Management of the Female Pa4ent with a Cardiac Murmur

Size: px

Start display at page:

Download "Management of the Female Pa4ent with a Cardiac Murmur"

Matilda Hutchinson
5 years ago
Views:

1 Management of the Female Pa4ent with a Cardiac Murmur Allen Mogtader, MD, FACC, FACP, FASE Director, Non- Invasive Cardiology Laboratory (No Disclosures) Strategy for Evalua4ng Heart Murmurs ACC/AHA 2008 Guidelines for the Management of Pa4ents with Valvular Heart Disease 1

Echocardiography in Assessment of Valvular

lesions Assess ventricular func4on Assess

2 Echocardiography in Assessment of Valvular Heart Disease Anatomy of valve to define the pathology Quan4tate the severity of valve stenosis/ insufficiency Evaluate for coexis4ng lesions Assess ventricular func4on Assess affect on other cardiac structures Assess cardiac hemodynamics 2

3 Who Knows What Evil Lurks in the Hearts of Men Women? 32 y/o female with palpita4ons, chest pain, shortness of breath 3

4 60 y/o Female - Palpita4ons 4

85 y/o Female No symptoms Study,Year Chandraratna, 1984 Use of Echocardiography for Risk Stra4fica4on in Mitral Valve Prolapse No. of Pts Features Examined Outcome P< 86 MV leaflet > 5.

6%; Marfan syndrome, TVP, MR, dilated ascending aorta) Incr sudden death, endocardi4s, cerebral embolus Incr MVR (26% vs. 3.1%) Marks, 1989 456 MV leaflet > 5 mm Incr endocardi4s (3.5% vs.

5 85 y/o Female No symptoms Study,Year Chandraratna, 1984 Use of Echocardiography for Risk Stra4fica4on in Mitral Valve Prolapse No. of Pts Features Examined Outcome P< 86 MV leaflet > 5.1 mm thick Nishimura, MV leaflet > 5 mm LVID > 60 mm Incr cardiovascular abnormali4es (60% vs. 6%; Marfan syndrome, TVP, MR, dilated ascending aorta) Incr sudden death, endocardi4s, cerebral embolus Incr MVR (26% vs. 3.1%) Marks, MV leaflet > 5 mm Incr endocardi4s (3.5% vs. 0%) Incr moderate- severe MR (11.9% vs. 0%) Incr MVR (6.6% vs. 0.7%) Incr stroke (7.5% vs. 5.8%) Takamoto, MV leaflet > 3 mm Incr ruptured chordae (48% vs. 5%) Babuty, Undefined MV thickening No rela4on to complex ventricular arrhythmias NS Zuppiroll, MV leaflet > 5 mm Incr complex ventricular arrhythmias NS ACC/AHA Guidelines 2008 for Management of Pa4ents with Valvular Heart Disease 5

5 yrs nega4ve for ischemia, cardiomyopathy, and channelopathy Bileaflet MVP found in 10 (42%) Compared with pa4ents with normal valves,

6 Malignant Bileaflet Mitral Valve Prolapse Syndrome in Pa4ents with Otherwise Idiopathic Out- of- Hospital Cardiac Arrest 1200 pa4ents with out of hospital cardiac arrest 24 persons (16 woman, median age 33.5 yrs nega4ve for ischemia, cardiomyopathy, and channelopathy Bileaflet MVP found in 10 (42%) Compared with pa4ents with normal valves, pa4ents with bileaflet MVP were over- represented by women (9 of 10) Journal of the American College of Cardiology 62:2013: Three Dimensional Echocardiography Mitral Valve Prolapse Flail Posterior Leaflet 6

7 Development of Lei Ventricular Systolic Dysfunc4on Mitral Valve Prolapse Two Years Later Postopera4ve Mortality Aier Mitral Valve Surgery Affec4ng Pa4ents Operated on for Symptoms or Low EF 7

8 Kaplan Meier of the Mean (±SE) Rates of Cardiac Events among with Mitral under Medical Management, According to the Regurgitant Orifice (ERO). Enriquez- Sarano M et al. N Engl J Med 2005;352: Kaplan Meier Es@mates of the Mean (±SE) Rates of Overall Survival among Pa@ents with Asymptoma@c Mitral Regurgita@on under Medical Management, According to the Effec@ve Regurgitant Orifice (ERO). Enriquez- Sarano M et al. N Engl J Med 2005;352:

9 Kaplan Meier of the Mean (±SE) Rates of Death from Cardiac Causes among with Mitral under Medical Management, According to the Regurgitant Orifice (ERO). Enriquez- Sarano M et al. N Engl J Med 2005;352: Early Surgery in Asymptoma4c Organic Mitral Regurgita4on with Normal Ejec4on Frac4on Valve should be reparable Effec4ve Regurgitant Orifice Area (ERO) > 0.4 cm 2 Atrial fibrilla4on LVESD = 36 to 39 mm Elevated B- type natriure4c pep4de Reduced exercise capacity (<84% of expected age) Valve Repair Surgery Opera4ve risk 1% High repair rates (> 85% - 90%) High durability of repair (< 10% reopera4on rates 10 years aier surgery) Enriquez- Sarano. Circula4on. 2010;121:

10 Concerns regarding early surgery in asymptoma4c pa4ents with severe mitral regurgita4on and normal lei ventricle Opera4ve mortality for valve repair 1.2% Opera4ve mortality for valve replacement 3.8% (10% may require valve replacement) Overall rate of valve related complica4on aier MVR = 1-2% per year 2% risk of early stroke aier surgery Freedom from moderate to severe mitral regurgita4on 65% for anterior leaflet repair to 80% for posterior leaflet repair The physician must have two special objects in view with regard to disease, namely, to do good or to do no harm - - Hippocrates Gillam, L. Is early surgery recommended for mitral regurgita4on? Circula4on. 2010;121: Watchful Wai4ng Serial history, physical examina4on, & echo evalua4on at 12- month intervals aier the stability of the findings are observed Interval decreased to 3 6 months if echo findings show a significant change or have moved close to thresholds for surgery Surgery advised if symptoms, atrial fibrilla4on or echo triggers occurr: LVESD > 40 mm LVEF < 60% PASP > 50 mmhg Rosenhek et al. Asymptoma4c Severe Mitral Regurgita4on. Circula4on. 2006;

11 Event- free Survival Watchful Wai4ng Overall Survival Rosenhek et al. Asymptoma4c Severe Mitral Regurgita4on. Circula4on. 2006; Associa4on Between Early Surgical Interven4on vs Watchful Wai4ng and Outcomes for Mitral Regurgita4on Due to Flail Mitral Valve Leaflets Survival A^er Diagnosis of MR Due to Flail Mitral Leaflet According to Treatment Strategy Heart Failure Incidence A^er Diagnosis of MR Due to Flail Mitral Leaflets According to Treatment Strategy JAMA, 2013;310(6):

12 Fibroelas4c Deficiency and Barlow s Disease Management Strategy for Chronic Severe Mitral Regurgita4on ACC/AHA Guidelines 2008 for Management of Pa4ents with Valvular Heart Disease 12

13 Carpen4er s Classifica4on of Mitral Regurgita4on Carpen4er s Classifica4on of Mitral Regurgita4on 13

14 81 y/o Female with CAD and Dyspnea Intraopera4ve Transesophageal Echocardography 14

15 55 y/o Female with history of rheuma4c fever and no symptoms 30 y/o Female with dyspnea 15

16 Postpartum Cardiomyopathy 3 years later 16

17 Knowledge is knowing a tomato is a fruit. Wisdom is not puwng it in a fruit salad. 17

18 Aor4c Valve Stenosis 18

Correla4on Between Doppler and Cardiac Catheteriza4on Determined Aor4c Valve Pressure Gradients 200 1-150.0 c E 100 E._ (cu 0) X to 5Q n=100 r=0.92 SEE=15 A 0 0 50 100 150 200 Max.

19 Correla4on Between Doppler and Cardiac Catheteriza4on Determined Aor4c Valve Pressure Gradients c E 100 E._ (cu 0) X to 5Q n=100 r=0.92 SEE=15 A Max. gradient (Doppler), mm Hg a) 50 ~ to c0 5 1-E CD (U 50 a) B Mean gradient (Doppler), mm Hg *S 0 n=100 r=0.93 SEE=10 Natural History of Asymptoma4c Pa4ents with Aor4c Stenosis Oxo; Circula4on 95:2262,

20 68 y/o Female with exercise intolerance Improvement in Lei Ventricular Systolic Func4on Aier Aor4c Valve Replacement 1 Year Post 20

21 Management Strategies for Severe Aor4c Stenosis ACC/AHA 2008 Guidelines for Management of Pa4ents with Valvular Heart Disease Evalua4on of Low Flow Low Gradient Aor4c Stenosis Cleveland Clinic 21

22 Dobutamine Stress Echocardiography 22

Primary Mitral Valve Disease: Natural History & Triggers for Intervention ACC Latin American Conference 2017

Disclosures: GE stock, Primary Mitral Valve Disease: Natural History & Triggers for Intervention ACC Latin American Conference 2017 Athena Poppas, MD FACC Past ACC Scientific Sessions Chair, ACC Board