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KEY POINTS

KEY POINTS

  • Heart failure in patients with chronic valvular heart disease is usually precipitated by concurrent illness, progressive deterioration of cardiac function, worsening valvular disease, or occurrence of a complication (eg, atrial fibrillation).

  • Acute onset of severe valvular regurgitation is uncommon. Murmur may be absent 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.

  • All decompensated valve diseases are mechanical valvular dysfunctions that require mechanical correction (surgical or interventional). Medical treatment is temporizing or palliative.

  • Transcatheter valvular therapies can be highly effective and should be considered promptly, such as transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and decompensated heart failure.

  • 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.

INTRODUCTION

Valvular heart disease (VHD) is one of the most common causes of heart failure and, despite the progress in treatment, remains associated with considerable excess mortality.1 There are multiple VHD etiologies, dominated by degenerative and functional causes in the Western world,2,3 while rheumatic disease predominates in developing countries.4 Patients with critical illness and valvular disease can be separated into two broad categories: (1) patients in whom acute medical illness precipitates heart failure on a background of compensated VHD and (2) 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 cardiovascular support is the cornerstone of management. In the second category, acute valvular disease itself causes cardiovascular compromise. Medical management is usually only temporizing; many of these patients represent true surgical emergencies.

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, or signs of vascular congestion are important clues to concurrent valvular conditions. It is important to remember that patients with acute severe valvular disease may not have significant ...

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