Evaluation of Acquired Valvular Heart Disease by the Pediatrician: When to Follow, When to Refer for Intervention? Part I.

Lesions of the heart valves are the commonest acquired cardiac abnormalities seen in pediatric age group. In India, the underlying cause for most valvular diseases is chronic rheumatic heart disease (RHD). The aim of evaluation of patients with valvular heart disease is not only to make a diagnosis, but also to decide the management plan. The pediatrician or physician is usually the first health care provider to whom such patients (or their parents) report. It is therefore imperative that the general physician and pediatricians are well versed with valvular heart diseases. Valvular abnormalities produce characteristic murmurs and a bedside diagnosis is possible in majority. However, further investigations such as X ray of the chest and an ECG are useful tools to refine the diagnosis. Echocardiography is now widely available to most of the patients in India and is very useful for assessing the severity of valve lesion and to identify the underlying etiology. Serial echocardiography is instrumental in deciding the timing of intervention. Mitral valve is most commonly affected followed by aortic; in some patients both valves may be affected. The valve may not close properly, resulting in regurgitation of blood flow in reverse direction or does not open fully (stenosis). In mitral regurgitation (MR), the blood flows in the reverse direction. MR can occur secondary to several causes, but in India, the commonest cause is RHD. Patient may remain asymptpmatic for a long period of time. Symptoms include fatigue, palpitations and later exertional breathlessness. MR typically produces a pansystolic murmur at apex, which may radiate to left axilla. Surgical intervention is reserved for all symptomatic patients with severe MR. Valve repair is preferred over prosthetic valve replacement. Mitral stenosis (MS) is almost always due to RHD. Severe MS results in pulmonary hypertension, right ventricular failure and tricuspid regurgitation. Patients are often symptomatic with dyspnea. Hemoptysis may occur. A typical rumbling mid diastolic murmur is the hallmark of MS. Balloon mitral valvotomy, performed in the catheterization lab, is recommended for severe MS.