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Key Clinical Questions

  • image What are the key factors that determine when to proceed to aortic valve replacement for patients with aortic stenosis? What guides decision making relating to aortic surgery for acute and chronic aortic regurgitation?

  • image Which patients with aortic stenosis should be considered for transcatheter therapies such as valvuloplasty or transcatheter aortic valve replacement?

  • image What are the indications for surgery in patients with mitral stenosis? What are the goals of medical therapy for mitral regurgitation and when should patients be considered for mitral valve repair or replacement?

  • image When should patients with mitral regurgitations be considered for transcatheter mitral valve procedures?

  • image What are the objectives of treatment of pulmonic valve disease? When should a patient be referred for surgery or transcatheter valve replacement?

  • image What are the factors that determine medical versus surgical treatment of tricuspid stenosis or tricuspid regurgitation?

Valvular heart disease is a common disorder seen by hospitalists. Often a cardiologist and/or cardiac surgeon is consulted to comanage these patients; however, a comprehensive understanding and appropriate screening by an internist is important for both an inpatient and outpatient practice. This chapter provides practical information regarding the pathophysiology, diagnosis, and therapy of the valvular abnormalities that commonly affect each of the four valves.




Aortic stenosis (AS) is the obstruction of blood flow through the aortic valve due to thickened or immobile leaflets. Aortic stenosis may be categorized into three disease processes: rheumatic, congenital, and degenerative. Rheumatic is the most common type of AS worldwide, but is rarely seen in industrialized countries due to improvements in therapy and diagnosis. Since it remains prevalent in developing nations, rheumatic disease should still be considered in immigrant populations. Congenital AS is caused by malformed aortic leaflets resulting in bicuspid or unicuspid aortic valve and is typically seen in symptomatic patients that are in their fourth or fifth decade of life. Degenerative AS (also known as calcific or senile AS) is the leading cause of valvular cardiac surgery in US adults, with an estimated prevalence of 2% to 7% in populations over the age of 65 years. Other less common causes of AS include connective tissue diseases, radiation therapy, and hyperlipoproteinemia syndromes.

Degenerative aortic disease represents a spectrum ranging from aortic sclerosis, defined as leaflet thickening without significant obstruction, to severe AS that significantly obstructs blood flow and requires replacement. Several risk factors have been associated with aortic sclerosis including smoking, hypertension, diabetes mellitus, and elevated low-density lipoprotein cholesterol and C-reactive protein. Recent data support the hypothesis that aortic valve calcification is an active process that may not completely reflect patient age or “wear and tear” of the valve. Abnormalities of blood flow across the valve can lead to damage of the valvular endothelium. Endothelial injury initiates an inflammatory process similar to atherosclerosis and ultimately leads to ...

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