Valvular Heart Disease
Core concepts
Valvular disease teaching focuses on lesion severity, symptoms, ventricular response, and timing of intervention. Aortic stenosis is classified by valve area, gradient, velocity, and flow; symptoms or LV dysfunction define severe disease requiring intervention. Mitral regurgitation requires distinguishing primary from secondary disease and acute from chronic compensation. Mitral stenosis is usually rheumatic and presents with dyspnea, AF, and pulmonary hypertension. Aortic regurgitation has wide pulse pressure and a decrescendo diastolic murmur. Prosthetic valve dysfunction and endocarditis are high-yield topics.
Question traps
Do not rely on one number when AS severity is discordant; low-flow low-gradient AS needs stress echocardiography or CT calcium scoring. Acute severe MR may have normal EF and a soft murmur. Auscultation maneuvers can mislead: inspiration increases right-sided murmurs, handgrip increases MR and AR, and Valsalva decreases most murmurs except HCM and MVP. Do not offer balloon valvuloplasty for routine calcific AS.
Worked example / rule of thumb
A 76-year-old with exertional syncope, severe AS by echocardiography, and no other cause has a class I indication for aortic valve replacement. Rule: symptomatic severe AS equals intervene; asymptomatic severe AS needs stress testing or LV dysfunction before acting.