Guidelines and Cases - Valvular Disease -...

Guidelines and Cases -Valvular Disease

Dr Andrew Ludman

Consultant Cardiologist

Royal Devon & Exeter NHS Foundation Trust

Aims • Brief overview of valvular heart disease in the EEGC

• Valve disease – overview and aetiology

• Common valve lesions o Natural history

o Assessment

o Triggers for intervention

o Surveillance

o Prosthetic valves

• Aortic disease (1 slide)

• Endocarditis o Main bugs

o Diagnosis

o Triggers for intervention

o Antibiotic prophylaxis

The European Exam in General

Cardiology (EEGC or KBA) • 120 questions in 3 hours

• Clinical stem followed by ‘best of five’ answer

• Valvular and Myocardial Disease will comprise approximately 20% of the questions

• Non-invasive investigation will comprise approximately 14% of the questions

• Other ‘General Cardiology ‘will compromise approximately 20% of the questions

• Likely to be crossover between topics

The EEGC • No more than an assessment of adequate core cardiology

knowledge.

• Part of the assessment strategy for higher specialist trainees in

cardiology.

• Not an exit exam and not an assessment of overall competence.

• No negative marking. The pass-mark is criterion referenced and usually around 60% correct answers.

• The pass-rate is usually between 85-95% of candidates.

• Passmark for my exam was 61% (or 72 questions correct) 2012.

The EEGC - revision • ESC guidelines

• 2014 – Aortic disease o European Heart Journal (2014) 35:2873-2926; doi:10.1093/eurheartj/ehu281

• 2012 – Valvular heart disease o European Heart Journal (2012) 33, 2451–2496; doi:10.1093/eurheartj/ehs109

• 2009 – Endocarditis o European Heart Journal (2009) 30, 2369–2413;doi:10.1093/eurheartj/ehp285

• NICE guideline CG 64 - Prophylaxis against infective endocarditis (2008) o Currently under review

Valvular heart disease

Sample question • A 52-year-old man attended the out-patient clinic for review having been lost to follow-

up for several years. He had a past history of aortic valve endocarditis 10 years earlier

which had been successfully treated with antibiotics. He was asymptomatic but his

family doctor had noted a murmur on routine examination.

• On examination his pulse was 60 beats per minute and his blood pressure was 155/70

mmHg. Auscultation revealed systolic and diastolic murmurs at the left sternal border.

There was no clinical evidence of heart failure.

• An echocardiogram revealed a left ventricular end-systolic dimension of 55mm, an end-

diastolic dimension of 65mm, a left ventricular ejection fraction of 53% and an aortic root

dimension of 46mm. The aortic valve was bicuspid with moderate regurgitation and a

peak trans-valvular pressure gradient of 30 mmHg.

• What is the most appropriate treatment at this stage?

• A aortic valve and root replacement

• B aortic valve replacement

• C bisoprolol

• D no intervention required

• E ramipril

Sample question • A 52-year-old man attended the out-patient clinic for review having been lost to follow-

up for several years. He had a past history of aortic valve endocarditis 10 years earlier

which had been successfully treated with antibiotics. He was asymptomatic but his

family doctor had noted a murmur on routine examination.

• On examination his pulse was 60 beats per minute and his blood pressure was 155/70

mmHg. Auscultation revealed systolic and diastolic murmurs at the left sternal border.

There was no clinical evidence of heart failure.

• An echocardiogram revealed a left ventricular end-systolic dimension of 55mm, an

end-diastolic dimension of 65mm, a left ventricular ejection fraction of 53% and an

aortic root dimension of 46mm. The aortic valve was bicuspid with moderate

regurgitation and a peak trans-valvular pressure gradient of 30 mmHg.

• What is the most appropriate treatment at this stage?

• A aortic valve and root replacement

• B aortic valve replacement

• C bisoprolol

• D no intervention required

• E ramipril

General Principles • Careful history and

examination (as always!)

• Symptoms are key

• Does the imaging fit the

symptoms (and vice

versa)

• ‘The Heart Team’ is now

expected to be involved

in decision making for

any challenging cases

Investigation • Echocardiography is the main investigation of

choice – TTE & TOE o Relatively cheap

o Safe

o Portable

o Well established and widely available

• But o Only as good as the operator/reporter

o TTE reliant on acoustic windows

o Accuracy of quantitative parameters sometimes limited

• E.g Assumptions in PISA calculation or LVOT dimensions

CMR is very good at structure, flow and volume

Don’t forget CT

Aortic stenosis • Predominantly due to calcific degeneration

• Progression is variable but roughly 0.1-0.2cm2/yr

• Asymptomatic severe AS will need reassessment every 6-12 months

• Mild to moderate AS will need repeat echo 1-2 yearly

• Once symptomatic, prognosis is poor with ~50% mortality at 5 years

• Valve replacement is most common treatment

• Balloon valvuloplasty o Does not generally change the natural history of the disease in isolation

o Increasing in frequency following TAVI development

• Transcatheter aortic valve implantation o For select high risk patients

o Higher risk of stroke than conventional surgery (1-5%)

o 1 year mortality remains ~20%+

o MDT ‘Heart Team’ decision making

Mitral stenosis • Predominantly post rheumatic

• Valve area >1.5cm2 rarely has clinical consequence

• Progression in severity is highly variable

• Asymptomatic patients have good 10 yr survival

• Once symptomatic, prognosis is poor (10 yr survival

30-40%)

• Valve replacement most common

• Percutaneous mitral commissurotomy may be used o Generally younger patients

o No more than mild MR

o Need favourable morphology (Wilkins or Cormier scores)

Aortic regurgitation

• Acute severe AR has a poor prognosis with

haemodynamic instability and so urgent surgery

should be planned

• Once symptomatic with chronic severe AR,

mortality is 10-20%/year without surgery

• Valve replacement is most common

• Mild to moderate AR – echo every 2 years

• Severe AR with no symptoms and normal LV

function – repeat echo 6 months

• In Marfans or bicuspid valve patients with dilated

aorta need imaging annually – consider CT/CMR

Mitral regurgitation

• Acute severe MR has a poor prognosis if not treated

surgically

• Chronic severe MR without symptoms has a 5yr

cardiac cause mortality of ~14%.

• Symptoms are primary driver of surgery

• Valve repair is preferred where possible

• Asymptomatic patients with severe MR not meeting

criteria for surgery need close follow up for

symptoms or LV dysfunction/dilatation (?6mths)

• Asymptomatic patients with moderate MR – echo 2

yearly

Prosthetic valves

Aortic disease

Endocarditis

Prophylaxis against endocarditis • British Society for

Antimicrobial Chemotherapy 2006 o Prophylaxis for high risk

only

• NICE guidelines 2008 o Antibiotic prophylaxis no

longer routinely recommended

o Emphasise importance of maintaining oral health

o Educate about symptoms of endocarditis

o Explain risks of non-medical invasive procedures

NICE guideline No 64. 2008. www.nice.org.uk/CG064

Conclusion • Don’t panic but do some work

• Almost everybody passes

• Learn the key triggers for intervention in each valve

lesion

• Work fairly quickly- there’s a lot to get through.

GOOD LUCK!