VALVE

REPLACEMENT

THERAPY IN

HEART

DISEASE IN

ADULTSSubhasish Deb

Burdwan Medical College

Department of General Medicine

SUBHASISH DEB, BMCH

ACC/AHAVALVULAR HEART DISEASE

GUIDELINES 2014

Rick A.Nishimura,M.D.,FACC

Catherine M.Otto,MD.,FACC

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

BASICS OF

ECHOCARDIOGRAPHY

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

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AORTIC STENOSIS

SUBHASISH DEB, BMCH

STAGES OF VALVULAR AS

Each of these stages are defined by:

1. Valve anatomy

2. Valve hemodynamics

3. The consequences of valve obstruction

on LT ventricle and vasculature

4. Patient symptoms

SUBHASISH DEB, BMCH

Hemodynamic severity is

best characterized by the

TRANSAORTIC MAXIMUM VELOCITY

Or

MEAN PRESSURE GRADIENT

SUBHASISH DEB, BMCH

Transortic maximum

velocity

By continuous wave

doppler• When flow stream

approaches a narrowed

orifice kinetic energy inc

and potential energy dec

• Distal to narrowed orifice,

pressure is lost due to the

dissipation of kinetic

energy as heat.

• This creates a Pressure

gradient across the valve

orifice.

Mean pressure gradient

= 4(V)2

SUBHASISH DEB, BMCH

STAGING OF AS

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SUBHASISH DEB, BMCH

AVAi – Aortic Valve Area Index:

Valve area should be indexed for body

surface area in smaller individuals so as to

not overestimate the severity of stenosis

based on valve area calculations.

SUBHASISH DEB, BMCH

SPECIAL SUB GROUPS

Some pts with AS have a low transaortic

volume flow rate due to either:

LV systolic dysfunction with a low LVEF

or

Small hypertrophied LV with low stroke

volume

Designated as

D2 (with low LVEF)

D3 (with normal LVEF)

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

NATURAL H/O OF AS WITH

SYMPTOMS

Survival in AS declines abruptly with onset of symptoms.

50% with onset of agina - die in 5yrs

50% with onset of syncope - die in 3 yrs

50% with onset of CHF – die in 2 yrs

Circulation. 1968;38[suppl V]:V-61

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

The exact pathophysilogic

changes that produce the onset of

symptoms and begin this

rapid downhill course are

unknown

SUBHASISH DEB, BMCH

INDICATIONS FOR TIMING OF

INTERVNTION

CLASS I :

1. AVR recommended in severe AS with

symptoms (D1)

Dec systolic opening of calcified valve AND

A Vmax >= 4m/s or MPG >= 40mm hg AND

Symptoms

2. AVR recommended in asymptomatic pts with

severe AS (C2)

Dec systolic opening of calcified valve AND

A Vmax >= 4m/s or MPG >= 40mm hg AND

Asymptomatic AND LVEF < 50%

CLASS 1

SUBHASISH DEB, BMCH

3. AVR is indicated in severe AS (C and D) when

undergoing cardiac surgery for other indications.

Dec systolic opening of calcified valve AND

A Vmax >= 4m/s or MPG >= 40mm hg AND

Symptoms or no symptoms

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

CHOICE OF TREATMENT

1. Aortic valve replacement (surgical)

2. Percutaneous Balloon Aortic valvuloplasty

Only in children and young adults with congenital,

non calcific AS

High restenosis rate in adults (80% in 1 yr)

Can be used as a “bridging operation” who are too ill

to tolerate surgery.

3. Transcatheter Aortic Valve Replacement

SUBHASISH DEB, BMCH

CHOICE OF SURGICAL OR

TRANSCATHETER INTERVENSION

SUBHASISH DEB, BMCH

TAVR

TAVI video

Dr Alain Criber Pioneered the 1st

transcathether aortic valve implatation

(TAVI) procedure 2002

SUBHASISH DEB, BMCH

Antegrade – Acute MR

Retrograde approaches

Transfemoral

Transapical

Transaortic

Two types of stent-vavle devices:

1. Balloon expandable valves (Edwards SAPIEN)

2. Self-expanding valves (Medtronic CoreValve)

SUBHASISH DEB, BMCH

C/I FOR TAVR/TAVI

1. MI at 1 month before treatment

2. Bicuspid/unicuspid/non calcified aortic valve

3. Native aortic annulus size by echo <18mm or > the largest annulus size for which TAVR device is available (Medronic– 29mm)

4. HOCM, LVEF < 20%

5. Sever PAH and RV dysfunction

6. Renal insufficiency (Cr > 3 mg/dl) and/or ESRD

7. MRI confirmed CVA or TIA within past 6 months

8. Expected life expectancy <12m due to other noncardiaccomorbid conditions

9. Severe MR

10. Thoracic or AAA >=5cm

SUBHASISH DEB, BMCH

CASE SCENARIO 1

A 38 yr old male,labourer by occupation,k/c/o RHD

on regular penicillin prophylaxis was evaluated by

echo on routine follow up.

