#10 Valvular Heart Disease Singh - arcard.orguserfiles/editor/docs/2018/Valvular Heart...

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Valvular Heart DiseaseB K Singh, MD, FACC

Disclosures: None

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S1S4S3

S2 S2=A2P2

S1=M1T1

CARDIAC CYCLE

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JVPCarotid

S1Slitting of S2

S3S4

Ejection clickOpening snap

Dynamic Auscultation

What is the most important part of the stethoscope?

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Pre Test – True or False?

Loud S1 is consistent with severe MRParadoxical splitting of S2 rules out severe ASDelayed carotid upstroke suggests severe ASMurmur of valvular aortic stenosis increases with ValsalvaMurmur of HCM and MVP increases on standingNormal peak velocity of blood flow across aortic valve is 5m/sec (Doppler Echo)Development of pressure gradient across the valve indicates stensis. Asymptomatic but severe aortic stenosis needs urgent surgery.Send patient with CP and new onset diastolic murmur to ER

Pre Test- True or False?

Asymptomatic but severe MR with LVEF 0.45, needs MV surgery.All symptomatic valvular disease needs intervention.Mild MR and Mild AS need echocardiogram every year.Cardiac catheterization is needed in all patients to confirm the severity of valvular stenosis or regurgitation. Endocarditis prophylaxis is needed in patient with MVP and moderate MR.Percutaneous Trans Catheter Aortic Valve Replacement (TAVR) is indicated in a patient who refuses to have surgical AVR.EF = Stroke Volume/End diastolic volume. 0.60 normal

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Valvular Heart Disease

• Etiology, Severity• Pathophysiology• Clinical Presentation• Testing: Echo/Doppler/Color Flow/Heart

Cath/EKG/X-ray• Natural History• Treatment

LVRV

LV

RA LA

LA

RA

Aortic Valve

Echocardiography

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LA

LVLV

LA

LV

LA

AO

Echocardiography

AO

LA

LV

LA

LV

AO

PW Doppler

CW Doppler

Echocardiography

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Critical Aortic StenosisCritical Aortic Stenosis

BernoulliEquationBernoulliEquation

PG = 4 V2PG = 4 V2

Catheterization vs DopplerCatheterization vs Doppler

max57

p-p 28

(55 mmHg)

Aortic StenosisAortic Stenosis

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Valvular Aortic Stenosis

• Age- related etiology

• <30: Congenital (Unicuspid, Bicuspid)

• 40-60: Calcified bicuspid

• 40-60: Rheumatic

• >70: Senile degenerative/ Calcific

• Most common cause

• Senile degenerative

Classification of Disease Severity

ACC/AHA Guidelines

SevereModerateMild

< 0.6Valve Areacm2/m2

< 1.01.0 – 1.5> 1.5Valve Areacm2

> 4025 – 40< 25Mean Gradientmm Hg

> 4.03.0 – 4.0< 3.0Jet Velocitym/sec

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Valvular Aortic Stenosis in Adults Average Course (Post Mortem Data)

Ross, Bruanwald:  Circulation 1968: 38 (Supp V)

SymptomsSymptoms

MeanGradient

Clinical examination

AorticValveArea= =

Correlating Symptoms & Severity

Correlating Symptoms & Severity

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Indications for AVR in Aortic Stenosis

• Symptomatic: Severe AS: irrespective of LVEF• Asymptomatic: Severe AS:• LVEF < 50• Abnormal Treadmill• Critical Aortic Stenosis• Moderate Aortic Stenosis: concomitant open heart surgery

like CABG, Aortic Aneurysm, Mitral Valve surgery• Low flow/low gradient/low aortic valve area: Dobutamine Echo• True critical AS with poor LVEF• Low LVEF with inability to open valve• SAVR vs TAVR

Bicuspid Aortic Valve

Screen first degree

relatives

Screen first degree

relatives

CoarctationDissectionAneurysm

Ascending AO 5 camsAscending AO 4.5 cms

Need surgery

CoarctationDissectionAneurysm

Ascending AO 5 camsAscending AO 4.5 cms

Need surgery

Scan entire aorta

(MRA or CTA)

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Aortic Regurgitation

• Acute vs Chronic : Recognize the difference in Murmur intensity and symptoms and signs

• Acute AR: Endocarditis/ Aortic Dissection

• Chronic AR: Valvular: Degenerative/ Bicuspid/RHD

• Aortic root Disease: Aneurysm/ Marfan

• Indications of AVR: Symptomatic & Severe AR

Asymptomatic & Severe

LVEF <50 %

LVESD>50 mm

Suboptimal Treadmill test

Severe ARWide pulse pressureColor DopplerRV 60mlRF 55%ERO 0.3 cm2Descending aorta flow reversal

Mitral Regurgitation

• Acute vs Chronic

• Acute MR: Ruptured Papillary Muscle, Chordal Rupture, Endocarditis, ischemic

• Chronic MR: MVP, ischemic, Rheumatic,Endocarditis, LV dilation

• Severe MR: ERO 0.4 cm2,

• Regurgitant He (>60ml)

• Regurgitant (>55%)

• Vena contracta, color jet area.

