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VALVULAR HEART DISEASE

Mayo Clin Proc. May 2010;85(5):483-500 doi:10.4065/mcp.2009.0706 www.mayoclinicproceedings.com 483

For personal use. Mass reproduce only with pe mission from o Clinic Proceedings.

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


2/18


Mayo Clin Proc. May 2010;85(5):483-500 doi:10.4065/mcp.2009.0706 www.mayoclinicproceedings.com484

For personal use. Mass reproduce only with pe mission from yo Clinic Proceedings.

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


3/18




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.


4/18




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


5/18




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,


6/18




, 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


7/18




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.


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-


8/18




, h p Q v I, VL, V3

hh V6. A h p, h p

, h QRS p .1


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).


9/18




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


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


10/18




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.


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


11/18




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


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.


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.


12/18




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.


13/18




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%.


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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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


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


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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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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, 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.


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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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 .

REERENCES

1. O CM. B RO. Vv h . I: Ly P, B RO,M DL, Zp DP, . Braunwalds Heart Disease: A Textbook of Cardio-vascular Medicine. 8h . Phph, PA: WB S; 2007:1625-1712. 2. B RO, C BA, Chj K, . 2008 F p -p h ACC/AHA 2006 h ph vv h : p h A C Cy/A H A Tk F P G (W C- Dvp G h M P Wh VvH D). Circulation. 2008;118:523-661. 3. R J J, B E. A . Circulation. 1968;38(1)(pp):61-67. 4. B BJ, v Bk RBA, v M JH, . T p y p h : h .

Heart. 1999;82:143-148.

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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Mayo Clin Proc May 2010;85(5):483 500 doi:10 4065/mcp 2009 0706 www mayoclinicproceedings com500

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h yp .N Engl JMed. 2005;352(9):875-883. 36. Zh WA, E-S M, F E, . R v h vy v vv h -- Dpp hphy.J Am Soc Echocardiogr. 2003;16:777. 37. Rhk R, R F, K U, . O h yp- v . Circulation. 2006;113(18):2238-2244. 38. E-S M, Sh HV, Ok TA, Tjk AJ, By KR, FyRL. Vv p pv h y : v y. Circulation. 1995;91:1022-1028. 39. Cp S, F O, G M, . B k h h: pv y v.

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y h .J Am Coll Cardiol. 2003;41:765-770. 42. A F, F T. P pph .Curr Treat Options Cardiovasc Med. 2009;11(6):476-482. 43. Wk GT, Wy AE, A VM, Bk PC, P IF. P- h vv: y hphv h h . Br Heart J.1988;60:299-308. 44. W CA. Py h . I: Ly P, B RO, MDL, Zp DP, .Braunwalds Heart Disease: A Textbook of Cardiovascular

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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..

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