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CHAPTER 41: Valvular Heart Disease 343

as a hemodynamic monitoring tool in the trauma bay. J Trauma
Acute Care Surg. 2014;76(1):31-37; discussion 7-8. • Acute severe aortic and mitral regurgitation (flail segments sec-
ondary to trauma, aortic dissection, ruptured papillary muscle) are
• Ha JW, Oh JK, Schaff HV, et al. Impact of left ventricular func- surgical emergencies. Acute severe tricuspid regurgitation is usu-
tion on immediate and long-term outcomes after pericardi- ally better tolerated, but on occasion can lead to cardiogenic shock.
ectomy in constrictive pericarditis. J Thorac Cardiovasc Surg. • Severe symptomatic aortic stenosis is a surgical disease. Medical
2008;136(5):1136. treatment is temporizing or palliative.
• Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK. • Transcatheter aortic valve replacement (TAVR) or aortic balloon
Transient constrictive pericarditis: causes and natural history.
J Am Coll Cardiol. 2004;43(2):271-275. valvuloplasty should be considered in patients with severe AS and
decompensated heart failure.
• Hurrell DG, Nishimura RA, Higano ST, et al. Value of dynamic respi-
ratory changes in left and right ventricular pressures for the diagno- • Hemodynamically significant mitral stenosis should be treated by
mechanical intervention on the valve (percutaneous mitral balloon
sis of constrictive pericarditis. Circulation. 1996;93:2007-2013. valvuloplasty or surgery). Medical treatment is temporizing or
• Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition palliative.
to conventional therapy for acute pericarditis: results of the
Colchicine for acute Pericarditis (COPE) trial. Circulation. • Valvular regurgitation, perivalvular extension of infection, and
systemic embolization are important complications of infective
2005;112:2012-2016. endocarditis and should be actively sought on clinical examina-
• Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice tion, ECG, and echocardiography.
therapy for recurrent pericarditis: results of the CORE (Colchicine
for REcurrent pericarditis) Trial. Arch Intern Med. 2005;165: • Prosthetic valve thrombosis presents with thromboembolic events
or heart failure due to valve obstruction. Diagnosis is made by
1987-1991. echocardiography or fluoroscopy. Treatment depends on loca-
• Lotrionte M, Biondi-Zoccai G, Imazio M, et al. International col- tion (left- vs right-sided valves) and thrombus burden.
laborative systematic review of controlled clinical trials on phar-
macologic treatments for acute pericarditis and its recurrences. • Structural failure of a mechanical prosthesis is rare and requires urgent
reoperation. Failure of a bioprosthesis is frequent and progressive due
Am Heart J. 2010;160(4):662-670. to degeneration. Reoperation after stabilization is recommended.
• Nicol AJ, Navsaria PH, Hommes M, Ball CG, Edu S, Kahn D.
Sternotomy or drainage for a hemopericardium after penetrating
trauma: a randomized controlled trial. Ann Surg. 2014;259(3):
438-442.
• Sagrista-Sauleda J, Angel J, Sanchez A, Permanyer-Miralda G, INTRODUCTION
Soler-Soler J. Effusive-constrictive pericarditis. N Engl J Med.
2004;350:469-475. Valvular heart disease is one of the most common causes of heart
failure. The etiology varies, with degenerative valvular disease being
• Talreja DR, Nishimura RA, Oh JK, Holmes DR. Constrictive predominant in the Western world and rheumatic disease in developing
pericarditis in the modern era: novel criteria for diagnosis in the countries. Patients with critical illness and valvular disease can be sepa-
cardiac catheterization laboratory. J Am Coll Cardiol. 2008;51: rated in two broad categories: (a) patients in whom acute medical illness
315-319. precipitates heart failure on a background of compensated valvular heart
• Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographi- disease and (b) acute valvular lesions causing acute de novo cardiac
cally guided pericardiocentesis: evolution and state-of- the-art decompensation. These entities are quite different in presentation, diag-
technique. Mayo Clin Proc. 1998;73(7):647. nosis, and management. Indeed, decompensated heart failure in the first
category is a result of increased demand and/or tachycardia (arrhyth-
mias, pain, anemia, hypotension, hypoxemia, fever) on a background
of reduced cardiac reserve due to valvular disease; prompt treatment of
REFERENCES the primary cause together with appropriate cardiac and vascular sup-
port is the cornerstone of management. In the second category, it is the
Complete references available online at www.mhprofessional.com/hall acute valvular disease itself causing cardiovascular compromise. Medical
management is usually only temporizing; many of these patients repre-
sent true surgical emergencies.
Physical examination is the first step in the diagnosis of any cardiac
CHAPTER Valvular Heart Disease disease. This remains true in patients with acute illnesses and coexist-
ing significant valvular disease. Indeed, all patients with critical illness
41 Sorin V. Pislaru should have a detailed examination of the cardiovascular system to
ascertain the presence of valvular lesions. Presence of murmurs, gallops,
Maurice Enriquez-Sarano
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
KEY POINTS and symptoms of extreme dyspnea (reflecting acute pulmonary edema),
profound hypotension (cardiogenic shock), and angina (coronary
• Heart failure in patients with chronic valvular heart disease is usu- hypoperfusion).
ally precipitated by concurrent illness, progressive deterioration of The key diagnostic modality in patients with critical illness and valvu-
cardiac function, or worsening valvular disease. lar disease is echocardiography. The unique advantages of this imaging
• Acute onset of severe valvular regurgitation is uncommon. Clinical modality (available at bedside, immediate interpretation, comprehensive
and echocardiographic diagnosis is challenging. assessment of valvular lesions, and ventricular function) render echocar-
diography irreplaceable in modern ICU care. Due to its versatility and

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