Valvular (1)

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Cases in Valvular Heart Disease

Casos clinicos de cardiopatia valvular

Howard Weitz, M.D.

February 2012

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Case 1

A 60 year old man underwent an aortic valve replacementas treatment of symptomatic aortic stenosis five years ago.A mechanical bileaflet aortic valve was implanted. He hasnormal left ventricular function and no history of atrial

fibrillation. He has been maintained on warfarinanticoagulation with his INR apprx 2.5. You have beennotified that as treatment of chronic cholecystitis he isscheduled to undergo laparoscopic cholecystectomy in 10days.

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Case 1

The surgeon requests your recommendations regarding themanagement of his anticoagulation prior to surgery. You suggest:

A. Perform the surgery while INR therapeutic.B. Discontinue warfarin 5 days prior to surgery and admit to hospital for

continuous heparin infusion. Discontinue heparin 8-12 hours beforesurgery.C. Discontinue warfarin 5 days prior to surgery and begin low molecular

weight heparin during the period of subtherapeutic INR.D. Discontinue warfarin 72 hours prior to procedure and restart warfarin

within 24 hours after the procedure.E. Discontinue warfarin 72 hours prior to procedure and start heparin

infusion12 hours after the procedure continuing until post procedurewarfarin is therapeutic

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Case 1

The surgeon requests your recommendations regarding themanagement of his anticoagulation prior to surgery. You suggest:

A. Perform the surgery while INR therapeutic.B. Discontinue warfarin 5 days prior to surgery and admit to hospital for

continuous heparin infusion. Discontinue heparin 8-12 hours beforesurgery.C. Discontinue warfarin 5 days prior to surgery and begin low molecular

weight heparin during the period of subtherapeutic INR.D. Discontinue warfarin 72 hours prior to procedure and restart warfarin

within 24 hours after the procedure.E. Discontinue warfarin 72 hours prior to procedure and start heparin

infusion 12 hours after the procedure continuing until post procedurewarfarin is therapeutic.

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Antithrombotic Therapy in Patients with MechanicalValves who Require Interruption of Warfarin Therapy

for Noncardiac Surgery

Continue antithrombotic therapy for procedures wherebleeding inconsequential:

Skin

Eye surgery

Dental

Cleaning

Caries

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Journal of the American Dental Association, November 2003

Review of clinical studies: anticoagulants and dental proceduresWarfarin and Low dose aspirin (100 mg/d)

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Journal of the American Dental Association, November 2003

Review of clinical studies: anticoagulants and dental proceduresWarfarin

Low dose aspirin (100 mg/d)

1

The weight of evidence in the dental literature does not

support the long-held belief that an oral anticoagulant regimenmust be altered or discontinued before most dental procedures,including oral surgery.

Currently the INR does not require alteration of the therapy

regimen unless the INR value is greater than 4.0, providedthat local hemostatic measures are used.

Articles that document oral surgery experiences of patientstaking aspirin alone or in combination with clopidogrel have notreported any cases of unusual intraoperative or postoperativebleeding problems. This experience is anecdotal.

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Low risk of valve thrombosis

Bileaflet aortic valveNormal LV functionSinus rhythm

Stop warfarin 48-72 hours before proceRestart warfarin within 24 hours after

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High risk of valve thrombosis:mitral valvetricuspid valve

Aortic valve ANDatrial fibrillationprior thromboembolismhypercoagulableolder generation valveLVEF < 30%a second mechanical valve

therapeutic unfractionated hepawhen INR < 2.0Restart as soon as possible

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LMWH

Usefulness / efficacy less well established by evidence / opinion

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How about LMWH for prosthetic valve?

ACCP 2008 Guideline

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ACCP 2008 GuidelineBridging anticoagulation and mechanical valve

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High Risk for thromboembolism

Mitral prosthesis

Older aortic prosthesisRecent TIA, stroke

Moderate Risk for thromboembol

Bileaflet aortic valve ANDatrial fibrillation

prior stroke, TIACHADS2 pts

Low Risk for thromboembolism

Bileaflet aortic valve

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Case 1: Prosthetic valve perioperative anticoag

In patients at Low Risk of valve thrombosis (egbileaflet aortic valve and no risk factors ((atrial fibrillation,

previous thromboembolism, left ventricular dysfunction, hypercoagulableconditions, older generation prosthetic valves, mechanical mitral valve,

or more than one mechanical valve)), it is recommended thatwarfarin be stopped 48-72 hours before surgery

and resumed within 24 hours following surgery.

