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KEY POINTS

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  • Heart failure in patients with chronic valvular heart disease is usually precipitated by concurrent illness, progressive deterioration of cardiac function, or worsening valvular disease.

  • Acute onset of severe valvular regurgitation is uncommon. Clinical and echocardiographic diagnosis is challenging.

  • Acute severe aortic and mitral regurgitation (flail segments secondary to trauma, aortic dissection, ruptured papillary muscle) are surgical emergencies. Acute severe tricuspid regurgitation is usually better tolerated, but on occasion can lead to cardiogenic shock.

  • Severe symptomatic aortic stenosis is a surgical disease. Medical treatment is temporizing or palliative.

  • Transcatheter aortic valve replacement (TAVR) or aortic balloon valvuloplasty should be considered in patients with severe AS and decompensated heart failure.

  • Hemodynamically significant mitral stenosis should be treated by mechanical intervention on the valve (percutaneous mitral balloon valvuloplasty or surgery). Medical treatment is temporizing or palliative.

  • Valvular regurgitation, perivalvular extension of infection, and systemic embolization are important complications of infective endocarditis and should be actively sought on clinical examination, ECG, and echocardiography.

  • Prosthetic valve thrombosis presents with thromboembolic events or heart failure due to valve obstruction. Diagnosis is made by echocardiography or fluoroscopy. Treatment depends on location (left- vs right-sided valves) and thrombus burden.

  • Structural failure of a mechanical prosthesis is rare and requires urgent reoperation. Failure of a bioprosthesis is frequent and progressive due to degeneration. Reoperation after stabilization is recommended.

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INTRODUCTION

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Valvular heart disease is one of the most common causes of heart failure. The etiology varies, with degenerative valvular disease being predominant in the Western world and rheumatic disease in developing countries. Patients with critical illness and valvular disease can be separated in two broad categories: (a) patients in whom acute medical illness precipitates heart failure on a background of compensated valvular heart disease and (b) acute valvular lesions causing acute de novo cardiac decompensation. These entities are quite different in presentation, diagnosis, and management. Indeed, decompensated heart failure in the first category is a result of increased demand and/or tachycardia (arrhythmias, pain, anemia, hypotension, hypoxemia, fever) on a background of reduced cardiac reserve due to valvular disease; prompt treatment of the primary cause together with appropriate cardiac and vascular support is the cornerstone of management. In the second category, it is the acute valvular disease itself causing cardiovascular compromise. Medical management is usually only temporizing; many of these patients represent true surgical emergencies.

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Physical examination is the first step in the diagnosis of any cardiac disease. This remains true in patients with acute illnesses and coexisting significant valvular disease. Indeed, all patients with critical illness should have a detailed examination of the cardiovascular system to ascertain the presence of valvular lesions. Presence of murmurs, gallops, and/or signs of vascular congestion are important clues to concurrent valvular conditions. It is important to remember that patients with acute severe valvular disease rarely have significant cardiac findings, with substantial discrepancy between quasi-silent cardiac examination and symptoms of extreme dyspnea (reflecting acute pulmonary edema), ...

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