Valve Disease

How does stenosis alter valve function compared to regurgitation?

Stenosis narrows the valve opening → same stroke volume must pass through a smaller cross‑sectional area → velocity increases and a pressure gradient forms with higher proximal pressure .

Regurgitation creates a leak → forward volume + regurgitant volume must cross the valve → increases chamber filling volume and preload depending on valve location .

Why does a stenotic valve create a pressure gradient?

Because the proximal chamber must generate higher pressure to push normal stroke volume through a narrowed orifice, producing a measurable gradient used to quantify severity (e.g., AS mean PG > 40 mmHg) .

How does regurgitation change ventricular loading conditions?

Regurgitation increases diastolic filling volume (mitral/tricuspid) or systolic forward volume (aortic/pulmonic), raising preload and eventually afterload as the ventricle must eject both forward and backward volumes .

What are the most common causes of aortic stenosis?

Degenerative calcific disease (most common), bicuspid aortic valve(inc risk for aortic aneurysm), and rheumatic disease (leaflet tip fusion) .

What are the most common causes of aortic regurgitation? (Acute vs Chronic)

Acute: aortic dissection, endocarditis.

Chronic: bicuspid valve, ascending aortic aneurysm, annular dilation, rheumatic disease, paravalvular leak after TAVR .

What are the most common causes of mitral regurgitation? (Acute vs Chronic)

Acute: papillary muscle rupture, chordae rupture, endocarditis. Chronic: MVP, annular calcification, LV dilation, myxomatous degeneration, HOCM, rheumatic disease .

What are the most common causes of mitral stenosis?

Rheumatic heart disease (most common), mitral annular calcification in elderly patients

What are the most common causes of tricuspid regurgitation?(Primary vs Secondary)

Primary: endocarditis, Ebstein’s anomaly, chordae rupture.

Secondary: RV dilation, carcinoid heart disease, rheumatic disease, pacemaker lead trauma .

What are the most common causes of pulmonic stenosis?

Congenital pulmonic stenosis, Noonan syndrome, and as part of Tetralogy of Fallot .

How does the LV respond to aortic stenosis?

LV hypertrophies concentrically to reduce wall stress (pressure × radius / wall thickness) and generate higher systolic pressure to overcome the stenotic valve .

Why is severe aortic stenosis preload‑dependent?

Contractility is maxed and afterload cannot be reduced(bc already stenotic)

How does the LV respond to chronic aortic regurgitation?

LV dilates (eccentric hypertrophy), increases wall thickness, increases preload and afterload due to large forward + regurgitant volumes, eventually leading to systolic dysfunction .

How does the LV respond to acute aortic regurgitation?

LV cannot dilate quickly → steep EDPVR → markedly elevated LVEDP → reduced coronary perfusion pressure → global ischemia and cardiogenic shock .

How does the LV respond to mitral regurgitation and vice versa?

LV dilates due to increased diastolic filling which will pull and dilate mitral annulus leaving leaflets unable to close

How does the RV respond to mitral stenosis?

MS elevates LA pressure → pulmonary hypertension → RV pressure overload → RV failure because the RV bears the brunt of MS .

Ancillary Findings/Indicators of Aortic Stenosis on tests

Weak pulse, Delayed pulse, Paradoxical splitting of S2

Which murmurs correlate with aortic stenosis?

Harsh crescendo‑decrescendo(starts soft grows louder then becomes softer) systolic murmur at RUSB radiating to carotids

Which murmurs correlate with aortic regurgitation?

Diastolic decrescendo murmur at RUSB or Erb’s point

Which murmurs correlate with mitral regurgitation?

Holosystolic(blowing noise characteristic of leaking) murmur at the apex radiating to axilla

Which murmurs correlate with mitral stenosis?

Diastolic murmur with opening snap at apex

Which murmurs correlate with tricuspid regurgitation?

Holosystolic murmur at LLSB that increases with inspiration (Carvallo’s sign) due to increased RV filling .

Which murmurs correlate with pulmonic stenosis?

Systolic ejection murmur at LUSB that increases with inspiration due to right‑sided volume changes .

Should you give nitroglycerin to someone with angina from Aortic Stenosis? Why/Whynot?

NO, because it will vasodilate and lower preload and SV would drop as a result which is the only thing we can control in severe Aortic Stenosis

What benchmarks indicate intervention for aortic stenosis?

Symptomatic severe AS (angina, syncope, CHF), valve area <1 cm², mean gradient >40 mmHg → requires valve replacement

What benchmarks indicate intervention for aortic regurgitation?

Symptoms (CHF, shock), LV EF <50%, or severe LV dilation indicating hemodynamically significant AR → valve replacement recommended .

What benchmarks indicate intervention for mitral regurgitation?

Symptoms or LV EF <60% (because EF appears falsely preserved), or LV dilation → surgical repair/replacement .

What benchmarks indicate intervention for mitral stenosis?

Symptomatic MS → balloon valvuloplasty if suitable

What benchmarks indicate intervention for tricuspid disease?

Usually treat underlying cause (pulmonary HTN, RV dilation)

Differentiating betweem Rheumatic and Calcific aortic stenosis

Rheumatic→immobilizes the leaflet tips; often spares valve leaflets

Calcific→starts at annulus and moves up towards leaflet tips

Williams Syndrome heart issue

Supravalvular Aortic Stenosis

Why can bicuspid aortic valve be dangerous?

Can lead to early aortic stenosis due to abnormal, turbulent flow(increased endothelial injury) + greater risk for developing ascending aortic aneurysm

Syncope and Aortic Stenosis

MAP= CO x SVR: If aortic stenosis is severe enough, then there can be a maximum limit of CO which can go through aortic valve»therefore if you increase demand via exercise or activity, the CO cannot increase and there is a drop in BP leading to syncope

Heyde’s Syndrome

Occurs due to severe aortic stenosis increasing blood velocity resulting in increased shear stress on blood»vWF unravels as if injury occurred»vWF gets depleted quickly and bleeding dramatically increases.

TLDR: aortic stenosis>higher velocity>more damage>less vWF>bleeding

Myxomatous Degeneration

Breakdown of connective tissue»can occur in connective tissue of valve. Seen in Marfan’s Syndrome and/or EDS

How can Hypertrophic Cardiomyopathy lead to Mitral Regurgitation?

As left ventricle thickens, it can distort the mitral valve by sucking the anterior leaflet into the LV outflow tract

Acute Rheumatic Fever: Cause? Associated with?

Group A Strep (pyogenes) infection, acutely Aschoff bodies present(fibrinoid necrosis) that later form scar tissue including in heart and on valves»causes Mitral Stenosis. The reason it attacks heart valves is because the Strep A antigen mimics collagen and its associated proteins so our autobodies attack it AND our own collagen which is present on heart valves(Mitral most common) leading to fibrosis+stenosis

Opening snap at LV apex think

Mitral stenosis with rheumatic disease

Ebstein’s Anomaly

Congenital defect in which septal and posterior leaflets of tricuspid valve are displaced towards the RV apex»enlarged right atrium (50% have Wolff-Parkinson-White)

Noonnan Syndrome

RASopathy»overactivation within RAS/MAPK pathway,associated with pulmonary stenosis