Valvular, Structural and Congenital Heart Disease Across the Lifespan
Valve disease
Stenosis obstructs forward flow; regurgitation causes volume overload. Aortic stenosis produces a crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids, with angina, syncope, or dyspnea. Mitral stenosis causes a diastolic rumble and predisposes to atrial fibrillation. Mitral regurgitation causes a holosystolic apical murmur; aortic regurgitation causes an early diastolic murmur. Prosthetic mechanical valves require lifelong anticoagulation; bioprosthetic valves have limited durability.
Structural and congenital disease
ASD, VSD, PDA, coarctation, and tetralogy of Fallot have distinct physiology. Adults with congenital heart disease need lifelong follow-up, endocarditis prevention when high risk, and pregnancy planning. Endocarditis prophylaxis is reserved for high-risk lesions and procedures, not routine dental work for everyone.
Traps
Do not assume a murmur is benign because the patient is asymptomatic. Aortic stenosis can present late; syncope is a poor prognostic sign. Mechanical valves need warfarin, not a DOAC. Right-sided murmurs may increase with inspiration.
Worked example
An older adult with exertional syncope, a systolic ejection murmur at the right upper sternal border, and a weak delayed carotid upstroke likely has aortic stenosis; avoid vigorous diuresis and arrange echocardiography.