common causes |
|---|---|
| Acute AR |
|
| Chronic AR (more common) |
|
Clinical Features
Symptoms
Signs
Possible examination findings: [ref]
| Examination aspect | Findings |
|---|---|
| Auscultation findings |
Additional sounds:
|
| Physical examination |
Some additional signs (common in exams):
|
Complications
Main complications of chronic AR are: [ref]
- Heart failure (from LV dilation) – most common
- Arrhythmias (from chamber dilation and fibrosis)
- Aortic root dilation can lead to aortic dissection or rupture
Investigation and Diagnosis
1st line: trans-thoracic echocardiography (TTE)
Management
Pharmacological Management
This applies to ALL valvular heart diseases:
- There is no specific pharmacological management for the valve disease itself
- Pharmacological management is offered to manage heart failure if it develops (see this article)
- Optimise management of comorbidities and cardiovascular risk factors (e.g. hypertension, smoking cessation)
Surgical Management
Indications
Offer intervention if there is symptomatic, severe AR
Considering referring asymptomatic, severe AR for intervention if ANY of the following:
- LVEFLeft ventricular ejection fraction <55%
- ESDEnd systolic diameter >50mm or ESDIEnd systolic diameter index >24mm/m2
The severity grading of non-AS valvular disease is more complicated and rarely assessed in exams. It depends on 1) visual assessment, 2) quantitative findings and 3) qualitative findings.
It is more important for students to be aware that symptomatic, severe valve disease (this applies to all types of valve disease) is an indication to offer intervention.
Choice of Intervention
- 1st line: surgery
- Surgical aortic valve replacement (SAVR) – standard procedure for most patients
- Aortic valve repair – preferred in selected patients with favourable valve anatomy
- 2nd line (if high surgical risk): transcatheter aortic valve implantation (TAVI)
Mitral Stenosis (MS)
Definition
Mitral stenosis is defined as an abnormal narrowing of the mitral valve orifice, obstructing blood flow from the left atrium to the left ventricle.
Aetiology
Clinical Features
Symptoms
Most patients remain asymptomatic initially.
When they become symptomatic:
- Most commonly presents as heart failure [ref]
- Haemoptysis is possible due to ruptured bronchial veins from elevated pulmonary venous pressure.
Signs
Possible examination findings: [ref]
| Examination aspect | Findings |
|---|---|
| Auscultation findings |
Additional sounds:
|
| Physical examination |
Signs of pulmonary hypertension:
|
Complications
Important complications: [ref]
- Atrial fibrillation (from left atrial dilation) – notable association
- Right-sided heart failure and pulmonary hypertension
- Infective endocarditis
Investigation and Diagnosis
1st line: trans-thoracic echocardiography (TTE)
Management
Pharmacological Management
This applies to ALL valvular heart diseases:
- There is no specific pharmacological management for the valve disease itself
- Pharmacological management is offered to manage heart failure if it develops (see this article)
- Optimise management of comorbidities and cardiovascular risk factors (e.g. hypertension, smoking cessation)
Surgical Management
Indications
Offer intervention if there is symptomatic, severe MS
ESC guidelines also recommend considering intervention if:
- Asymptomatic severe MS, and
- ↑ Pulmonary artery pressure (>50 mmHg)
The severity grading of non-AS valvular disease is more complicated and rarely assessed in exams. It depends on 1) visual assessment, 2) quantitative findings and 3) qualitative findings.
It is more important for students to be aware that symptomatic, severe valve disease (this applies to all types of valve disease) is an indication to offer intervention.
Choice of Intervention
- 1st line: transcatheter valvotomy (also called balloon valvuloplasty)
- 2nd line: surgical mitral valve replacement
Mitral Regurgitation (MR)
Definition
Mitral regurgitation is defined as the backflow of blood from the left ventricle into the left atrium during systole due to incompetent closure of the mitral valve.
Aetiology
Primary causes:
- Mitral valve prolapse
- Degenerative changes
- Rheumatic heart disease
- Infective endocarditis
- Connective tissue disorder (e.g. Marfan syndrome, Ehlers-Danlos syndrome)
Secondary (functional) causes:
- Ischaemic mitral regurgitation (post-MI complication from anterior papillary muscle rupture)
- Left ventricular dilation (e.g. chronic volume overload, dilated cardiomyopathy)
- Atrial dilation (common in atrial fibrillation)
- HCMHypertrophic cardiomyopathy / HOCMHypertrophic obstructive cardiomyopathy (causes abnormal papillary muscle/leaflet movement)
Acute severe mitral regurgitation (e.g., presenting with flash pulmonary oedema) should raise suspicion of more acute causes, including post-MI papillary rupture or infective endocarditis.
Clinical Features
Symptoms
Most patients remain asymptomatic initially.
When they become symptomatic:
- Most commonly present as heart failure [ref]
- Features of the underlying cause
Signs
Possible examination findings: [ref]
| Examination aspect | Findings |
|---|---|
| Auscultation findings |
Additional sounds:
|
| Physical examination |
Signs of pulmonary hypertension:
|
Complications
Important complications: [ref]
- Atrial fibrillation (from left atrial dilation) – notable association
- Right-sided heart failure and pulmonary hypertension
Investigation and Diagnosis
1st line: trans-thoracic echocardiography (TTE)
Management
Pharmacological Management
This applies to ALL valvular heart diseases:
- There is no specific pharmacological management for the valve disease itself
- Pharmacological management is offered to manage heart failure if it develops (see this article)
- Optimise management of comorbidities and cardiovascular risk factors (e.g. hypertension, smoking cessation)
Surgical Management
Indications
Offer intervention if there is symptomatic, severe MR
Considering referring asymptomatic, severe MR for intervention if ANY of the following:
- LVEFLeft ventricular ejection fraction <60%
- ↑ Systolic pulmonary artery pressure on exercise testing (>60 mmHg)
- ESDEnd systolic diameter >45mm or ESDIEnd systolic diameter index >22mm/m2
Choice of Intervention
- 1st line: surgical mitral valve repair (by median sternotomy or minimally invasive surgery)
- 2nd line: surgical mitral valve replacement
- 3rd line (if unfit for surgery): transcatheter edge-to-edge repair (e.g., using MitraClip device)
- Device used to approximate the mitral valve leaflets, reducing regurgitation
References
NICE guideline Heart valve disease presenting in adults: investigation and management