Heart Valve disease: MR. AS tough patient When to echo, When to refer, What s new

Transcription

1 Heart Valve disease: MR. AS tough patient When to echo, When to refer, What s new B. Sonnenberg UAH Cardiology CME Day 5 May 2015

2 Disclosures Speaker s or Advisory Boards: none Research grants: none (co-investigator in multi-center trials, no remuneration)

3 OUTLINE Cases When to echo for a murmur Brief overview of Mitral Regurgitation, Aortic Stenosis When to refer to a cardiologist for murmur How often to order echo s When to (dis)trust echo reports

4 CASE 1 60yo M with large MI 6 years ago now bad shortness of breath, sleeps on 4 pillows, wakening night Swollen ankles, weight gain BP 150/80, HR 110 (irregular), high JVP, lung crackles, axilla hyperkinetic Loud harsh systolic murmur obscuring S1 & S2 at apex whole precordium

5 TESTS? CASE 1

6 CASE 1 TESTS: ECG: Afib with LBBB CXR: interstitial and mild alveolar edema, cardiomegaly ECHO:

7 CASE 1 ECHO

8 CASE 1 ECHO

9 CASE 1 ECHO LV dilated, inferior / posterior akinesis Severe posteriorly directed MR?? What would you do next??

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11 When to echo...

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13 What are we listening for?

14 Left-Sided Valve Disease Mitral Regurgitation Aortic Stenosis

15 Left-Sided Valve Disease Prevalence in Mayo clinic series: surprisingly high for moderate / severe leftsided valve lesions: 1-6% Age-related increase

16 Valvular Disease: Consequences If valve tight = stenotic PRESSURE overload upstream If valve leaks VOLUME overload receiving AND pumping chambers

17 Mitral Regurgitation

18 Mitral Regurgitation RA RV LA Back pressure LV Aorta

19 Mitral Regurgitation 1 mitral valve disease = abnormal leaflets / chords = Degenerative MR Mitral valve prolapse (usually just chordal stretching, rarely whole mitral structures thickened, redundant and stretched = myxomatous degeneration) much less common rheumatic, infective endocarditis, simple age-related degeneration causing severe MR 2 = distorted LV = relatively normal mitral valve leaflets / chords but 1 LV problem = Functional MR Ischemic MR = most often scarred distorted LV post infarct, very rarely just pure ischemia Dilated non-ischemic cardiomyopathy

20 When to echo / refer for consult Holo-systolic murmur or grade 3 murmur If moderate MR, consider every 1-2 years If severe, need every year (likely refer to cardiologist to follow) Refer if echo data not fit? LV not dilated, severe MR unexplained bad LV dilation / dysfunction + not severe MR Symptoms out of proportion to non-severe MR

21 MR treatments Degenerative MR better studied no known medical Rx Repair >> replace for MVProlapse Surgery: NYHA 2+ symptoms EF < 60%, LV endsystolic dimension > 40mm Functional MR even less evidence LV failure drugs help? revascularization may help if hibernating LV and not infarcted / scarred irreversibly?resynchronization pacing Replacement = more definitive? = repair

22 Mitral Regurgitation Refer when: Asymptomatic: LV failing (EF<60%, dilation end-systolic >40mm) Left-sided heart failure symptoms Atrial fibrillation Pulmonary hypertension / right heart fails

23 What s new in MR Various repair techniques for mitral regurgitation replace chords with Teflon excise redundant floppy MV tissue new MV rings MV replacment keep some of native chords attached to remnant MV prevent the LV springing into globular shape, maintain normal (efficient) bullet shape LV?percutaneous techniques

24 MV repair 1 degenerative MV repairs 2 degenerative MV repairs

25 Percutaneous MV technique Percutaneous clip tries to grab anterior / posterior MV leaflets clip together MR approved by Health Canada for patients with symptoms from 3+ MR but too high risk for open heart surgery

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27 Aortic Stenosis

28 CASE 2 70 year old lady with decades murmur History of hypertension, dyslipidemia usually active, short of breath on exertion now after a debilitating RTI no angina or major pre-syncope Px: mildly hypertensive, HR 80, JVP normal, moderately reduced carotid upstroke / volume. Harsh mid-peaking systolic murmur from R upper sternal border to apex, S4

