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Secondary Mitral Regurgitation

Acknowledgments The authors acknowledge the contributions of Drs. Jacob Dal-Bianco, Robert Levine, and Steven Goldstein, who were the authors of this chapter in the previous edition. Mitral regurgitation (MR) is a frequent complication of myocardial infarction (MI), severe coronary artery disease, and congestive heart failure that is associated with an adverse prognosis independent of underlying left ventricular (LV) dysfunction. In the medical literature, several terms have…

Mitral Valve Prolapse

Mitral valve prolapse (MVP) is the most common cause of mitral regurgitation (MR) in developed countries. It is also known as degenerative or myxomatous mitral valve (MV) disease and consists of a spectrum, with its mildest form known as fibroelastic deficiency and its most severe as Barlow disease ( Table 96.1 ). In this chapter, will discuss the etiology, diagnosis, and management of MVP. TABLE 96.1…

Etiologies and Mechanisms of Mitral Valve Dysfunction

Mitral valve (MV) disease may best be described by defining the cause of the disease, the specific lesions caused by the disease, and the dysfunction it creates in the MV apparatus. This “pathophysiologic triad,” first described by Carpentier and coworkers in the early 1980s, is still useful today in characterizing different types of MV disorders. Causes of Mitral Valve Disease MV disease is caused by either…

Consequences of Mitral Stenosis

Mitral stenosis (MS) results from obstruction of blood flow from the left atrium into the left ventricle at either the valve or the subvalvular level ( Fig. 94.1 and Videos 94.1, Videos 94.2, Videos 94.3, Videos 94.4 ). Complications from MS include pulmonary edema, pulmonary hypertension (PH), right heart failure, atrial arrhythmias, and low cardiac output ( Fig. 94.2 ). In addition to these complications, this…

Role of Hemodynamic Stress Testing in Mitral Stenosis

Acknowledgments We thank Kathleen Stergiopoulos, MD, PhD, and Fabio Lima, MPH, for their contributions to the previous edition of this chapter. Mitral valve (MV) stenosis causes a fixed obstruction in the left ventricular (LV) inflow and decreases the LV preload, thus leading to decreased cardiac output (CO). When severe enough, it can result in elevated pulmonary artery pressures (PAP) and right ventricular (RV) failure. The severity…

Nonrheumatic Etiologies of Mitral Stenosis: Situations That Mimic Mitral Stenosis

Mitral Annular Calcification Rheumatic mitral stenosis (MS) is, by far, the most common cause of left ventricular (LV) inflow obstruction. Less common cause are listed in Box 92.1 . Among these, a heavily calcified mitral annulus is the most often encountered. Calcium deposits in the mitral annulus are extremely common, mainly in older persons or “prematurely” in patients with chronic renal disease on long-term dialysis. ,…

Quantification of Mitral Stenosis

Echocardiography is the modality of choice for the diagnosis of mitral stenosis (MS). The joint American Society of Echocardiography and European Association of Echocardiography guidelines for native valvular stenosis feature an exhaustive review of echocardiographic methods for quantitative assessment of MS. Full echocardiographic evaluation of MS includes the following triad: (1) MVA; (2) mean diastolic transmitral pressure gradient; and (3) secondary changes, including measurements of relevant…

Rheumatic Mitral Stenosis

Worldwide, rheumatic heart disease (RHD) is the predominant cause of mitral stenosis (MS) but is rare in developed countries. Most cases of rheumatic mitral stenosis (RMS) in developed countries are found among immigrants from less developed parts of the world where the prevalence of rheumatic fever may be as high as 150 cases per 100,000 people. Acute rheumatic fever is triggered by rheumatogenic group A β-hemolytic…

Risk Stratification: Timing of Surgery and Percutaneous Interventions for Aortic Regurgitation

Aortic regurgitation (AR) may lead to serious morbidity and excess mortality. As noted in the preceding chapters, the diagnosis of AR should be based on the guidelines for native valvular regurgitation by the American Society of Echocardiography and other international organizations. , The role of medical, percutaneous, and surgical options for the treatment of AR is discussed in this chapter. The recommendations for AR treatment follow…

Quantitation of Aortic Regurgitation

Aortic regurgitation (AR), either acute or chronic, can be caused by valvular pathology, aortic root pathology, or a combination of the two. In developed countries, chronic isolated AR is predominantly caused by aortic root disease or congenital aortic valve disease, but rheumatic fever still remains the leading cause of chronic AR in developing countries. Surgery is frequently needed for patients with acute AR, and the timing…

