Overview of Valvular Heart Disease

1. Overview of Valvular Heart Disease January 28, 2006 David R. Richards, DO, FACC, FASE MidOhio Cardiology and Vascular Consultants Director, Heart Disease Management Program Riverside Hospital

2. Valve Disease: general concepts • Etiology and natural history • Physical findings • Therapy • types of surgical therapy • indications for surgery • indications for anticoagulation • antibiotic prophylaxis

3. Etiology of valve disease • “Secondary” valve disease • “Primary” valve disease

4. Etiology of valve disease • “Secondary” valve disease • Hypertension • CAD • Cardiomyopathy • “Primary” valve disease

5. Etiology of valve disease • “Secondary” valve disease • “Primary” valve disease • Calcific aortic stenosis • Rheumatic valve disease • Mitral prolapse / myxomatous mitral disease • Primary aortic regurgitation • Infective endocarditis

6. Diseases primary degenerative rheumatic endocarditis myxomatous congenital secondary CAD / cardiomyopathy Mechanisms Aortic stenosis Mitral stenosis Mitral regurg. Aortic regurg. Tricuspid regurg

7. Mechanisms of Valve Disease

8. Valvular Emergencies • Acute Endocarditis • Papillary Muscle Rupture • Flail Mitral Leaflet • Prosthetic Valve Thrombosis / Dehiscence

9. 65 y.o. female with MVR and acute CHF

10. 65 y.o. female with MVR and acute CHF

11. 65 y.o. female with MVR and acute CHF

12. S/P thrombolytic therapy

13. S/P bioprosthetic valve replacement

14. Valve disease: Diagnosis • Physical exam suggests diagnosis • Transthoracic Echo (TTE) confirms mechanism and severity of lesion • Transesophageal Echo (TEE) usually reserved to: • plan surgery • confirm borderline diagnosis/severity

15. 2 D Echocardiography

16. Transesophageal Echo (TEE)

17. S1 S2 systole diastole MV closure AV closure

18. Severe AS Mitral regurg MVP S1 S2 Mild AS

19. Mild AR Severe AR S1 S2 Mitral Stenosis

20. Valve disease: Management • Medical therapy ineffective • except: vasodilators for AR • Surgical therapy curative • Surgery for symptoms or LV dysfunction • Surgical trends: • minimally invasive surgery • valve repair • homograft use

22. Mechanical Prostheses

23. 2D Echo: normal mechanical MV

24. Heterografts: Porcine

25. Aortic Homograft

26. TEE: aortic homograft

27. Mitral Annuloplasty Ring

28. Prosthetic Valves: selection Pros Cons • Bioprosthetic • Mechanical • Homograft • No Coumadin needed • Less thromboembolic complications • Lifelong cure • No Coumadin needed • Potential lifelong integrity Lifespan 10-15 yrs. Lifelong Coumadin 1% annual comp. Rate Limited availability ? Late failure Technically challenging

29. Prosthetic Valves: selection • Elderly pts.(lifespan < 15 yrs. • Contraindication to Coumadin • Elderly who already need Coumadin • All other patients • Young patients with Aortic Valve disease • Bioprosthetic • Mechanical • Homograft

30. Prosthetic Valves:types of dysfunction • Stenosis • degenerative • thrombosis • Regurgitation • Paravalvular • Transvalvular • Endocarditis • Mechanical Failure

31. Prosthetic Valve Endocarditis

32. High-risk procedure High-risk patient = + prophylaxis Valve disease: Management • Endocarditis prophylaxis

33. High-risk procedure High-risk patient + Endocarditis prophylaxis • Dental • GU • GI • Resp • *Congenital disease • *Prior endocarditis • *Prosthetic valves • Acquired valve disease • MVP with MR

34. Antibiotic Regimens Oral, Dental, Upper Resp Procedures: • Amoxicillin 2.0 gm p.o. • Alternative: • Clindamycin 600 mg p.o. • Cephalexin, Azithromycin GU, GI Procedures: • Ampicillin and Gentamycin • Alternative: Vancomycin

36. Case 1 • 36 year old male presents with palpitations. No past history. No meds. Sibling has heart murmur. • Exam: normal S1, S2. No murmur. Soft mid-systolic click. • EKG: normal except for PACs.

37. Case 1: 2D echo Findings: Posterior Leaflet Prolapse Mild (1+) Regurgitation

38. Mitral Valve Prolapse • A form of myxomatous valve disease • symptoms may be from: • mitral regurgitation • hyperadrenergic state • May progress to “surgical” MR • Often familial • Overdiagnosed clinically

39. Severe Posterior Leaflet Prolapse

41. Case 2 • 56 year old male with known heart murmur and MVP for 20 years. 3 days prior to admission, he had acute onset dyspnea and orthopnea. • Exam: pulse 110. 3/6 holosystolic murmur at apex. Bilateral crackles. • Labs: Troponin negative • EKG: sinus tachy • CXR: pulmonary edema

42. Case 2: TEE Findings: Severe MV prolapse Flail Posterior Leaflet Severe (4+) MR

43. Flail Mitral Valve Leaflet • A complication of myxomatous valve disease: rupture of chordae tendinae • Rarely from endocarditis, rheumatic, etc • Presents as severe MR with CHF • Accurately diagnosed with TEE • High untreated mortality • Accounts for 30 to 50 % of MV surgery • Highly amenable to valve repair

44. Mitral Regurgitation • Etiology: Chronic _ Myxomatous valve disease (MVP) • LV dysfunction, prior MI • Endocarditis, rheumatic disease • Etiology: Acute • Papillary muscle rupture s/p AMI • Chordal rupture (flail leaflet) • Acute endocarditis • Accurately diagnosed with TEE (mechanism, severity, reparability) • Surgery indicated for symptoms or LV dilatation/dysfunction • No role for med therapy

46. Case 3 • 53 y.o. female with chronic dyspnea. Atrial fib for 12 years. • Exam: • 4/6 blowing systolic murmur at apex with harsh component at LSB • harsh diastolic rumbling murmur • reduced S2, loud opening snap • prominent JVD

47. Case 3: 2D echo Findings: Rheumatic changes of MV Severe MS, Moderate AS Moderate MR

48. Mitral Valve Stenosis • A complication of acute rheumatic fever • Valve disease occurs 20 yrs after initial acute illness • Presents as exertional dyspnea and murmur • Complications: A.Fib., emboli, refractory pulmonary hypertension • Therapy: Commisurotomy or valve replacement

50. Case 3b • 72 y.o. female with dyspnea. • Exam: • 2/4 systolic murmur • Normal S1 and S2