VALVULAR HEART DISEASE

TRICUSPID REGURGITATION
Most common cause functional tricuspid regurgitation
CLINICAL MANIFESTATION
In the absence of pHPN. TR is generally well tolerated
With pHPN cardiac output declines with manifestations of systemic venous
congestion
Neck veins are distended with prominent V waves
PHYSICAL EXAMINATION
Holosystolic murmur at the 4th ICS LPS is intensified by inspiration
- Carvallos sign
Prominent RV pulsations
Electrocardiogram
- usually nonspecific and RV enlargement
Radiologic findings
- enlargement of both RA & RV
Echocardiogram
- demonstrates RV dilatation and abnormalities in the tricuspid valve
- color flow Doppler estimates the severity and pulmonary artery pressure
TRICUSPID STENOSIS
generally rheumatic and more common in women
hemodynamic hallmark - diastolic pressure gradient bet the right atrium and the
ventricle
gradient of >4mmhg -systemic venous congestion
low cardiac output causes fatigue
elevated systemic venous pressure - hepatomegaly, ascitis, and anasarca
severity of these symptoms is out of proportion to the degree of dyspnea
PHYSICAL FINDINGS
giant s waves
slow Y descent
diastolic murmur heard best at the 4th ICS LPS is accentuated by
inspiration
Mueller maneuver
leg raising
amyl nitrite inhalation
squatting and isometric exercise
MANAGEMENT
TR in the absence of pulmonary hypertension usually does not require surgical
treatment
Annuloplasty - Carpentier ring or De-Vega annuloplasty
Valve replacement
PULMONIC VALVE STENOSIS
congenital - most common cause
degree of obstruction - principal determination of clinical severity
PHYSICAL EXAMINATION
RV hypertrophy
prominent a wave in jugular venous pulse
systolic thrill along the upper left sternal border

 ejection systolic murmur at the left upper sternal border

holosystolic murmur of TR
LABORATORY EXAMINATION
Electrocardiogram
tall right atrial P waves
Radiological findings
dilated right atrium without enlarged pulmonary artery
dilated superior vena cava
Echocardiography
diastolic doming of the leaftlets with thickening and restriction of motion
MANAGEMENT
intensive salt restriction and diuretic therapy
Surgical treatment - for severe TS with mean diastolic pressure gradient of >5mmHg
or TVA of <2 cm2
Electrocardiogram
RA D and RV hypertrophy
Chest Roentgenography
RA and RV enlargement
poststenotic dilatation of the left pulmonary artery - valvar pulmonic stenosis
dysplastic valve - thickened and immobile leaflets with hypoplasia of the
pulmonary valve annulus without post stenotic dilatation of the LPA
Cardiac catheterization
usual indication is to provide therapy for the lesion
MANAGEMENT
mild to moderate PS - generally have favorable course
percutaneous transluminal balloon valvuloplasty
initial procedure of choice
surgical relief of the obstruction
IE prophylaxis
PULMONARY REGURGITATION
dilatation of the valve ring secondary to pHPN
infective endocarditis
RV volume overload
Graham steel murmur - high-pitched, decrescendo diastolic blowing murmur along
the left sternal border
usually of little hemodynamic significance