• Assess. LV size and contractility (EF 60%) and LVESD (40mm), pulmonary hypertension, Afib

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Valvular RegurgitationIndications for Operation

Presence of severe regurgitation

Presence of severe regurgitation

Any SymptomsAny Symptoms

Drop in EF(<60%MR, < 50%AR)

Drop in EF(<60%MR, < 50%AR)

LV Dilation. LVESD(>40mm MR, > 50 mm AR)

LV Dilation. LVESD(>40mm MR, > 50 mm AR)

OperateOperate

+

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Mitral Stenosis

• Etiology: Rheumatic, Calcific

• Signs & Symptoms• Echocardiogram: Gold Standard to assess

severity and valve and sub valvular pathology, MR• 220/Pressure half time, (Doppler)• Severe MS: Mean gradient > 10 mmHg, MV. Area

less than 1 cm2

• Balloon Mitral Valvotomy• MVR• Atrial Fib could be very detrimental

Prosthetic Valve Complications

• Structural failure• Endocarditis• Thromboembolism• Thrombosis• Perivalvular leak• Hemolysis• Prosthesis – patient mismatch

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Mechanical Valve

bileaflet Tilting disk

RossHomograft

Mechanical StentlessTissue

Gold Standard Treatment for ValvularDiseases had been Prosthetic Valves

Edwards SAPIEN

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60 Year-old Male St. Jude AVR

• No Hx thromboembolism, EF 60%• A) INR 2.5-3.5• B) INR 2.0-3.0• C) INR 2.5-3.5 + ASA 81mg• D) INR 2.0-3.0 + ASA 325mg• E) INR 2.0-3.0 + ASA 81mg

Mechanical Valves Target INR

INR 2.5 INR 3

AORTIC Other AVR ( Mechanical)

Bileaflet St jude Risk Factors

Medtronic - Hall ALL MITRAL

No risk factors

ASA is needed for all mechanical & biological valvesOn -X valve: INR 1.5-2

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• INR 2-3 INR 2.5-3.5

• INR 2.5-3.5 INR 3.5-4.5

• No ASA Add ASA

Prosthetic ValvesEmbolic Events at Target INR

Pre/Post ProcedureMechanical Valves

Bridging Anticoagulation

• No Heparin Heparin

• Bileaflet AVR (ST JUDE) Bjork Shiley Valve

• No Risk factors Any MVR or TVR

AVR - 1 risk factor

• Previous event off Warfarin

• Recent thromboembolism (1yr)

AFHx ThromboembolismHyper coagulableLV < 30

AFHx ThromboembolismHyper coagulableLV < 30

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Prosthetic Heart ValvesManagement of Anticoagulation

• Mechanical valves – all require warfarin• DO NOT USE DOACS (dabigatran etexilate,

apixaban, Xarelto, etc.• Bioprosthesis – warfarin for 3-6 months, then D/C

unless risk factors**

• AVR, no risk factors, first 3 months. Class iib – ASA only

AFHx ThromboembolismHyper coagulateLV < 30

AFHx ThromboembolismHyper coagulateLV < 30

Anticoagulation for Atrial Fibrillation in Patients with VHD (New Section)

Recommendations COR LOE

New: Anticoagulation with a VKA is indicated for patients with rheumatic mitral stenosis and AF I B-NR

New: Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or MR

I C-LD

New: It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater

IIa C-LD

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Infective Endocarditis Prophylaxis

Recommendations COR LOE

Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis

I C

Modified: Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:1. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.(con’t)

IIa C-LD

Infective Endocarditis Prophylaxis

Recommendations COR LOE

(con’t)3. Previous IE.4. Unrepaired cyanotic congenital heart disease or

repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve

IIa C-LD

Prophylaxis against IE is not recommended in patients with VHD at risk of IE for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection

III: No Benefit

B

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2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart

Disease(2014 guideline with 2017 focused update incorporated)

Developed in Collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions,

Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons

© American College of Cardiology Foundation and American Heart Association

Thank You