Exercise Management
Valvular Heart Disease (VHD)
Chapter 9
Exercise Management
Pathophysiology
•The primary causes for disease of the heart valves include
rheumatic fever (resulting in rheumatic heart disease
[RHD]), valves with congenital abnormalities, infection, and
aging.
•Limiting Factors:
– heart valve(s) involved (i.e., mitral, aortic, tricuspid,
and/or pulmonary); condition of the valve (e.g.,
narrowing, or stenosis;
–or not closing properly, regurgitation or insufficient
–severity of the valve lesions; and
–presence of coronary artery disease, myocardial
dysfunction
Exercise Management
Overview of Heart Valves
Exercise Management
Overview of Heart Dynamic Flow
Exercise Management
Pathophysiology
Conditions –
–Mitral Stenosis
–Mitral Regurgitation
–Mitral Valve Prolapse
–Aortic Stenosis
–Aortic Regurgitation
–Tricuspid Stenosis
–Tricuspid Regurgitation
–Pulmonic Stenosis
–Pulmonic Regurgitation
Exercise Management
Mitral Stenosis
–blood flow is obstructed across the mitral heart valve
–emptying of the left atrium is impeded
–resistance is increased across the mitral valve, which
decreases ventricular filling.
–decreased ventricular filling causes a decreased left
ventricular stroke volume and cardiac output.
–there is an elevation of the left atrial pressure, which
may result in pulmonary hypertension.
–When the left atrium becomes chronically overloaded,
the atrial conduction fibers are stretched promote atrial
fibrillation (thus an increased risk of atrial thrombus formation)
Exercise Management
Mitral Stenosis (MS)
•predominant cause of MS is rheumatic fever
•rheumatic MS includes thickening and shortening
of the chordae tendineae, calcification of the valve
leaflets, and fusion of the commissures (the borders
where the leaflets meet).
•Patients may present:
•Dyspnea
•Hemoptysis
•CP (angina)
•Infective endocarditis
•Echo (transesophageal [ TEE ] ) is helpful in the
diagnosis
Exercise Management
Mitral Regurgitation (MR)
Mitral regurgitation (MR) occurs when the
leaflets of the mitral valve do not close
properly.
Annular Dilation is the most common cause of
MR, complicated with congestive heart failure
•Other factors involved:
•congenital abnormalities,
•mitral valve prolapse,
•chordae tendineae rupture
Exercise Management
Symptoms of MR
Depend on the severity and the rate of development of the
MR.
• mild MR produces no symptoms.
• moderately severe MR can lead to increased left atrial and left
ventricular volumes. This can manifest itself to pulmonary venous
congestion, elevation of pulmonary artery pressures, and dyspnea.
Echocardiography (TEE) helps to determine whether or not
left ventricular dysfunction or pulmonary hypertension has
developed. Angiography can also be used for determining
the severity of MR.
Patients with MR need to be monitored for symptoms of
ventricular dysfunction, dilation, or pulmonary hypertension.
Exercise Management
Mitral Valve Prolapse
Mitral valve prolapse (MVP) is a bowing of the
mitral valve leaflets into the left atrium during
ventricular systole. It is the most prevalent form of
VHD.
Symptoms
•is most often asymptomatic.
•physical examination may identify MVP by the presence of
a mid-systolic "click" and/or
murmur.
•Can be confirmed with echocardiography 3-D
echocardiography is now possible
Exercise Management
Aortic Stenosis
Aortic stenosis (AS) is a narrowing of the aortic
valve leaflets. It is commonly caused by gradual
fibrosis and calcification of the aortic valve, thus the
valve cannot open or close properly.
•AS is accompanied by dyspnea, angina, and / or
syncope, or combinations of the above. As AS
progresses ventricular hypertrophy and dysfunction
ensue. There is an increased risk of myocaridal
ischemia, reduced Cardiac Output and poor
coronary perfusion
•Echocardiography can help to determine the severity of
AS.
Exercise Management
•People with symptomatic/progressed AS
are not candidates for exercise programs.
The danger of sudden death is present,
particularly during exercise.
•Clients with mild or moderate AS may have
a normal exercise capacity. Exertional
hemodynamics must be assessed
•Angina, dyspnea, and fatigue are common
symptoms with exercise.
