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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 10–27 and 10–28). 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 10–27.

A: The ascending aorta (yellow dotted line) leading into the arch is dilated, whereas the distal arch and descending aorta (red dotted line) are normal in size. The left heart border (blue dotted line) can be traced upwards along the mediastinum to blend with the aortic arch, explaining why the medial (left) border of the ascending aorta is not visible on radiographs. B: CTA of the thorax confirms enlargement of the ascending aorta with a normal caliber descending aorta. Source: Case used with permission from Dr. Frank Gaillard,, rID: 15391. Copyright 2020 Dr. Frank Gaillard. Used under license.

eFigure 10–28.

Calcification of the aortic valve, better seen in the lateral view in the area of the aortic root (A, arrow). Sagittal and coronal CT confirm the location of the calcium at the aortic valve (B,C, arrows). Cáceres J, "Dr. Pepe's Diploma Casebook: Case 60 — Solved," Dr. Pepe's Diploma Casebook (blog), September 8, 2014, Used with permission.

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. Echocardiography yields key information about valve morphology, LV mass and function, and atrial and ventricular chamber size. Doppler ultrasound provides quantitative measurements of transvalvular gradients and RV systolic pressure (a surrogate for peak PA pressure when there is no pulmonic stenosis) and provides qualitative estimates of the ...

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