Aortic Regurgitation: Pathophysiology

Aortic regurgitation (AR) results from reflux of blood from the aorta into the left ventricle during diastole, caused by aortic valve or aortic root disease. The pathophysiology of AR depends whether the AR is acute or chronic. Acute AR is a medical emergency characterized by abrupt left ventricular (LV) volume overload, leading to rapid increase in left ventricular end-diastolic pressures (LVEDPs). Conversely, chronic AR is a…

Aortic Regurgitation: Etiologies and Left Ventricular Responses

Anatomy of the Aortic Valve The aortic valve is a semilunar valve, which typically has three cusps that are attached to the aortic wall to form the sinuses of Valsalva. The highest point of attachment at the leaflet commissures defines the sinotubular junction, and the most ventricular point (i.e., the nadir of the cusps) defines the annular plane. Note that the aortic annulus is not a…

Subaortic Stenosis

Epidemiology Subaortic stenosis (SAS) is rarely found in infants and is responsible for 10% of cases of left ventricular outflow (LVOT) obstruction in children. Although it can be diagnosed at any age, the most common presentation is in the first decade of life. Similar to valvular aortic stenosis, SAS is more common in males, with a male-to-female ratio of 2 to 1. Up to 50% of…

Asymptomatic Severe Aortic Stenosis

Acknowledgment The authors acknowledge the contributions of Dr. Patrizio Lancellotti, who was the author of this chapter in the previous edition. According to the guidelines, there are four stages of aortic stenosis (AS), which are differentiated by valve anatomy, hemodynamics, left ventricular (LV) dysfunction, and patient symptoms: A. Stage A: at-risk anatomy, such as aortic sclerosis or bicuspid aortic valve B. Stage B: progressive hemodynamic obstruction…

Low-Flow, Low-Gradient Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

Low-flow, low-gradient (LF-LG) aortic stenosis (AS) is characterized by a small aortic valve area (AVA<1.0 cm 2 ), a low gradient (mean <40 mm Hg), and a low-flow state (stroke volume index [SVI] <35 mL/m 2 ). The LF-LG AS pattern may occur in the context of either a reduced (i.e., “classical” low-flow; see Chapter 82 ) or preserved (i.e., “paradoxical” low-flow) left ventricular ejection fraction…

Low-Flow, Low-Gradient Aortic Stenosis With Reduced Left Ventricular Ejection Fraction

Low-flow, low-gradient (LF-LG) aortic stenosis (AS) with reduced left ventricular ejection fraction (LVEF) occurs in approximately 5% to 10% of patients with AS. This entity is characterized by a small aortic valve area (AVA) compatible with severe AS (i.e., ≤1.0 cm 2 and/or ≤0.6 cm 2 /m 2 ) combined with low mean transvalvular gradient (MG i.e., less than 40 mm Hg), a low LVEF (i.e.,…

Aortic Stenosis: Risk Stratification and Timing of Surgery

Echocardiography plays a pivotal role in decision making in patients with aortic stenosis (AS) and contributes to decision making for aortic valve replacement (AVR), as guided by the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Valvular Heart Disease and its 2017 Focused Update, as well as the 2017 American College of Cardiology Appropriate Use Criteria Task Force/American…

Asymptomatic Aortic Stenosis

Acknowledgment The authors acknowledge the contributions of Dr. Smith, who was the author of this chapter in the previous edition. Aortic stenosis (AS) is the most commonly encountered valvular degenerative pathology in the world, affecting between 2% and 5% of the general population. The prevalence of AS increases with age and can be as high as 4% to 13% in those older than 75 years of…

Quantification of Aortic Stenosis Severity

Aortic stenosis (AS) is the most common cardiac valve lesion in developed countries, including North America and Europe, with an incidence of 2% to 9% in patients older than 65 years of age. Moreover, the incidence is increasing as the population ages. Aortic sclerosis, the precursor of AS, is present in nearly one-third of patients older than age 65 years. AS is suspected clinically when a…

Aortic Stenosis Morphology

Congenital Aortic Stenosis Bicuspid Aortic Valve Congenital aortic valve malformation reflects a phenotypic continuum of unicuspid valve (severe form), bicuspid valve (moderate form), tricuspid valve (normal, but may be abnormal), and the rare quadricuspid forms. Bicuspid aortic valves (BAVs) are the result of abnormal cusp formation during the complex developmental process. In most cases, adjacent cusps fail to separate, resulting in one larger conjoined cusp and…