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Valvular Heart Disease: An Update in Management. Bruce W. Andrus MD DHMC Cardiology Symposium December 2002. Learning Objectives . Locate and review ACC/AHA guidelines Review timing of surgery in VHD Consider role of medicine in VHD Discuss impact of VHD on operative risk

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valvular heart disease an update in management

Valvular Heart Disease:An Update in Management

Bruce W. Andrus MD

DHMC Cardiology Symposium

December 2002

learning objectives
Learning Objectives
  • Locate and review ACC/AHA guidelines
  • Review timing of surgery in VHD
  • Consider role of medicine in VHD
  • Discuss impact of VHD on operative risk
  • Revisit endocarditis prophylaxis
outline
Outline
  • Case Presentations (with audience participation)
  • Specific Valve Lesions
    • Physiologic principles/natural history
    • Images
    • Guidelines
  • Cases Revisited
audience response test
Audience Response Test

What did you have for breakfast?

A) cereal or bagel

B) donuts or danish

C) eggs, bacon, and/or sausage

D) a foil wrapped energy bar

E) none of the above

case 1
Case 1
  • JB, a 45 yo contractor, presents with a cc of increasing dyspnea over the past 6 months. Able to climb stairs, but very tired climbing scaffolding. Occ pounding in chest/neck.
  • Denies cp, syncope.
  • PMH significant only for htn. No rheumatic fever, anorexigen use, IE.
case 16
Case 1
  • On Exam:
    • Brawny, mildly overweight, no distress.
    • HR 80 regular, BP 160/50.
    • Rapidly collapsing pulse, subtle head nodding
    • Apical impulse hyperdynamic, diffuse and laterally displaced. Diastolic thrill at base.
    • Soft S1, soft S2, ejection sound at base (diaphragm), +S3 at apex (bell), descrescendo murmur leaning forward in expiration.
case 17
Case 1
  • CXR:
    • enlarged LV, widened mediastinum.
  • Echo:
    • dilated LV (ESD 57 mm, EDD 80 mm), EF 50%.
    • bicuspid aortic valve, 4+ AR, mildly dilated Asc Ao.
case 18
Case 1

As the next step in management, would you

A) start beta blocker for htn and repeat echo in 6 mos

B) start long acting nifedipine

C) refer for surgery now

D) start diuretic and see in 1 month

case 2
Case 2
  • MB, a 50 yo woman, native of India, now working as a medical technologist in your hospital.
  • Makes appt to discuss frequent episodes of “bronchitis”, declining exercise tolerance and occasional episodes of hemoptysis.
  • PMH neg. for htn, tobacco use, dm, dyslipidemia, obesity.
case 210
Case 2
  • On exam:
    • Thin, pleasant woman. Comfortable looking.
    • HR 96 irreg, irreg. BP 146/88.
    • JVP 7 cm H20. Bibasilar insp crackles.
    • Apical impulse not displaced.
    • S1 varies in intensity, nl S2. Opening snap

and diastolic rumble shortly following S2.

case 211
Case 2
  • Echo:
    • Thickened and immobile mitral valve. No calcification. Minimal fusion of subvalvular apparatus.
    • Moderately enlarged LA.
    • Doppler evidence of stenosis with estimated pressure gradient of 8 m Hg and MVA of 1.7 cm2.
case 212
Case 2

Which of the following would you do next?

A) begin asa for stroke prophylaxis

B) begin warfarin

C) start metoprolol

D) B and C

E) begin Coenzyme Q10

case 213
Case 2

Which of the following would you next pursue?