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Case 2

A 40 year old man has recently moved to your city and you are seeinghim for initial internal medicine evaluation.

Hx: Heart murmur since childhood. He was told that it was due to anabnormal heart valve.

Hx: Leads active life, exercises. No symptoms

No medications.

Pe: BP 130/55. HR 60

II/VI crescendo - decrescendo systolic murmur heard in aortic areapeaking in mid-systole. Radiates to carotid arteries

II/VI diastolic descrescendo diastolic blowing murmur heard in aortic arearadiating to left sternal border

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Case 2

Echocardiogram

Normal left ventricular systolic function

Bicuspid aortic valve

valve area 1.2 cm2, mean aortic valve gradient 28 mm Hg

Mild aortic regurgitation Normal mitral and tricuspid valves

Aortic root dilated 5.1 cm (normal < 4.0 cm)

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Case 2

Upon review of the echocardiogramyou recommend:

A. Repeat echo in 6 months

B. Repeat echo in 1 year

C. Initiate beta blocker therapy

D. Aortic root replacement

E. Aortic root replacement and aortic valve replacement

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Case 2

Upon review of the echocardiogramyou recommend:A. Repeat echo in 6 months

B. Repeat echo in 1 year

C. Initiate beta blocker therapyD. Aortic root replacement

E. Aortic root replacement and aortic valve replacement

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Case 2

Echocardiogram

Normal left ventricular systolic function


valve area 1.2 cm2, mean aortic valve gradient 28 mm Hg

Mild aortic regurgitation Normal mitral and tricuspid valves

Aortic root dilated 5.1 cm (normal up to 4.0 cm)

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Classification of Aortic Stenosis

Mild Valve area > 1.5 cm2

Mean aortic valve gradient < 25 mm Hg

or Jet velocity < 3.0 m/s

Moderate Valve area 1.0 1.5 cm2

Mean aortic valve gradient 25-40 mm Hg

Or Jet velocity 3.0 4.0 m/s

Severe Valve area < 1.0 cm2

Mean aortic valve gradient > 40 mm Hg Jet velocity > 4.0 m/s

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Our patient


Moderate aortic stenosis

Mild aortic regurgitation

Dilated aortic root

Normal left ventricle

No symptoms

Healthy

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Case 2

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Case 2

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From: Tadros T., et l.: Circulation 2009;119;880-890

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Bicuspid aortic valve Ascending Aorta

From: Fedak P, Verma S, David T., et al.: Circulation 2002;106;900-904

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Bicuspid Aortic Valve

Most common congenital heart lesion 1-2% of population Males 4:1 Family clusters. Echo screening of first degree relatives

Majority will require intervention (surgery)

Consequences Aortic stenosis Aortic regurgitation Disease of the aorta (dilatation, dissection)

More rapid than in idiopathic aortic dilatation

No evidence that Beta blocker prevents progression of aortic

dilatation

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When is BAV Surgery Indicated ?

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Ascending aorta replacement

Aortic valve replacement

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Aortic valve replacement

Approach to the patient with BAV severe AS or AR

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Approach to the patient with BAV severe AS or ARwho is undergoing valve replacement

Approach to the patient with BAV severe AS or AR

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Approach to the patient with BAV severe AS or ARwho is undergoing valve replacement

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Case 2 Bicuspid aortic valve

Surgery to repair or replace the ascending aorta in a patientwith bicuspid aortic valve is indicated when the ascendingaortic diameter is > 5.0 cm Bicuspid aortic valve disease is often accompanied by disruption of

aortic media (elastin, collagen, smooth muscle) and may involve:

Aortic valve Aortic annulus

Sinus of valsalva

Ascending aorta

Pulminary trunk

Coronary ostia

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Case 2: Bicuspid Aortic Valve Disease

Bicuspid aortic valve disease is often accompanied bydisruption of aortic media (elastin, collagen, smooth muscle)and may involve:

Aortic valve

Aortic annulus Sinus of valsalva

Ascending aorta

Pulminary trunk

Coronary ostia

Aortic dilatation may result in aortic dissection

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Case 3

You recommend

Answer D. Refer for mitral valve

repair.

He has symptomatic severe MR. Valve

repair is the desired approach.

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From: Otto, C.: New England Journal of Medicine 345:740-746. 2001

Ch i S Mi l R i i

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Chronic Severe Mitral Regurgitation

From Otto, C. New England Journal of Medicine, 345:740-746, 2001

Ch i S Mit l R it ti

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Chronic Severe Mitral Regurgitation

From Otto, C. New England Journal of Medicine, 345:740-746, 2001

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Mitral Regurgitation - Surgical Rx.