29 ECG

30 CASE 2 (continued) Echo: low normal LV size / normal function, borderline LVH very sclerotic aortic valve (can t tell if bicuspid or not) peak / mean gradients 41/22mm Hg, AV area ~0.9cm² No major aortic dilation No other valve dysfunction

31 CASE 2 ECHO

32 CASE 2 ECHO

33 Aortic Stenosis RA RV LA LV Aorta

34 Pitfalls of severe AS Official guidelines say AV area <1cm² AND peak gradient >64mmHg (mean >40) Laws of physics if very small LV, small stroke volume IMPOSSIBLE to get high gradient! Can have severe AS with LOW gradients (either very small LV, or poor LV function)

35 Aortic Stenosis mostly degenerative (earlier if bicuspid) big LV pressure load conc. LVH Long asymptomatic, then S.A.D. story! Low / slow pulse, S4, mid-late peaking M. Rx: replace valve! ECG Aortic stenosis murmur diamond-shaped = mid or late-peaking S4 S1 S2

36 Aortic Stenosis Refer when: Asymptomatic severe AS Asymptomatic drop in LV function Syncope Angina Dyspnea = Left-sided heart failure

37 When to echo (refer) if worrisome symptoms + aortic area murmur (remember sash radiation) if known mild AS, every 3-5 years moderate AS, every 2-3 ys severe AS, every year (refer) refer if symptoms (1-2% / month death!!) refer if echo questionable (valve area <1 but peak / mean gradients < 60/35mm Hg)

38 Aortic Stenosis treatments Conventional aortic valve replacement theoretically no upper age limit Mortality / morbidity of open heart surgery in eldery patients high (= typical AS population) Percutaneous AV replacement now approved for patients too high risk for open heart surgery, or very high risk

39 Percutaneous AV replacement TAVR, TAVI) TAVR%252520Baba_Cover_Fig% png%3Bhttp%253A%252F%252Fwww.cathlabdigest.com%252Farticles%252FTranscatheter-Aortic-Valve-Replacement-Emory-Structural-Heart-Disease-Valve-Center%3B541%3B494

40 TAVR can go up femoral artery (or less commonly, directly into LV apex) and cross AV and crack open stenotic valve, spring open new tissue valve few % risk stroke (crack open AV) few % fatal rupture aorta or coronary occlusion needs enough tri-leaflet AV calcification to anchor the new valve high mortality even post-tavr

41 Summary: valve referral

42 Valve disease referral Major left-sided valve disease Left-sided heart failure Atrial fibrillation with mitral disease Angina with major aortic valve disease Syncope with major aortic stenosis

43 Valve disease referral Major left-sided valve disease Major displacement of apex Elevated JVP and heart failure signs Echo dysfunction, or major dilation of LV, especially end-systolic dimensions

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45 Valve disease referral Major right-sided valve disease Symptoms of edema / tender liver / ascites Major parasternal heave Elevated JVP, ascites, edema Echo dysfunction, or major dilation of RV

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47 How often to order echo s Severe asymptomatic left-sided valve disease annually (at least) Moderate asymptomatic left-sided valve disease: If changes in clinical symptoms / signs every 2-5 years if subtle signs maybe more severe Mild asymptomatic valve disease only if symptoms / signs dramatically change

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49 When to distrust echo reports Modern echo machines pick up small amount of regurgitation that used to be missed guess timates of severity of valve leakage based on color now grossly over-estimate severity Need to see chamber dilation if true major regurgitation

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51 When to distrust echo reports Estimates of valve area depend on many technical Doppler measurements Estimates of valve stenosis should fit clinical picture

52 When to distrust echo reports Severe aortic stenosis: not just area<1cm² LV hypertrophy high gradient (mean >40) if N LV

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54 QUESTIONS?

55 3 KEY POINTS Echo 1 x for any murmur other than short mid-systolic asymptomatic murmur Refer if severe left-sided valve lesions, especially if heart failure/ angina / syncope Read all echo reports with skepticism, need to fit : regurgitation volume load, stenosis pressure overload