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At one time, most cases of valvular disease in the United States were due to rheumatic heart disease. While this is still true in many developing countries, other causes are much more common in the developed world. In the elderly, “degenerative” calcific aortic valvular disease is believed to be due to a process similar to that which produces atherosclerosis; studies have suggested that up to 25% of adults over age 65 have some thickening of their aortic valve (aortic sclerosis) while 2–3% have frank aortic stenosis (eFigures 10–30 and 10–31). Aortic sclerosis alone is a marker for future cardiovascular events and death. There is also increasing information that genetic markers associated with aortic stenosis play a role in the expression of this disease. Calcium deposition may also occur in the mitral annulus creating enough dysfunction of the valve that either stenosis or regurgitation (or both) results. Mitral valve prolapse is still frequently seen and rarely may be associated with the hyperadrenergic syndrome in younger patients. AV valvular regurgitation may be due to LV dysfunction and papillary muscle displacement (functional mitral regurgitation) or RV dysfunction (tricuspid regurgitation). Low-flow, low-gradient aortic stenosis is recognized as occurring with both a normal LVEF as well as an abnormal LVEF. Both entities carry significant morbidity and mortality.

eFigure 10–30.

Serial chest radiographs of a patient with aortic stenosis taken 10 years apart. The left ventricle (LV) and aorta (AO) are prominent in both radiographs. The heart is larger and the right hilar vessels more prominent in the film at the bottom, which was taken after the development of symptoms. (Reproduced, with permission, from Cheitlin MD, Sokolow M, McIlroy MB. Clinical Cardiology, 6th ed. Originally published by Appleton & Lange. Copyright © 1993 by The McGraw-Hill Companies, Inc.)

eFigure 10–31.

A: Congenital bicuspid aortic valve, producing isolated aortic stenosis. The aortic valve is calcified (black arrow). The left ventricular contour on the PA chest film is rounded (reflecting hypertrophy) but not enlarged. The ascending aorta is too prominent (arrowheads) and is out of proportion to the rest of the aorta. B: L ateral film. Arrow shows aortic valve calcification, and arrowheads point to prominent ascending aorta. (Used, with permission, from H Goldberg.)

The 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines provide information on valvular heart disease diagnosis and treatment. The typical findings of each native valve lesion are described in Table 10–1. Table 10–2 outlines bedside maneuvers to distinguish among the various systolic murmurs. These guidelines were updated in 2017 to reflect the remarkable increase in the use of percutaneous valvular devices, some of the newer information regarding anticoagulation usage, and when to intervene....

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