Exercise Management
Aortic Regurgitation
Aortic regurgitation (AR) occurs when the leaflets
of the aortic valve do not close properly.
•Valvular disease may develop in the setting of
RHD, infective endocarditis, trauma, congenital
lesions, or connective tissue-related diseases (ex.
Marfan’s Syndrome)
•Long- standing hypertension (HTN) or aging can
cause dilation of the aortic root, resulting in mild
AR.
Exercise Management
Aortic Regurgitation
• Mild AR may be tolerated with only mild dypsnea
•Progressed AR presents fatigue, dypsnea,
arrhythmias, and angina
•Strenuous exercise (e.g., isometric
exercises) should be avoided in AR if
weakening of the aortic wall is present.
•People with mild to moderate AR can
pursue normal exercise activities.
Exercise Management
Tricuspid Stenosis
Tricuspid stenosis (TS) is a rare condition
resulting from narrowing of the tricuspid
valve. It is almost always secondary to RHD.
Symptoms:
•Fatigue and lower extremity edema
•Distended neck veins
•Echo preferred for diagnosis
•Often people with TS are not candidates for
testing or rehabilitation until after valve surgery.
Exercise Management
Tricuspid Regurgitation
Tricuspid regurgitation (TR) occurs when the
leaflets of the tricuspid valve do not close properly.
TR is often caused by dilation of the right ventricle
and tricuspid annulus.
Signs / Symptoms
•If pulmonary arterial pressure is elevated, fatigue, dilated
neck veins, and peripheral edema develop.
•Echo effective in accurate diagnosis of severity of TR
Exercise Management
Pulmonic Stenosis
Pulmonic stenosis (PS) is a narrowing or tightening
of the pulmonary valve. It is most often congenital,
or RHD.
Signs / Symptoms
•Usually asymptomatic
•People with PS may present with:
–heart failure,
–exertional dyspnea
–syncope,
–or chest pain (caused by the inability to increase pulmonary
blood flow during exercise)
Exercise Management
Pulmonic Regurgitation
Pulmonic regurgitation (PR) occurs when the
leaflets of the pulmonary valve do not close
properly. Caused by Pulmonary Hypertension.
PR itself does not present symptoms, the
underlying pulmonary hypertension does.
Pulmonary HTN can include symptoms of fatigue,
pre-syncope, and dypsnea.
Exercise Management
Effects on the Exercise Response
Mild VHD usually present few restrictions to exercise,
problems arise as the severity of the disease
progresses
(see pg. 87-88 for the following):
•Mitral Stenosis
•Mitral Regurgitation
•Aortic Stenosis
•Aortic Regurgitation
Exercise Management
Effects of Exercise Training
•The mechanical function of a valve will not
improve with exercise. However, the working
capacity of the skeletal muscles can be improved.
•Significant mitral stenosis may cause limitation to
exercise because demands of the exercising
muscle may be greater than the cardiac output
available.
•People with severe aortic stenosis should avoid
vigorous physical activity because there is an
increased risk of syncope or sudden death.
Exercise Management
Recommendations for Exercise Testing
(see Table 11.1, p.89)
A cardiac examination should be performed prior to
exercise testing to rule out AS and determine if exercise
testing is contraindicated.
•Severe AS is an absolute contraindication to exercise.
•Severe TS, TR, and PS are also contraindications to
exercise. Indications for terminating exercise testing
include:
– ECG changes (>2 mm ST-segment depression or elevation,
– T-wave inversion with significant ST change, and serious
dysrhythmias.
– Abnormal changes in blood pressure (SBP > 250 mmHg or DBP >
115 mmHg).
Exercise Management
Recommendations for Exercise Programming
•Before an exercise program begins, the upper training rate
and description of any symptoms should be documented
from a diagnostic exercise test.
•The severity of the stenosis must be established
•Patients with significant PS or severe AS should refrain
from weight training
•For patients who are unable to undergo surgery of the
heart valves, the primary goal is to improve the working
capacity of the skeletal muscles.
Exercise Management
•Dynamic low-moderate intensity
physical activity in individuals with mild
VHD.
•See special considerations for (p. 89):
•Mitral Stenosis
•Mitral Regurgitation
•Aortic Stenosis
•Aortic Regurgitation
Exercise Management
End of Presentation