Valve repair when possible. Lower operative mortality

Better late outcomes

Better preservation of LV function.

Lower likelihood of long term anticoagulation 7-10% reoperation at 10 years (similar reop rate

following MV Replacement)

If valve replacement necessary, preservechordal apparatus. Better post op LV function.

Mitral valve repair (from Otto, C., Heart 83:2003)

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Case 3 Mitral regurgitation

In the patient with severe mitral regurgitation andnormal left ventricular function, ejection fraction

should be higher than normal.

The treatment of symptomatic severe mitralregurgitation is surgery even if left ventricularfunction is normal and as long as the left ventricularejection fraction is > 30%.

Mitral valve repair is preferred over mitral valvereplacement.

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Case 4

Answer A. AVR

He has severe aortic insufficiency and impairedleft ventricular function (LVEF < 50%)

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Chronic Aortic Regurgitation

Chronic AI Increased stroke volume isejected into aorta - systemic hypertensionand increased afterload.

Chronic Aortic Regurgitation - Medical Rx

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Chronic Aortic Regurgitation Medical Rx

Vasodilator therapy (improve stroke vol., reduceregurgitant volume, does NOT decrease mortality)

Three uses of vasodilators in chronic severe AR Rx when patient inoperable

Short term improvement in hemodynamics while awaitingAVR

Prolongation of the asymptomatic phasein pts with normalsystolic fxn.

Only 2 studies (nifedipine; ACEI)

Mixed results

2006 Guideline witholds recommendation

No data to support empiric use of diuretic,verapamil,ACE-I.

Ch i S A i R i i

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Chronic Severe Aortic RegurgitationIndications for Valve Replacement

Symptomatic

Unoperated mortality > 10%/yr

Asymptomatic with:

Decreasing LV function (LVEF < 50%) Unoperated progression to symptoms > 25%/yr

Increasing LV size (LV end systolic dimension > 55mm)

Note: normal LV end systolic dimension < 45mm

Case 4: Aortic regurgitation

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Case 4: Aortic regurgitationIndications for Valve Replacement Severe AR (June 2006)

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Case 5

An 80 year old man presents for evaluation of fatigue.

Known severe aortic stenosis (no angina, syncope, chf)

No prior history of abnormal bleeding, or clotting disorder.

Bp 120/70 HR 90 sinus

III/VI mid peaking crescendo-decrescendo murmur of aorticstenosis heard in aortic area and radiating to carotids andprecordium

Stool heme positive

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Case 5

Echo: Severe aortic stenosis, normal left ventricular function

No change from echo of one year ago

Hbg 7.5 (was 14.0 six months ago), microcytic hypochromic

Colonoscopy

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Colonoscopy

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Case 5

Which of the following, in addition to the finding noted atcolonoscopy, best explains the cause of his anemia?

A. Acquired disorder impairing platelet adhesion

B. Inherited disorder impairing platelet adhesion

C. Acquired disorder of thrombin generation

D. Inherited disorder of thrombin generation

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Case 5

Which of the following, in addition to the finding noted atcolonoscopy best explains the cause of his anemia?

A. Acquired disorder impairing platelet adhesion

B. Inherited disorder impairing platelet adhesionC. Acquired disorder of thrombin generation

D. Inherited disorder of thrombin generation

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N Engl J Med 1958;259:196

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Von Willebrand Factor

Gigantic multimeric protein

Mediates adhesion of platelets to sites of vascular damage

Large multimers cleaved by plasma metalloprotease underconditions of high shear stress

Absence of large multimers of vWF cause bleeding fromgastrointestinal angiodysplasia

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From Warkentin TE, Moore JC, Anand SS, et al.: Gastrointestinal bleeding, anngiodysplasia, cardiovasculardisease and acquired von Willebrand syndrome. Transfus Med Rev 2003; 17:272-86.

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From Vincentilli A, Susen S, Le Tourneau T, et al.: Acquired von Willebrand syndrome in aortic stenosis.N Engl j Med 2003;349:343-9.

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Case 5: Aortic stenosis and GI bleed

Gastrointestinal bleeding in the setting of criticalaortic stenosis is often a result of gastrointestinalangiodysplasia and a relative decrease in

functioning von Willebrands factor (vWF) caused by

shear dependant vWF proteolysis. Aortic valvereplacement often results in recovery of active highmolecular weight multimers of vWF and cessationof bleeding.

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