A) closely observe, repeat echo in 6 mos

B) refer for mitral valve replacement

C) refer for percutaneous balloon vavuloplasty

D) schedule for exercise echocardiography

case 3
Case 3
  • EA, an 84 yo widow and retired english teacher, sees you for vague chest discomfort and a near syncopal episode while climbing stairs with groceries.
  • Longstanding “benign” murmur.
  • PMH: htn, mild hyperlipidemia, OA, familial tremor. On HCTZ 12.5 mg qD and atenolol 25 mg BID.
case 315
Case 3
  • On exam:
    • thin, elderly woman neatly dressed.
    • HR 60. BP 155/76 both arms. BMI 19.
    • JVP ~11 cm H2O. Carotid upstrokes brisk.
    • Fine bibasilar crackles.
    • Apical impulse sustained. Thrill at RUSB. Nl S1 and harsh late peaking sys murmur at RUSB obscuring S2. Musical sounding sys murmur at apex. Valsalva strain and standing diminish murmur. Handgrip increases murmur.
case 316
Case 3
  • ECG:
    • LAD, LA abn, mild IVCD (QRS 110 ms), asymmetric T wave inversion in V5 and V6
  • Echo:
    • dilated LA, normal LV chamber size, moderate LVH
    • normal LV systolic function
    • calcified Ao valve, estimated valve area 0.6 cm2
case 317
Case 3

How would you manage her?

A) refer for EP study and possible ICD

B) begin atorvastatin 80 mg qD

C) refer for consideration of valvuloplasty

D) refer for coronary arteriography in anticipation of AVR

E) initiate Hospice referral, palliative care

case 4
Case 4
  • RD, a 73 yo retired insurance salesman, sees you because a urologist evaluating him for erectile dysfunction heard a murmur.
  • Denies SOB, chest pain or syncope but is very sedentary. Has notice some fatigue and dependent edema.
  • Diagnosed with MVP 25 yrs ago.
case 419
Case 4
  • On exam:
    • obese, loquacious man with petite wife
    • HR 86. BP 170/94. BMI 45.
    • JVP 12 cm H2O. Nl carotid upstrokes
    • diminished bs, no crackles
    • apical impulse not palpable
    • Neither S1 or S2 are well heard, obscured by a holosystolic blowing murmur at apex and left parasternal border
case 420
Case 4
  • ECG:
    • SR, RAD, LA abn, R>S in V1, NSSTT abn
  • CXR:
    • LA and LV enlargement
  • Echo:
    • severe LA enlargement, mild LV dilatation (ESD 45mm), nl LVEF (60%), pulmonary hypertensio (est PASP 55 mmHg)
case 421
Case 4

How would you manage this gentleman?

A) begin ACE inhibitor

B) begin digoxin for inotropic support

C) refer for exercise echo

D) refer for consideration of MV repair

E) A and D

case 422
Case 4

Does this man need endocarditis prophylaxis for a dental extraction?

A) yes

B) only if the tooth is infected

C) only if local anaesthetic will be used

D) no

aortic stenosis physiologic principles natural history
Aortic StenosisPhysiologic Principles-Natural History
  • Normal aortic valve area is 3.0 - 4.0 cm2
  • Circulation affected when valve area is reduced by ~ 75% (i.e. 0.75 - 1.0 cm2)

valve area (cmsq)mean gradient (mm Hg)*

Mild > 1.5 < 25

Moderate 1.0 - 1.5 25 - 50

Severe < 0.75 > 50

* assumes normal cardiac output

aortic stenosis physiologic principles natural history24
Aortic StenosisPhysiologic Principles-Natural History
  • Primary adaptation is concentric hypertrophy
  • Latent phase usually lasts decades
  • Risk of sudden death is very low during this phase
  • Rate of progression ranges from 0-0.3 cm2/yr. (average rate is 0.12 cm2/yr)
  • 50% of patients with severe AS do not progress
  • Cannot predict who will progress
aortic stenosis physiologic principles natural history25
Aortic StenosisPhysiologic Principles-Natural History

Bonow et al. Valvular Guidelines. Circ

aortic stenosis physiologic principles natural history26
Aortic StenosisPhysiologic Principles-Natural History
  • Once symptoms develop, average survival is 2-3 yrs
  • With LV systolic dysfunction, there may be increased risk of sudden death and permanent LV dysfunction
aortic stenosis management guidelines
Aortic StenosisManagement Guidelines

Initial Diagnostic Testing

  • Lipids, renal fxn, Ca, P---all patients
  • CXR, ECG, Echocardiography---all patients
  • Cardiac catheterization with angiography
    • If clinical and echo data are discordant
    • To assess coronary circulation prior to surgery
aortic stenosis management guidelines29
Aortic StenosisManagement Guidelines

Initial Diagnostic Testing (cont.)

