CHAPTER 20 



The dynamics and consequences of stenosis or 

 insufficiency of the cardiac valves 



LARS W'ERKO | GiJteborgs L'niversitet, Goteborg, Sweden 



CHAPTER CONTENTS 



Estimation of Valvular Stenosis 

 Estimation of Valvular Incompetence 



Hydraulic Formula 



Indicator Dilution Techniques 

 Atrial Pressure Pulse 



Left Atrium 



Pulmonary arterial wedge pressure 



Left atrial pressure in mitral valve disease 



Right Atrium 



Tricuspid stenosis 

 Tricuspid incompetence 

 Atrial Volume Changes 



Electrok^TTiography 



Angiocardiography 

 Left Heart Lesions 



Aortic Stenosis 



Aortic Incompetence 



Mitral Stenosis 



Mitral Incompetence 

 Right Heart Lesions 



Pulmonary Incompetence 



Pulmonary Stenosis 



Tricuspid Valvular DefoiTnities 

 Pulmonary Blood Vessels and Pulmonary Vascular Resistance 

 Regional and Peripheral Blood Flow 



ades, studies have been conducted in humans with 

 valvular lesions due to disease and added to those 

 made earlier in animals with experimental lesions. 

 The necessary technical advancement to make this 

 possible was, above all, the introduction of the tech- 

 nique of catheterization of the right and left heart 

 in man (i, 16-19, '65, 166, 169), and the develop- 

 ment of manometers, mechanical or electrical, with 

 characteristics that made them suitable for clinical 

 and pliysiologic studies. Increasing knowledge has 

 been collected regarding the influence of alterations 

 of valvular function on myocardial performance. As 

 studies have been made in intact indi\iduals with 

 long-standing lesions, it has also been possible to 

 register the effect of altered \al\ular function on the 

 circulation as a whole and on the function of .several 

 organs that are influenced by changes in blood flow 

 and blood pressure. The concept of the circulation in 

 diseases with valvular deformities has been broadened. 

 The new information thus collected has added to our 

 understanding of the basic physiologic disturbances 

 behind many well-known clinical syndromes. This has 

 also created sounder foundations for effective treat- 

 ment — surgical or medical — of \alvular di.seases. 



THE STUDY of valvular stenosis and regurgitation was 

 started at the end of the nineteenth century in circula- 

 tory models and later in Isolated heart preparations. 

 The methods used were of necessity crude and the in- 

 formation obtained uncertain. The development of 

 more exact manometers and their use in phvsiologic 

 research, especially by Wiggers and his collaborators 

 (68, 69, 73, no. III, 203, 204), signified a most 

 important progress. However, even in those skilled 

 hands the instruments did not always give answers 

 that have stood the test of time. During the last dec- 



ESTIM.ATION OF V.iiLVUL.AR STENOSIS 



Estimations have been made primarily from pres- 

 sure tracings. In the case of atrioventricular valves 

 these have been done either from the form of the 

 atrial pressure curve or from the simultaneouslv ob- 

 tained tracings from the ventricle and the atrium 

 (20-22, 26, 42, 80, 98, 108, 141, 142, 146, 148, 155, 

 '57' '65, 212, 213). In the case of stenosis of the semi- 

 lunar valves some information has been obtained from 



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