Blank DISCLOSURES 1/17/2017 COMPLEX VALVE CASES CHALLENGES IN EVALUATING AND MANAGING MULTIVALVULAR HEART DISEASE ECHO HAWAII 1/23/17 NONE

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1 Blank COMPLEX VALVE CASES ECHO HAWAII 1/23/17 1 David A. Orsinelli, MD, FACC, FASE Professor, Internal Medicine Director, Structural Heart Imaging The Ohio State University Division of Cardiovascular Medicine Columbus, Ohio Maryellen H. Orsinelli, RN, RDCS, FASE Lead Cardiac Sonographer The Richard M. Ross Heart Hospital The Ohio State University Wexner Medical Center Columbus, Ohio DISCLOSURES NONE 2 1

2 CURRENT GUIDELINES FOR THE EVALUATION and MANAGEMENT OF VALVE DISEASE ADDRESS EACH VALVE LESION IN ISOLATION LITTLE DATA and LIMITED GUIDELINES ON THE ASSESSMENT OF MIXED OR MULTIVALVE DISEASE NO GUIDELINES ON MULTIVALVE DISEASE MANAGEMENT OFTEN DIFFICULT TO QUANTITATE LESION SEVERITY IN MULTI-VALVE DISEASE CHALLENGING TO DETERMINE WHICH LESION IS RESPONSIBLE FOR SYMPTOMS 3 CHALLENGES IN EVALUATING TWO CASES OF AORTIC STENOSIS WITH MITRAL VALVE DISEASE HOW DOES THE PRESENCE OF MITRAL VALVE DISEASE AFFECT THE ASSESSMENT OF AORTIC STENOSIS? DOES THE PRESENCE OF AORTIC STENOSIS AFFECT THE EVALUATION OF MITRAL REGURGITATION? PATIENT 1 IS IN ATRIAL FIBRILLATION 4 2

CASE 1 86 Y/O WOMAN WITH A PRIOR HISTORY OF AORTIC

BIOPROSTHETIC VALVE 11YRS PTA HISTORY OF HTN, CKD3

PROGRESSIVE MODEST DOE PRESENTS WITH ABRUPT SUBACUTE

ON EXAM, THERE IS A 3/6 SEM, NO AR AND A BLOWING 3/6

3 CASE 1 86 Y/O WOMAN WITH A PRIOR HISTORY OF AORTIC STENOSIS AND CAD, s/p CABG AND AVR WITH A BIOPROSTHETIC VALVE 11YRS PTA HISTORY OF HTN, CKD3 AND DM FAIRLY ACTIVE AND INDEPENDENT BUT HAS HAD PROGRESSIVE MODEST DOE PRESENTS WITH ABRUPT SUBACUTE WORSENING OF HER CHRONIC DYSPNEA OVER A 2 WEEK PERIOD ON EXAM, THERE IS A 3/6 SEM, NO AR AND A BLOWING 3/6 APICAL HOLOSYTOLIC MURMUR TTE PERFORMED ON ADMISSION 5 CASE 1 ECHO DATA 6 3

4 CASE 1 ECHO DATA 7 CASE 1 QUANTITATIVE ECHO DATA Vm 4.7 M/s MEAN GRADIENT 38 MM Hg 8 4

5 CASE 1 HEMODYNAMIC SUMMARY PATIENT IS IN AFIB NORMAL EF BIOPROSTHETIC AV Vm 4.7 M/s MEAN GRADIENT 38 MM Hg AVA 0.4 CM 2 DI 0.21 ACCELERATION TIME 113 ms MITRAL VALVE VC 0.98 cm PISA ERO 0.49 CM 2 REGURGITANT VOLUME 63 cc 9 ASSESSING PROSTHETIC AV DYSFUNCTION OUR PATIENT Zoghbi et al. JASE Sept

6 PRIMARY MR EVALUATION OUR PATIENT 11 Nishimura et al. ACC / AHA Valve Guidelines 2014 ECHO / DOPPLER PARAMETERS FOR ASSESSING MR Zoghbi et al JASE 2003:16:

7 QUALITATIVE / QUANTITATIVE PARAMETERS FOR THE ASSESSMENT OF MR Zoghbi et al JASE 2003:16: CASE 2 74 Y/O WOMAN WITH A HISTORY OF RHEUMATIC FEVER, s/p OPEN MV COMMISSUROTOMY 25 YEARS AGO PRESENTS WITH PROGRESSIVE DOE AND FATIGUE OTHERWISE HEALTHY WITH WELL CONTROLLED HTN AND DM TTE REVEALS AORTIC STENOSIS AND MITRAL STENOSIS, OUTSIDE SURGEON QUOTED A 20% PERI-OPERATIVE MORTALITY RISK SHE PRESENTS FOR A SECOND OPINION re OTHER POTENTIAL OPTIONS OUTSIDE TTE REVIEWED 14 7

8 CASE 2 ECHO EVALUATION 15 CASE 2 QUANTITATIVE ECHO EVALUATION 16 8

9 CASE 2 HEMODYNAMIC SUMMARY (TTE DATA) MV DATA MEAN GRADIENT 12 MM Hg MVA (PHT 200 ms) 1.1 CM 2 MILD MR AV DATA MILD AR MEAN GRADIENT 24 MM Hg AVA 0.72 CM 2 SVI 21 cc /M 2 TV DATA 3+ TR MEAN GRADIENT 10 MM Hg PHT 177 ms (TVA 1.1 CM 2 ) 17 GRADING NATIVE VALVE AORTIC STENOSIS Stage D3 AS o AVA < 1.0 cm 2 o Mean gradient < 40 mm Hg o SVI < 35 cc/ m 2 18 Nishimura et al. ACC / AHA Valve Guidelines

ASSESSING MITRAL STENOSIS Nishimura et al. ACC / AHA Valve Guidelines 2014 19 20 CHALLENGES IN EVALUATING HOW DOES THE PRESENCE OF MV DISEASE AFFECT THE ASSESSMENT OF AORTIC STENOSIS?

10 ASSESSING MITRAL STENOSIS Nishimura et al. ACC / AHA Valve Guidelines CHALLENGES IN EVALUATING HOW DOES THE PRESENCE OF MV DISEASE AFFECT THE ASSESSMENT OF AORTIC STENOSIS? SIGNIFICANT MS or MR MAY RESULT IN LOW SV (LOW GRADIENT AS) SIGNIFICANT AR CAN RESULT IN UNDERESTIMATING MS SEVERITY BY PHT (shortened) DOES THE PRESENCE OF AORTIC STENOSIS AFFECT THE EVALUATION OF MITRAL REGURGITATION? MAY INCREASE JET AREA (increased driving pressure) MR V m will be significantly higher than predicted by SBP CONCOMMITANT AR CONFOUNDS RV / RF ASSESSMENT BY SPECTRAL DOPPLER PATIENT 1 IS IN ATRIAL FIBRILLATION NEED TO OBTAIN HEMODYNAMIC DATA WITH MULTIPLE CONSECTIVE BEATS AND AVERAGE 10

CHALLENGES IN MANAGING MULTIVALVULAR HEART

AND MITRAL DISEASE ARE THE SYMPTOMS DUE TO

11 CHALLENGES IN MANAGING MULTIVALVULAR HEART DISEASE BOTH CASES HAVE AORTIC STENOSIS AND MITRAL DISEASE ARE THE SYMPTOMS DUE TO THE AS? TAVR ARE THE SYMPTOMS DUE TO THE MV DISEASE? MITRACLIP or BMV ARE BOTH LESIONS RESPONSIBLE? MANAGEMENT OPTIONS: TAVR AND MV (CLIP or BMV) STAGED OR SIMULTANEOUS SURGICAL AVR / MVR 21 CASE 1 TEE DATA 22 11

