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
Disclosures Speaker s or Advisory Boards: none Research grants: none (co-investigator in multi-center trials, no remuneration)
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
CASE 1 60yo M with large MI 6 years ago now bad shortness of breath, sleeps on 4 pillows, wakening 4x @ night Swollen ankles, weight gain BP 150/80, HR 110 (irregular), high JVP, lung crackles, apex @ axilla hyperkinetic Loud harsh systolic murmur obscuring S1 & S2 at apex whole precordium
TESTS? CASE 1
CASE 1 TESTS: ECG: Afib with LBBB CXR: interstitial and mild alveolar edema, cardiomegaly ECHO:
CASE 1 ECHO
CASE 1 ECHO
CASE 1 ECHO LV dilated, inferior / posterior akinesis Severe posteriorly directed MR?? What would you do next??
When to echo...
What are we listening for?
Left-Sided Valve Disease Mitral Regurgitation Aortic Stenosis
Left-Sided Valve Disease Prevalence in Mayo clinic series: surprisingly high for moderate / severe leftsided valve lesions: 1-6% Age-related increase
Valvular Disease: Consequences If valve tight = stenotic PRESSURE overload upstream If valve leaks VOLUME overload receiving AND pumping chambers
Mitral Regurgitation
Mitral Regurgitation RA RV LA Back pressure LV Aorta
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
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
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
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
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
MV repair 1 degenerative MV repairs 2 degenerative MV repairs
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
Aortic Stenosis
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
ECG
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
CASE 2 ECHO
CASE 2 ECHO
Aortic Stenosis RA RV LA LV Aorta
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)
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
Aortic Stenosis Refer when: Asymptomatic severe AS Asymptomatic drop in LV function Syncope Angina Dyspnea = Left-sided heart failure
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)
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
Percutaneous AV replacement TAVR, TAVI) www.google.ca/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1680&bih=989&q=tavr&oq=tavr&gs_l=img.3..0l10.6668.7607.0.8572.4.4.0.0.0.0.92.315.4.4.0.msedr...0...1ac.1.64.img..0.4.299.5hcpprfsmks#imgrc=bwsuyf9gwtbftm%253a%3bmt0fw4iqujtl2m%3bhttp%253a%252f%252fwww.cathlabdigest.com%252ffiles%252f2%252520 TAVR%252520Baba_Cover_Fig%2525202.png%3Bhttp%253A%252F%252Fwww.cathlabdigest.com%252Farticles%252FTranscatheter-Aortic-Valve-Replacement-Emory-Structural-Heart-Disease-Valve-Center%3B541%3B494
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
Summary: valve referral
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
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
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
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
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
When to distrust echo reports Estimates of valve area depend on many technical Doppler measurements Estimates of valve stenosis should fit clinical picture
When to distrust echo reports Severe aortic stenosis: not just area<1cm² LV hypertrophy high gradient (mean >40) if N LV
QUESTIONS?
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