Valvular Heart Disease

Transcription

1 Valvular Heart Disease B K Singh, MD, FACC Disclosures: None 1

2 CARDIAC CYCLE S2 S2=A2P2 S1=M1T1 S4 S1 S3 2

3 JVP Carotid S1 Slitting of S2 S3 S4 Ejection click Opening snap Dynamic Auscultation What is the most important part of the stethoscope? 3

4 Pre Test True or False? Loud S1 is consistent with severe MR Paradoxical splitting of S2 rules out severe AS Delayed carotid upstroke suggests severe AS Murmur of valvular aortic stenosis increases with Valsalva Murmur of HCM and MVP increases on standing Normal peak velocity of blood flow across aortic valve is 5m/sec (Doppler Echo) Development of pressure gradient across the valve indicates stensis. Asymptomatic but severe aortic stenosis needs urgent surgery. Send patient with CP and new onset diastolic murmur to ER Pre Test- True or False? Asymptomatic but severe MR with LVEF 0.45, needs MV surgery. All symptomatic valvular disease needs intervention. Mild MR and Mild AS need echocardiogram every year. Cardiac catheterization is needed in all patients to confirm the severity of valvular stenosis or regurgitation. Endocarditis prophylaxis is needed in patient with MVP and moderate MR. Percutaneous Trans Catheter Aortic Valve Replacement (TAVR) is indicated in a patient who refuses to have surgical AVR. EF = Stroke Volume/End diastolic volume normal 4

5 Valvular Heart Disease Etiology, Severity Pathophysiology Clinical Presentation Testing: Echo/Doppler/Color Flow/Heart Cath/EKG/X-ray Natural History Treatment Echocardiography LA LV RV LV RA RA LA Aortic Valve 5

6 Echocardiography LA LA LA LV LV LV AO Echocardiography LA LV PW Doppler LV AO AO LA CW Doppler 6

7 Critical Aortic Stenosis Bernoulli Equation PG = 4 V 2 Aortic Stenosis Catheterization vs Doppler max 57 p-p 28 (55 mmhg) 7

8 Valvular Aortic Stenosis Age- related etiology <30: Congenital (Unicuspid, Bicuspid) 40-60: Calcified bicuspid 40-60: Rheumatic >70: Senile degenerative/ Calcific Most common cause Senile degenerative Classification of Disease Severity Mild Moderate Severe Jet Velocity m/sec < > 4.0 Mean Gradient mm Hg < > 40 Valve Area cm 2 > < 1.0 Valve Area cm 2 /m 2 < 0.6 ACC/AHA Guidelines 8

9 Valvular Aortic Stenosis in Adults Average Course (Post Mortem Data) Ross, Bruanwald: Circulation 1968: 38 (Supp V) Correlating Symptoms & Severity Clinical examination Symptoms Mean Gradient = = Aortic Valve Area 9

10 Indications for AVR in Aortic Stenosis Symptomatic: Severe AS: irrespective of LVEF Asymptomatic: Severe AS: LVEF < 50 Abnormal Treadmill Critical Aortic Stenosis Moderate Aortic Stenosis: concomitant open heart surgery like CABG, Aortic Aneurysm, Mitral Valve surgery Low flow/low gradient/low aortic valve area: Dobutamine Echo True critical AS with poor LVEF Low LVEF with inability to open valve SAVR vs TAVR Bicuspid Aortic Valve Screen first degree relatives Scan entire aorta (MRA or CTA) Coarctation Dissection Aneurysm Ascending AO 5 cams Ascending AO 4.5 cms Need surgery 10