His echo showed thickened mitral valve,no MS.

Aortic valve tricuspid,thickened,calcified

Aortic valve area 0.9cm2

AJV – 4.5m/sec,MPG – 81mmHg.

LVEF - 45%,grade I LVDD.

What is the diagnosis (stage) ?

Will he be posted for surgery?

SUBHASISH DEB, BMCH

Severe Asympotmatic AS with LV

dysfunction (stage C2)

Take him for surgery

SUBHASISH DEB, BMCH

AORTIC

REGURGITATION

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Vena Contracta:

is defined as the

Narrowest central

flow region of a jet

that occurs at, or just

downstream to,

the orifice of

a regurgitant valve

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

STAGING OF AR

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INTERVENTION IN AR

1. AVR indicated for SYMPTOMATIC pts with SEVERE AR regardless of LV systolic function. STAGE D

2. AVR indicated for ASYMTOMATIC pts with chronic SEVERE AR and LVEF < 50%. STAGE C2

3. AVR indicated for SEVER AR (STAGE C or D) while undergoing cardiac surgery for other indications.

CLASS 1

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

MITRAL STENOSIS

SUBHASISH DEB, BMCH

Diastolic pressure half time:

the time during diastole when the

transmitral gradient falls to 50% of initial

peak gradient.

More the DPHT, more sever the stenosis.

SUBHASISH DEB, BMCH

MITRAL VALVE DOMINGNORMAL DOMING

Seen in diastoleSUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

SEVERE MS – MVA < 1.5cm2

Transmitral pressure gradient > 5-10 mm

Hg at normal heart rate

Doppler Haemodynamics (apical 4 C

view) – peak and mean TVG averaged

from 2-5 beats in SR and 5-10 beats in

AF

SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH

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MITRAL

REGURGITATION

SUBHASISH DEB, BMCH

MITRAL REGURGITATION

PRIMARY

ACUTE CHRONIC

SECONDARY

CHRONIC

SUBHASISH DEB, BMCH

On the atrial surface of

the leaflets exist two

zones, one peripheral

smooth or body zone

and one central rough or

coaptation zone. The

rough zone represents

the coaptation surface

of the valve. The depth

and length of coaptation

is now often viewed as

an important

assessment of mitral

valve function.

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MITRAL CLIP

In October 2013, the FDA approved the MitraClip valve

repair system for patients with symptomatic

degenerative MR with a prohibitive risk for mitral-valve

surgery. Approval was based on registry data and the

Endovascular Valve Edge-to-Edge Repair Study

(EVEREST II), in which percutaneous repair of the

mitral valve was less effective in reducing MR but was

associated with similar improvement in clinical

outcomes and with superior safety

SUBHASISH DEB, BMCH

COMPARING OPTIONS FOR HEART VALVE SURGERY

SUBHASISH DEB, BMCH

PROSTHETIC VALVES

SUBHASISH DEB, BMCH

TYPES OF PROSTHETIC VALVES

Mechanical valves-

A. Ball and Cage valve- first generaion valves . A

spherical occuluder ( barium coated silastic ball)

is retained within a metal cage Starr Edwards

valve belonged to this class

B.Tilting disc valve- The best known examples

are Bjork –Shiley model ( now withdrawn) and

TTK valve (Indian).It has single disc which is

restrained by struts

C.Bileaflet valve- It has two cusps (disc

occuluders) in a sewing ring .St Jude medical

valve is the best example. SUBHASISH DEB, BMCH

STARR EDWARDS VALVE

Ball Cage

valve

Pt with S E valve 40 yrs after operationSUBHASISH DEB, BMCH

PROSTHETIC VALVES (MECHANICAL)

SREE CHITRA TTK VALVE (PRIDE OF

INDIA)

Tilting Disc

valve

SUBHASISH DEB, BMCH

BILEAFLET VALVES

SUBHASISH DEB, BMCH

TYPES OF PROSTHETIC VALVES

Biological valves-

a.Autograft –Pulmonary valve of pt is removed and

put in aortic position and replacing pulmonary valve

with aortic homograft ( Ross procedure ). It is

technically demanding operation

b.Homograft or allogaft –removed from cadavers,

antibiotic sterlised,cryo preserved.

C.Heterograft or xenograft- from animal tissue like

glutaraldehyde treated porcine (pig valves) mounted

on stents.

Homo and Heterografts are indicated in pts over 60

yrs age or where anticoagulants are contraindicated (

bleeding diathesis, uncontroled hypertension , GIT

ulcers etc) SUBHASISH DEB, BMCH

PROSTHETIC VALVES -

BIOPROSTHESIS

Bovine pericardial

valve

AorticHomograftPorcine valve

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SUBHASISH DEB, BMCH

SUBHASISH DEB, BMCH