  • Treadmill stress testing
    • Dangerous in symptomatic pts
    • Not useful for dx of CAD
    • May be used to assess functional significance of severe AS in pts who deny symptoms (e.g. bp response)
aortic stenosis management guidelines30
Aortic StenosisManagement Guidelines

Scheduled Follow-up

office intervalecho interval

Mild AS 12 mos 5 yrs

Moderate AS 6 mos 2 yrs

Severe AS 6 mos 1 yr

aortic stenosis management guidelines31
Aortic StenosisManagement Guidelines

Low Gradient AS

  • Special case
  • Minimal valve mobility and low cardiac output
  • Calculated valve area is small but pressure gradient is also small
  • Functional vs. fixed AS?
  • Consider dobutamine stress test (DSE) to clarify
acc classification of recommendations
ACC Classification of Recommendations

Class I:

Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II:

Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa. Weight of evidence/opinion is in favor of usefulness/efficacy

IIb. Usefulness/efficacy is less well established by evidence/opinion.

Class III:

Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

aortic stenosis management guidelines33
Aortic StenosisManagement Guidelines

Recommendations for AVR

Class I

  • Severe AS and symptoms
  • Severe AS (with or without sxs) and need for CABG, other valve replacement or aortic surgery

Class IIa

  • Moderate AS and need for other cardiac surgery
  • Asymptomatic severe AS and diminished LVEF or hypotensive response to exercise
aortic stenosis management guidelines34
Aortic StenosisManagement Guidelines

Recommendations for AVR (cont.)

Class IIb

  • Asymptomatic AS and VT, severe LVH (>15mm)

or valve area <0.6 cm2

Class III

  • Asymptomatic AS with none of the above
aortic regurgitation physiologic principles natural history
Aortic RegurgitationPhysiologic Principles-Natural History
  • LV faces combined pressure and volume load
  • Primary adaptation is dilatation (eccentric hypertrophy)
  • Since this adaptation takes time, AR classified as acute or chronic
  • Acute AR results in sudden increase in LVEDP >>> pulmonary edema and cardiogenic shock
aortic regurgitation physiologic principles natural history36
Aortic RegurgitationPhysiologic Principles-Natural History
  • Latent phase of AR, like AS, may last decades
  • Decompensation when
    • LV systolic function begins to fail
    • Progressive LV dilatation occurs
    • Spherical geometry develops
  • Initially this is reversible
  • LV systolic function and ESD are the most important predictors of postop survival and LV function
aortic regurgitation physiologic principles natural history37
Aortic RegurgitationPhysiologic Principles-Natural History
  • In asymptomatic pts with severe AS and nl LV systolic function, progression is slow
    • 4.3%/yr develop symptoms of LV systolic dysfunction
    • 1.3%/yr progress to LV dysfunction without symptoms†

† pooled data from 7 series. 490 pts with mean follow-up of 6.4 yrs

aortic regurgitation management guidelines
Aortic RegurgitationManagement Guidelines

Initial Evaluation

  • ECG
  • CXR
  • Echo
  • ETT (if pt asymptomatic but sedentary or if symptoms are equivocal)
aortic regurgitation management guidelines39
Aortic RegurgitationManagement Guidelines

Scheduled Follow-up (office and echo)

Severe AR without symptoms

  • q 4-12 month depending on pace of change and current LV ESD/EDD

Moderate AR without symptoms

  • 1st follow-up in 2-3 months to establish pace, then ~ q 12 months
aortic regurgitation management guidelines40
Aortic RegurgitationManagement Guidelines

Vasodilator Therapy

  • Expected to  afterload,  stroke volume and

 regurgitant volume

  • Hemodynamic benefit shown with hydralazine and nifedipine, less consistent results with ACEi
  • Improvement in clinical outcomes in trial of LA nifedipine vs. digoxin (need for AVR in 143 pts followed for 6 yrs--- 15% vs 34%)
  • Dose titrated to achieve  in SBP, not normalization
aortic regurgitation management guidelines41
Aortic RegurgitationManagement Guidelines

