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

Lesions of the heart valves are the commonest acquired cardiac abnormalities seen in pediatric age group. Aortic regurgitation (AR) results from abnormality of the valve leaflets or of the aortic root. Mitral valve lesion may be associated in patients with rheumatic heart disease (RHD). Left ventricle dilates and may develop dysfunction in advanced states. Coronary perfusion also tends to suffer in severe AR. The symptoms develop later and include dyspnea and palpitations. An early diastolic, high pitched murmur, best heard at base of the heart is the hallmark of AR. All symptomatic patients with severe AR and those with left ventricular dysfunction should undergo surgical intervention. Aortic stenosis (AS) is often due to congenitally bicuspid or unicuspid valve. RHD rarely results in AS; associated AR is common in such cases. The most common cause of tricuspid valve involvement is secondary to dilatation of right ventricle and tricuspid annulus resulting in tricuspid regurgitation (TR). Rarely RHD affects the tricuspid valve directly; resulting in stenosis with TR. Involvement of both mitral and aortic valves is almost pathognomonic of RHD etiology. Severity of individual lesions may be difficult to ascertain as proximal valve lesion tends to modify the assessment of the distal valve lesion. It is important to understand that all valvular lesions do not require surgery. Regular secondary prophylaxis with long acting penicillin (for patients with RHD) may retard further progression of valve lesion and must be emphasized to the family. For mild and asymptomatic moderate valvular lesions, periodic monitoring with clinical examination and echocardiography is sufficient. No guidelines are available for timing of intervention in such children; data may have to be extrapolated from published guidelines for adult patients. Various types of surgical options are available for regurgitant valves, but none is ideal. The pediatricians are required to have knowledge of valvular diseases so as to refer the patient at an appropriate time for intervention or further evaluation. His/ her role is also crucial in follow up of post operated patients, especially those on oral anticoagulation.