Valves, endocarditis and congenital circulation
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; severity is established through an integrated anatomical and hemodynamic assessment. Symptoms and ventricular dysfunction influence intervention decisions rather than independently defining valve severity. 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. Intervention in confirmed severe disease is individualized by the Heart Team. Symptoms, ventricular function, exercise findings, valve calcification, progression, procedural risk, life expectancy and patient preferences can matter. Contemporary guidance also addresses selected asymptomatic patients, so the absence of symptoms does not impose a universal prohibition on intervention.
Congenital Heart Disease
Core concepts
Adult congenital heart disease questions emphasize shunt physiology, cyanosis, murmurs, and complications. ASD causes a fixed split S2 and right-heart volume overload; VSD causes a holosystolic murmur; PDA causes a continuous murmur. Tetralogy of Fallot includes VSD, RV outflow obstruction, overriding aorta, and RV hypertrophy. Coarctation presents with upper-lower extremity BP discrepancy and rib notching. Eisenmenger syndrome is irreversible pulmonary vascular disease with reversed shunt. Pregnancy in cyanotic congenital disease is high risk.
Question traps
Do not assume a murmur is innocent without assessing timing and maneuvers. A normal oxygen saturation does not exclude a shunt. Paradoxical embolism can occur with PFO or ASD. Endocarditis prophylaxis is limited to specific high-risk lesions. Repair timing depends on shunt size, pulmonary pressures, and symptoms.
Worked example / rule of thumb
A 35-year-old with exertional dyspnea, fixed split S2, and right ventricular enlargement likely has an ASD; closure is considered if pulmonary vascular resistance is not severely elevated. Rule: fixed split S2 points to ASD until proven otherwise.