New Horizons in Cardiovascular Disease Management Christopher Wulff, MD Cardiovascular Consultants Medical Group
Structural Heart Valvular TAVR MitraClip Congenital Pharmacology Heart Failure Management Arrhythmia Treatment Ablation Anticoagulation ICD Coronary Artery Disease Surgery
Structural Heart Disease Aortic Stenosis Mitral Regurgitation Prosthetic valve failure Special Considerations 1. Aortic regurgitation 2. Bicuspid aortic valve Congenital Heart 1. PFO 2. ASD
Defining Landing Zone
Valve Positioning
Valve Deployment
Etiology of Mitral Regurgitation Functional MR Abnormal function of anatomically normal leaflets Annular enlargement secondary due to left ventricular dilatation Papillary muscle displacement due to left ventricular remodeling may result in excessive tenting of the leaflet Degenerative MR Elongation or rupture of the chordae Leaflet tissue expansion and thickening (Barlow s Disease) Fibroelastic deficiency resulting in a thinning of leaflet tissue or rupture of chordae Generally occurs in the older population (60+ years) 1 Normal Mitral Valve FMR DMR Prolapse DMR Flail 1. Enriquez-Sarano, M et al. Lancet. 2009;373:1382-94.
Procedural Overview
PFO Associated with cryptogenic stroke Present in 25% of the population Higher risk of stroke if associated with IAS Device closure now approved after randomized trial showed outcome benefit ASD Largely a pediatric condition Close if shunt deemed large enough
Pharmacy Statin therapy guideline ASCVD Risk Calculator PCSK-9 9 Inhibitors Arrhythmia medications Heart Failure treatments
Current statin guidelines are based on the ASCVD risk calculation Age Sex Race Cholesterol Blood pressure Diabetes Smoking Use of antihypertensive medications Risk >7.5% over 10 yrs: High intensity statin
Alternative for statin intolerant patients, sub optimal treatment or FH PCSK-9 9 inhibitors Repatha Praluent Injectable biologic Expensive Efficacy is still being evaluated Preliminary data looks promising
Ventricular Amiodarone Sotalol Supraventricular amiodarone Propafenone Dronederone Flecainide Sotalol Tikosyn Arrhythmia Initiation of sotalol and tikosyn require ~3 day hospitalization
Heart Failure Triad: beta blockers, ACE/ARB, aldosterone blockers Sacubitril/valsartan Neprilysin inhibition-impairs impairs breakdown of BNP Ivabradine Blocks the channel responsible for cardiac pacemaker ( funny( funny ) Jardiance (Empagliflozin) Reduces mortality in adults with DM II and CVD
Heart Failure Management GMT Neurohormonal blockade Triad Neprilysin inhibition Tachycardia sacubitril Revascularization CardioMems Cardiac resynchronization (CRT) LV Assist devices Transplantation
Revascularization/Valve surgery Revascularization of ischemia improves outcomes PCI CABG Valve repair/replacement-timing timing is key Functional and non-functional MR Aortic stenosis and regurgitation
LVAD/CRT CRT resynchronizes LV wall motion Heart Mate II-III III Helps patients breathe more easily Improves organ function Fewer moving parts Requires anticoagulation Considered destination therapy
Supraventricular Drugs Ablation Ventricular Drugs Ablation ICD Oral Anticoagulation VKA DOAC Left Atrial Appendage Closure Watchman Lariat Arrhythmia Management
Coronary Artery Disease Medical Therapy (it works) Percutaneous Intervention Stents CTO Atherectomy Surgical Revascularization
Cardiovascular Surgery Coronary Artery Bypass Valve Replacement/Repair Minimally invasive approaches Lateral thoracotomy Port access surgery Endovascular Management Aneurysm (TEVAR)
Cardiology and OMT Cardiac Case ALEXANDER WULFF, MS, OMS I OPSC CONFERENCE SAN DIEGO FEBRUARY 2018
Screening-Who Are These Patients? Cardiac Patient CHF SOB, fatigue, weakness Lower extremity edema Chest pain Rapid or irregular heartbeat Ascites
Autonomic Balance T1-5: Heart T10-L2: Lower Extremity Sub Occipital Release
Biomechanics Cardiac Rib raising Chest wall compliance OA Pre/post-operative MFR
Circulation Cardiac Considerations Lymphatics lymphatic pump techniques Thoracic Inlet outlet/outlet Vascular Considerations Popliteal fossa and Pelvic Floor opening
Thank You Alesia Wagner, DO Jordan Keys, DO Christopher Wulff, MD John Glover, DO
References Kuchera ML. Osteopathic Considerations in Systemic Dysfunction. Greyden Press LLC, 1994 Williams A. An osteopathic cardiologist's review of hypertension: beyond the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. J Am Osteopath Assoc 1994;94(10):833. Osteopathic manipulation as a complementary treatment for the prevention of cardiac complications: 12-Months follow-up of intima media and blood pressure on a cohort affected by hypertension. Cerritelli, Francesco et al. Journal of Bodywork and Movement Therapies, Volume 15, Issue 1, 68 74 Nicholas, A. Osteopathic manipulative treatment for postoperative pain. JAOA September 2002; 102(9):S5-S8 Noll D. The effect of OMT on postoperative medical and functional recovery of coronary artery bypass graft patientsletter to the editor. JAOA August 2013; 113(8) 595-597