What are the management approaches for different cardiovascular valvular disease states, including Aortic Stenosis (AS), Aortic Regurgitation (AR), Mitral Stenosis (MS), Mitral Regurgitation (MR), Mitral Valve Prolapse, and Tricuspid Regurgitation (TR)?

Management of Cardiovascular Valvular Disease States

The management of valvular heart disease requires a systematic approach based on valve-specific pathophysiology, with intervention timing guided by symptoms, ventricular function, and hemodynamic severity, prioritizing early intervention before irreversible cardiac damage occurs. 1

Aortic Stenosis (AS)

Physical Examination

• Harsh systolic ejection murmur at right upper sternal border radiating to carotids, with diminished or absent S2 in severe cases 1
• Systolic thrill may be present in severe AS 1
• Narrow pulse pressure and pulsus parvus et tardus in advanced disease 1

Natural History

• Progressive disease with long asymptomatic period followed by rapid decline once symptoms develop 1
• Average survival after symptom onset: 2-3 years with heart failure, 3-5 years with syncope, 5 years with angina if untreated 1

Management

• Asymptomatic patients with severe AS require regular monitoring with echocardiography every 6-12 months 1
• Intervention indicated for:
  • Symptomatic severe AS (dyspnea, angina, syncope) 1
  • Asymptomatic severe AS with LV dysfunction (LVEF <50%) 1
  • Severe AS in patients undergoing CABG or other cardiac surgery 1
• AVR is reasonable in patients undergoing CABG who have moderate AS (mean gradient 30-50 mmHg) 1
• Choice between surgical AVR and transcatheter AVR based on surgical risk, anatomy, and comorbidities 1

Aortic Regurgitation (AR)

Physical Examination

• Early diastolic decrescendo murmur at left sternal border 1
• Wide pulse pressure with water-hammer pulse 1
• Peripheral signs of increased pulse pressure (Corrigan's pulse, pistol-shot femoral pulses) 1

Natural History

• Chronic AR has prolonged compensated phase with gradual LV dilation 2
• Rate of progression to symptoms or LV dysfunction: ~4-6% per year 2

Management

• Regular echocardiographic monitoring every 1-2 years for moderate AR 2
• Medical therapy:
  • Vasodilators (ACE inhibitors, dihydropyridine calcium channel blockers) for symptomatic improvement 2
  • Avoid beta-blockers in significant AR as they may worsen regurgitation by prolonging diastole 2
• Surgical intervention indicated for:
  • Symptomatic severe AR 1
  • Asymptomatic severe AR with LV dysfunction (LVEF <55%) 2
  • Asymptomatic severe AR with LV dilation (LVESD >50mm or indexed LVESD >25mm/m²) 2
  • Severe AR with aortic root dilation ≥50mm (especially with bicuspid valve) 2

Mitral Stenosis (MS)

Physical Examination

• Loud S1, opening snap, and diastolic rumble at apex 1
• Signs of pulmonary hypertension and right heart failure in advanced cases 1

Natural History

• Slow progression (decrease in valve area ~0.1 cm²/year) 1
• Increased risk of atrial fibrillation and systemic embolism 1

Management

• Medical therapy:
  • Heart rate control (beta-blockers, calcium channel blockers) to prolong diastolic filling time 1
  • Anticoagulation for patients with atrial fibrillation or prior embolism 1
  • Diuretics for symptom relief 1
• Intervention indicated for:
  • Symptomatic moderate-to-severe MS (valve area <1.5 cm²) 1
  • Percutaneous mitral commissurotomy preferred for favorable valve morphology 1
  • Surgical valve replacement for unfavorable anatomy or when commissurotomy contraindicated 1
• Contraindications to percutaneous commissurotomy include:
  • Left atrial thrombus 1
  • More than mild MR 1
  • Severe bicommissural calcification 1
  • Concomitant severe aortic or tricuspid valve disease 1

Mitral Regurgitation (MR)

Physical Examination

• Holosystolic murmur at apex radiating to axilla 1
• Hyperdynamic precordium and displaced apical impulse 1
• Third heart sound in severe cases 1

Natural History

• Primary (degenerative) MR: progressive with risk of LV dysfunction over time 1
• Secondary (functional) MR: prognosis tied to underlying ventricular disease 1

Management

• Primary MR:
  • Surgical repair preferred over replacement when feasible 1
  • Intervention indicated for:
    • Symptomatic severe MR 1
    • Asymptomatic severe MR with LV dysfunction (LVEF ≤60%) or LV dilation (LVESD ≥40mm) 1
    • Percutaneous edge-to-edge repair considered for high surgical risk patients 3
• Secondary MR:
  • Optimize treatment of underlying heart disease 1
  • Surgical intervention considered when severe MR persists despite optimal medical therapy 1
  • Combined MR and AS requires careful assessment as MR may improve after AVR in some patients 4, 5

Mitral Valve Prolapse (MVP)

Physical Examination

• Mid-systolic click followed by late systolic murmur 1
• Click-murmur complex varies with loading conditions 1

Natural History

• Most patients have benign course 1
• Risk factors for progression: severe MR, leaflet thickening, left atrial enlargement 1

Management

• Regular monitoring for asymptomatic patients with no significant MR 1
• Same intervention criteria as primary MR when significant regurgitation develops 1
• Endocarditis prophylaxis only for those with previous endocarditis or prosthetic material 1

Tricuspid Regurgitation (TR)

Physical Examination

• Holosystolic murmur at left lower sternal border that increases with inspiration 1
• Signs of right heart failure (jugular venous distension, hepatomegaly, peripheral edema) 1

Natural History

• Primary TR: poor prognosis if severe and untreated 1
• Secondary (functional) TR: may improve with treatment of underlying left-sided heart disease, but often persists 1
• Severe TR with concomitant left-sided valve disease associated with worse outcomes 6

Management

• Medical therapy:
  • Diuretics for symptom relief and management of congestion 1
  • Treatment of underlying conditions 1
• Surgical intervention indicated for:
  • Severe TR in patients undergoing left-sided valve surgery 1
  • Symptomatic severe primary TR without severe RV dysfunction 1
  • Asymptomatic or mildly symptomatic severe primary TR with progressive RV dilation or dysfunction 1
  • Moderate TR with dilated annulus (≥40mm) in patients undergoing left-sided valve surgery 1
• Conservative repair preferred over valve replacement when technically feasible 1
• Isolated TR surgery should be considered in patients with persistent severe TR after left-sided valve surgery who develop symptoms or progressive RV dysfunction 1

Multiple and Combined Valve Disease

Management Principles

• When either stenosis or regurgitation is predominant, follow recommendations for the predominant lesion 1
• For balanced mixed disease, base intervention decisions on symptoms and objective consequences rather than severity indices alone 1
• Consider interactions between valve lesions (e.g., MS may lead to underestimation of AS severity due to reduced flow) 1
• Intervention may be considered for non-severe multiple lesions that are symptomatic or causing ventricular dysfunction 1
• Decision for multiple valve intervention must account for increased surgical risk 1
• Patients with combined valve disease may develop symptoms earlier than those with isolated lesions 2