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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!