12 CASE 1 (PROSTHETIC AS and MR) TEE DATA SEVERE MR DUE TO A FLAIL A 2 PISA ERO = 2π (1.1) 2 *38.5 = 0.56 CM ERO PROBABLY OVERESTIMATED SEVERE PROSTHETIC AS DUE TO LEAFLET CALCIFICATION 23 CASE 1 MANAGEMENT VIV TAVR AND / OR MITRACLIP STAGED? SIMULTANEOUS? OPTED TO DO MITRACLIP CHALLENGING ANATOMY 2 CLIPS DEPLOYED MR DECREASED TO

13 CASE 1 MANAGEMENT BASELINE V WAVE 15 SBP 100 POST CLIP 2 MR IMPROVED, EXTUBATED AND DISCHARGED READMITTED WITH CHF 2 WEEKS LATER AND VIV TAVR PERFORMED 25 CASE 1 3 MONTHS POST PRESENTATION o o MITRAL VALVE o MEAN GRADIENT 6 mm HG o 1-2+ MR AORTIC VALVE o MEAN GRADIENT 11 mm Hg o AVA 0.8 CM 2 o DI 0.28 o SVI 21 cc/m

14 CASE 2 (RHEUMATIC AS AND MS) TEE EVALUATION 27 CASE 2 HEMODYNAMIC SUMMARY WILKINS SCORE (MOSTLY DUE TO SUBMITRAL DISEASE AND LEAFLET IMMOBILITY) MILD MR MVA BY PLANIMETRY 1.0 CM 2 SEVERE AS LOW FLOW, LOW GRADIENT (SVI 21 cc/m 2 ) AVA 0.8 CM 2 (PLANIMETRY) AVA 0.72 CM 2 (TTE VTI) 28 14

15 CASE 2 MANAGEMENT PATIENT CONCERNED RE HIGH SURGICAL RISK QUOTED BY OSH? BMV +/ - TAVR? TAVR +/- BMV BASED ON TTE AND TEE NOT FELT TO BE AN OPTIMAL BMV CANDIDATE PRIOR COMMISSUROTOMY HIGH WILKINS SCORE (11) TV DISEASE AVR / MVR WITH BIOPROSTHETIC VALVES AND TVR DID WELL, D/C POD 8 29 THANK YOU 30 15

COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU 52 y/o WOMAN WITH A HISTORY OF

WITH FEVERS, RIGORS AND DYSPNEA ECHO REVEALED AV VEGETATIONS AND AR BLOOD

AR, LEAFLET PERFORATION R / L CUSPS), VEGETATIONS ON AV AND MV EPIDURAL

16 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU 52 y/o WOMAN WITH A HISTORY OF POLYSUBSTANCE ABUSE, INCLUDING IV OPIATES and COCAINE PRESENTED 4 MONTHS PTA WITH FEVERS, RIGORS AND DYSPNEA ECHO REVEALED AV VEGETATIONS AND AR BLOOD CULTURES POSITIVE FOR ENTEROCOCCUS TRANS TO OSU FOR MANAGEMENT TEE (SEVERE AR, LEAFLET PERFORATION R / L CUSPS), VEGETATIONS ON AV AND MV EPIDURAL ABSCESS / SPINAL OSTEO 31 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU PRESENTING TEE 32 16

COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU INITIAL MANAGEMENT ONCE BC WERE STERILE, TO OR TRILEAFLET AV WITH PERFORATION OF R/L CUSPS, SMALL MV VEGETATION, NO ABSCESS AVR WITH A 21 mm ST JUDE

17 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU INITIAL MANAGEMENT ONCE BC WERE STERILE, TO OR TRILEAFLET AV WITH PERFORATION OF R/L CUSPS, SMALL MV VEGETATION, NO ABSCESS AVR WITH A 21 mm ST JUDE TRIFECTA BIOPROSTHETIC VALVE AND DEBRIDEMENT / PATCHING OF ANT MV LEAFLET 33 DISCHARGED TO AN ECF 2 WEEKS POST OP TO COMPLETE A 6 WEEK COURSE OF ANTIBIOTICS LEFT LTACH AMA AFTER 10 DAYS, READMITTED 3 DAYS LATER WITH FEVERS / CP TTE / BC NEGATIVE D/C HOME TO COMPLETE ABX / AGREED TO DRUG TESTING (REFUSED ECF) COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU REPRESENTATION KEPT NO F/U APPTS or DRUG SCREENS / PULLED PICC LINE REPRESENTED 3 MONTHS LATER WITH FATIGUE, FEVERS AND CHILLS, SEPSIS, AKI BC POSTIVE FOR MSSA TOXICOLOGY SCREEN POSITIVE FOR OPIATES AND COCAINE TEE PERFORMED 34 17

COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU TEE AT REPRESENTATION 35 COMPLEX VALVE DISEASE

INTERVENTION DUE TO RISK OF REINFECTION AND CONTINUED SUBSTANCE ABUSE BC CLEAR BUT

AVB SECOND SURGEON ALSO DECLINED TO OFFER REDO AVR WHAT ARE THE CHALLENGES / OPTIONS FOR

MANAGEMENT POST OP (PAIN, PLACEMENT, COMPLIANCE) IV ANTIBIOTICS FOLLOWED BY CHRONIC

18 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU TEE AT REPRESENTATION 35 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU MANAGEMENT DECISIONS SEEN BY ORIGINAL SURGEON WHO DECLINED SURGICAL INTERVENTION DUE TO RISK OF REINFECTION AND CONTINUED SUBSTANCE ABUSE BC CLEAR BUT REMAINED FEBRILE NEURO IMAGING WITH NO PROGRESSION OF SPINE LESIONS ECG WITH 1 ST DEGREE AVB SECOND SURGEON ALSO DECLINED TO OFFER REDO AVR WHAT ARE THE CHALLENGES / OPTIONS FOR MANAGEMENT? SURGICAL (TECHNICAL) / SOCIAL / MEDICAL ISSUES REOPERATE? MANAGEMENT POST OP (PAIN, PLACEMENT, COMPLIANCE) IV ANTIBIOTICS FOLLOWED BY CHRONIC SUPPRESSIVE THERAPY? HOSPICE? TREATEMENT OF UNDERLYING DISEASE (ADDICTION) HOW WOULD YOUR INSTITUTION HANDLE SUCH A CASE? 36 18

COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU OPIOD ADDICTION INCREASINGLY COMMON PROBLEM COMPLICATES MANAGEMENT HIGH RISK OF RECURRENCE INFECTION DRUG USE CHALLENGES WITH POST OP PAIN MANAGEMENT

19 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU OPIOD ADDICTION INCREASINGLY COMMON PROBLEM COMPLICATES MANAGEMENT HIGH RISK OF RECURRENCE INFECTION DRUG USE CHALLENGES WITH POST OP PAIN MANAGEMENT PLACEMENT ISSUES NEED TO TREAT UNDERLYING ILLNESS (SUBSTANCE ABUSE / ADDICTION) 37 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU MANAGEMENT PATIENT REQUESTED A SECOND OPINION AT ANOTHER TERTIARY CARE CENTER ARRANGEMENTS MADE TO TRANSFER, PLACED ON WAITING LIST PENDING BED REMAINED FEBRILE BUT HEMODYNAMICALLY STABLE NEW AR MURMUR APPRECIATED LIMITED TTE REVEALS PROGRESSION OF INFECTION, TV VEGETATION AND SEVERE AR 38 19

20 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU 39 COMPLEX VALVE DISEASE ENDOCARDITIS IN IVDU OUTCOME BED AVAILABLE DAY AFTER TTE AND SHE WAS TRANSFERRED EVALUATED BY SURGICAL TEAM AT SECOND HOSPITAL AND SURGERY DECLINED DUE TO CONTINUED IVDU AND PROGRESSION OF INFECTION EXPIRED 5 DAYS AFTER TRANSFER 40 20

21 THANK YOU 41 21

MAKING SENSE OF MODERATE GRADIENTS IN PATIENTS WITH SYMPTOMATIC AORTIC STENOSIS

MAKING SENSE OF MODERATE GRADIENTS IN PATIENTS WITH SYMPTOMATIC AORTIC STENOSIS David A. Orsinelli, MD, FACC, FASE Professor, Internal Medicine Director, Structural Heart Imaging The Ohio State University