Worldwide rheumatic fever is the most common cause of valve disease. In industrialized areas, valvular disease of old age predominates

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1 Michael Sumners DO

2 Epidemiology Worldwide rheumatic fever is the most common cause of valve disease In industrialized areas, valvular disease of old age predominates Calcific aortic stenosis Functional Mitral Regurgitation

3 Epidemiology Valvular heart disease accounts for 10-20% of cardiac surgical procedures. Two-thirds of heart valve operations are for aortic valve replacement The most common reason for AVR is bicuspid aortic valve. 2/3 of <70yo. Mitral valve surgery is most often performed for MR

4 Valvular Disease is Under-detected Post-mortem studies show approximately 50% of aortic stenosis is identified before death. **** Perioperative and Maternal deaths

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6 Major Changes to the Guideline Restructured to help determine timing of interventions Transcatheter therapies Recommendations for use of heart valve team More patients with asymptomatic severe valve disease can be considered for intervention

7 2008 Update 2014 ABCD Helps to determine Timing of intervention Assess risk Severity of Valve Lesion Symptoms Response of LV and RV Rhythm Changes

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10 Aortic Stenosis Not a Passive Disease Process Active lipid deposition Inflammation Neo-angiogenesis Calcification Risk Factors Male, diabetes, dyslipidemia Metabolic syndrome, smoking

11 Natural History of Aortic Stenosis Sclerosis Valve calcification with velocity <2.5m/ sec Progression to severe AS 10% at 5 years. Once moderate disease is detected Increase in mean gradient 7 mmhg/yr Decrease in valve area of 0.1 cm^2/yr Increase velocity of 0.3 m/sec/yr

12 Aortic Stenosis

13 Aortic Stenosis Medical therapy Treat Hypertension Vasodilators Statins - Class 3

14 Aortic Stenosis Active Disease Process Lipid deposition Inflammation Neo-angiogenesis Calcification

15 The Simvastatin and Ezetemibe in Aortic Stenosis Trial (SEAS) Randomized double blind: 1873 pts Simvastatin + Zetia or Placebo Mild Moderate Aortic Stenosis Followed for average of 52 months No difference in rate of AVR or hemodynamic progression

16 Aortic Stenosis Timing of Intervention

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18 Aortic Stenosis AVR

19 Asymptomatic Severe Aortic Stenosis Which patients with asymptomatic severe aortic stenosis should be considered for intervention. EF < 50 Already undergoing cardiac surgery Velocity >5m/sec, Mean gradient >60, low risk Abnormal Exercise Treadmill Fast progression on echo >0.3m/s/yr

20 Bicuspid Aortic Valve Prevalence of 0.5-2% 70-80% of cases are male Should be considered a general thoracic aortopathy.

21 Bicuspid Aortic Valve Aortopathy No medical therapy has proven to reduce the rate of progression of aortopathy associated with a bicuspid valve.

22 Bicuspid Aortic Valve Aortopathy >4.5 cm: cm: >5.5cm:

23 TAVR >50% risk of death or major morbidity at 1 year with surgery Disease affecting 3 major organ systems Anatomic factors that increase risk of surgery

24 How is risk determined?

25 Extreme Risk High Risk Higher rate of survival with TAVR at 2 years

26 Ongoing Intermediate Risk Trials PARTNER 2A SURTAVI Moderate risk Corevalve trial

27 : 3815 Consecutive patients from registry data with severe AS 300 Initial surgical Conservative 5 yr All cause death and HF hospitalization 15% - Initial surgical 26% - Conservative

28 Aortic Insufficiency Testing

29 Aortic Insufficiency Medical Treatment

30 Aortic Insufficiency: AVR Symptomatic LV Dysfunction Undergoing surgery LV Dilation

31 Mitral Stenosis Left Atrium Natural history: Rate of progression is highly variable. Avg rate of decrease in area of 0.1cm

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33 Mitral Regurgitation Primary (Degenerative) Mitral Prolapse Correction of MR curative Secondary (Functional) LV dysfunction

34 Mitral Regurgitation Intervention Benefits of Mitral Repair vs. Replacement Lower operative mortality LV Function is better preserved Risks with anticoagulation Valve degeneration

35 Mitraclip EVEREST II Reduced MR Improved symptoms LV remodeling

36 Mixed Valve Disease 64yo M presents to establish care after not having a physician for the past 10 years. Reports slowly progressive exertional fatigue for the past 10 years. Echo Moderate mitral regurgitation. Moderate mitral stenosis.

37 Mixed Valve Disease Symptoms and routine treatment follow the predominant lesion Require more frequent evaluation than isolated disease of the same severity May require intervention despite the lack of severe quantification

38 Prosthetic Valves Mechanical or Bio-prosthetic How long will a bio-prosthetic valve last Inversely related to age. Deterioration rate at years 10% if age 70 90% if age 20 Individualized decision.

39 Prosthetic Valves Anticoagulation Mechanical: Thrombogenicity and alteration of flow. Aortic Valve goal INR 2.5 if low risk. Mitral Valve or AVR with higher risk goal INR 3.0. ASA 81mg for all.

40 Prosthetic Valve Bridging Anticoagulation Atrial Fibrillation Prior VTE Hypercoagulable Older Mechanical Valve EF < 30 >1 Mechanical Valve ADD Class 1 indications***

41 Mild: 3-5 years Moderate: 1-2 years Severe: 6mo to 1 year

42 Review Treatment for valve disease is becoming progressively more complex with increasing treatment options and a heart team approach is recommended for complex decisions.

43 Review Trans-catheter treatments for valve disease with TAVR or Mitra-clip are becoming more common and ongoing trials assessing utility in lower risk patients are ongoing.

44 Review Patients with moderate mixed valve disease require closer follow-up and may require intervention despite lack of severe quantification.

45 Review Bicuspid Aortic Valve should be considered a global thoracic aortopathy and imaged in its entirety with routine follow up.

46 References****pending 2008 update 2014 guideline Braunwalds Hemodynamic rounds Partner* Mitra clip trials**