11 Aortic Regurgitation Acute vs Chronic : Recognize the difference in Murmur intensity and symptoms and signs Acute AR: Endocarditis/ Aortic Dissection Chronic AR: Valvular: Degenerative/ Bicuspid/RHD Aortic root Disease: Aneurysm/ Marfan Indications of AVR: Symptomatic & Severe AR Severe AR Wide pulse pressure Asymptomatic & Severe Color Doppler LVEF <50 % RV 60ml RF 55% LVESD>50 mm ERO 0.3 cm2 Descending aorta flow Suboptimal Treadmill test reversal Mitral Regurgitation Acute vs Chronic Acute MR: Ruptured Papillary Muscle, Chordal Rupture, Endocarditis, ischemic Chronic MR: MVP, ischemic, Rheumatic,Endocarditis, LV dilation Severe MR: ERO 0.4 cm2, Regurgitant He (>60ml) Regurgitant (>55%) Vena contracta, color jet area. Assess. LV size and contractility (EF 60%) and LVESD (40mm), pulmonary hypertension, Afib 11

12 Valvular Regurgitation Indications for Operation Presence of severe regurgitation + Any Symptoms Drop in EF (<60%MR, < 50%AR) Operate LV Dilation. LVESD (>40mm MR, > 50 mm AR) 12

13 Mitral Stenosis Etiology: Rheumatic, Calcific Signs & Symptoms Echocardiogram: Gold Standard to assess severity and valve and sub valvular pathology, MR 220/Pressure half time, (Doppler) Severe MS: Mean gradient > 10 mmhg, MV. Area less than 1 cm 2 Balloon Mitral Valvotomy MVR Atrial Fib could be very detrimental Prosthetic Valve Complications Structural failure Endocarditis Thromboembolism Thrombosis Perivalvular leak Hemolysis Prosthesis patient mismatch 13

14 Mechanical Valve bileaflet Tilting disk Gold Standard Treatment for Valvular Diseases had been Prosthetic Valves Mechanical Tissue Stentless Homograft Ross Edwards SAPIEN 14

15 60 Year-old Male St. Jude AVR No Hx thromboembolism, EF 60% A) INR B) INR C) INR ASA 81mg D) INR ASA 325mg E) INR ASA 81mg Mechanical Valves Target INR INR 2.5 INR 3 AORTIC Bileaflet St jude Medtronic - Hall Other AVR ( Mechanical) Risk Factors ALL MITRAL No risk factors ASA is needed for all mechanical & biological valves On -X valve: INR

16 Prosthetic Valves Embolic Events at Target INR INR 2-3 INR INR INR No ASA Add ASA Pre/Post Procedure Mechanical Valves Bridging Anticoagulation No Heparin Heparin Bileaflet AVR (ST JUDE) Bjork Shiley Valve No Risk factors Any MVR or TVR AVR - 1 risk factor AF Hx Thromboembolism Hyper coagulable LV < 30 Previous event off Warfarin Recent thromboembolism (1yr) 16

17 Prosthetic Heart Valves Management of Anticoagulation Mechanical valves all require warfarin DO NOT USE DOACS (dabigatran etexilate, apixaban, Xarelto, etc. Bioprosthesis warfarin for 3-6 months, then D/C unless risk factors** AF Hx Thromboembolism Hyper coagulate LV < 30 AVR, no risk factors, first 3 months. Class iib ASA only Anticoagulation for Atrial Fibrillation in Patients with VHD (New Section) Recommendations COR LOE New: Anticoagulation with a VKA is indicated for patients with rheumatic mitral stenosis and AF I B-NR New: Anticoagulation is indicated in patients with AF and a CHA 2 DS 2 -VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or MR I C-LD New: It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA 2 DS 2 -VASc score of 2 or greater IIa C-LD 17

18 Infective Endocarditis Prophylaxis Recommendations COR LOE Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral I C stenosis Modified: Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following: 1. Prosthetic cardiac valves, including transcatheterimplanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords. (con t) IIa C-LD Infective Endocarditis Prophylaxis Recommendations COR LOE (con t) 3. Previous IE. 4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. 5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve Prophylaxis against IE is not recommended in patients with VHD at risk of IE for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection IIa III: No Benefit C-LD B 18

19 2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (2014 guideline with 2017 focused update incorporated) Developed in Collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons American College of Cardiology Foundation and American Heart Association Thank You 19