**3.1 General principles**

*Advances in Complex Valvular Disease*

those industrially developed countries.

incidence of rheumatic fever had declined.

groups [20–22].

Structural biological valves deterioration would be the future burden on health resources world-wide; this is due to its current popularity as a therapeutic option even in young patients, mainly to avoid the complications of anticoagulation [11, 12]. Lack of equitable access to health care takes place in all countries, as a consequence of many complex economic and social forces. Because of the escalating technological cost of health care around the world, the situation is the same, even

The salient global errand is the prevention of rheumatic heart disease, which would necessitate cooperation among social, political, and medical programs that lead to creating enhancements in living conditions by better housing, nutrition and improved access to health care [13–16]. Penicillin for streptococcal throat infections and secondary prophylaxis would continue to be a cornerstone in the global fight against rheumatic heart disease [17–19]. It is also reported that there was a natural reduction in the virulence of streptococcal serotypes, but it happened after the

Most of the serum biomarkers that have been shown related to VHD are detecting secondary effects on the ventricular myocardium. Biomarkers associated with myocardial stress include the natriuretic peptides and GDF-15. Troponin is linked to myocardial necrosis, and the micro RNAs, ST2, and galectin-3 are associated with myocardial hypertrophy and fibrosis. Of these, the natriuretic peptides are the most widely studied, but they are not specific to VHD, and there is considerable overlap in serum levels between different clinical

The aortic valve is the last gate the blood pumped from the heart to the rest of the organs. It is at the junction between the aorta and the outflow tract of the left ventricle. Its function is to maintain unidirectional blood flow during the diastole while allowing the blood forward flow with minimal resistance during systole. The aortic valve has typically three semilunar cusps (tricuspid) named by their relationship to the coronary Ostia: the left coronary and right coronary, and the third is the noncoronary cusp. Cusps are attached to the aortic annulus at the bottom of slight dilations of the aorta associated with each cusp (sinuses of Valsalva end at the sinotubular junction). The sinotubular junction is the narrowest part of the aortic

**2. Practical anatomy and physiology of the aortic valve**

**18**

**Figure 1.**

*Aortic valve anatomy.*

Detection of valvular heart disorder can be difficult. The state of the patient may range in gravity from asymptomatic to cardiogenic shock. Endocarditis may mimic systemic illness, vascular or neurologic condition, while acute aortic incompetence may be presented as a primary respiratory disorder (acute asthmatic episode). Making a timely, accurate diagnosis, while averting excessive laboratory studies, may try the acumen of a seasoned clinician.

Commonly, observing a murmur in a well individual or a patient with symptom referable to the cardiovascular system, arouse the suspicion of valvular abnormality. It is essential to reassure the patients; murmur is not synonymous with heart disease. It does represent turbulent blood flow which may result from several possible conditions. These include: (i) increased flow secondary to anaemia, pregnancy, or a hyperadrenergic state; accelerated flow through a restricted orifice (ii) regurgitant flow through a leaking valve; or (iii) abnormal shunting between two chambers. In an unselected population, most systolic murmurs are physiologic, caused by conditions of increased blood flow [25, 26]. The echocardiogram is the best way to evaluate the patients and reassure them [27, 28].

The practical approach to these patients relies upon an open-minded history and thorough physical examination.

### **3.2 History**

As in nearly all of medicine, most cues to a diagnosis are from history.

The clinician assessment should not be compromised, trying to spare minutes at this stage drain hours in the wasted investigation later.

The patient may provide a history of rheumatic fever, pervious episode of infective endocarditis, intravenous drug use, use of anorectic medications, carcinoid tumours, indwelling vascular devices, dental, genitourinary or gastrointestinal procedures; Marfan's syndrome, syphilis; congenital bicuspid aortic valve; treated or untreated coronary artery disease, radiation therapy.

Finally, a history of past surgery increases the risk of future valve problems by way of prosthetic valve endocarditis or structural failure.

Family genetics undoubtedly plays a role in so doing; the clinician may identify a family with a previously unrecognised genetic mutation and allowed early diagnosis of relatives. The social history may provide valuable information. For example, a childhood spent in a no industrialised region of the world dramatically increases the risk of rheumatic valve disease. History of unprotected sex or intravenous drug abuse raises the TE.

Course for valvular heart disease varies widely, ranging from minutes to decades dependent on primary pathology and age and risk factors related to patients as well as the geographical location in the world.

### *3.2.1 Dyspnea*

Unfortunately, it is also very nonspecific, occurring in nearly any disturbance of cardiopulmonary function. Orthopnoea and paroxysmal nocturnal dyspnea are somewhat more specific for left ventricular failure.