Vasodilator Therapy Indications

Class I

  • Severe AR with symptoms or severe LV dilatation but contraindications to surgery
  • Severe AR without symptoms but LV dilatation and elevated SBP
  • Any degree of AR with hypertension
  • Persistent LV systolic dysfunction s/p AVR (ACEi)
  • Short term therapy prior to AVR
aortic regurgitation management guidelines42
Aortic RegurgitationManagement Guidelines

Vasodilator Therapy Indications

Class III

  • Mild to mod AR without sxs and nl LV function
  • In lieu of AVR in pts without contraindications
aortic regurgitation management guidelines43
Aortic RegurgitationManagement Guidelines

Recommendations for AVR (chronic severe AR)

Class I

  • NYHA functional class III or IV sxs
  • NYHA functional class II sxs and progressive LV dilatation or declining LVEF on serial studies
  • CCS class II angina
  • Mild or moderate reduction in EF (25-50%)
  • Need for CABG or surgery on other valves
aortic regurgitation management guidelines44
Aortic RegurgitationManagement Guidelines

Class IIa

  • NYHA class II sxs with nl LVEF (>50%) with stable EF, LV size and exercise tolerance
  • Asymptomatic pts with nl LVEF but severe LV dilatation (ESD > 55 mm or EDD > 75 mm)

Class IIb

  • LVEF < 25%
  • Asymptomatic pts with nl LVEF and progressive LV dilatation with ESD 50-55 mm or ESD 70-75 mm
mitral stenosis physiology natural history
Mitral StenosisPhysiology/Natural History
  • Normal MVA 4 -5 cm2
  • Symptoms not apparent until area < 2.5 cm2

valve area (cmsq) mean gradient (mmHg)*

Mild > 1.5 < 5

Moderate 1.0 - 1.5 5 -10

Severe < 1.0 > 10

* assumes normal cardiac output

mitral stenosis physiology natural history53
Mitral StenosisPhysiology/Natural History
  • Akin to severe diastolic dysfunction
  • V = IR (electrical)
  • P = QR (hydraulic)
  • Q = P/Rvalve
mitral stenosis physiology natural history54
Mitral StenosisPhysiology/Natural History
  • LA pressure  PV pressure  interstitial edema  ± alveolar flooding
  • Adaptations:

-pulmonary vascular constriction, intimal hyperplasia, medial hypertrophy  reversible pulmonary hypertension  ± fixed pulm htn

-downregulation of neuroreceptors, lymphatic drainage

mitral stenosis physiology natural history55
Mitral StenosisPhysiology/Natural History
  • Latent (subclinical) phase in RHD 20-40 yrs
  • 10 yrs of symptoms before disabling
  • With physically limiting symptoms
    • 10 yr survival 0-15%
    • 10-20% systemic embolism
    • 30-40% develop AF
  • With onset of severe pulm hypertension
    • Mean survival < 3 yrs
mitral stenosis management guidelines
Mitral StenosisManagement Guidelines

Initial Evaluation

  • History
  • Physical
  • ECG
  • CXR
  • Echocardiogram
  • ± Exercise echocardiogram
mitral stenosis management guidelines57
Mitral StenosisManagement Guidelines

Medical Therapy

  • Rheumatic fever prophylaxis
  • Infective endocarditis prophylaxis
  • Limitation of strenuous physical activities
  • Control of HR (negative chronotropes)
  • Na restriction, intermittent diuretic use
  • Prompt management of AF
mitral stenosis management guidelines58
Mitral StenosisManagement Guidelines

Interventional and Surgical Options

  • Percutaneous mitral balloon valvotomy (PMBV)
  • Closed commissurotomy (obselete)
  • Open commissurotomy
  • Mitral valve replacement
mitral stenosis management guidelines59
Mitral StenosisManagement Guidelines

Indications for PMBV (class I and IIa)

  • Suitable anatomy, no LA clot, ≤ mild MR
  • Symptomatic pts (NYHA class II-IV) with MVA <1.5 cm2
  • Asymptomatic pts with MVA <1.5 cm2 and PASP 50 mmHg at rest, 60 with exercise
mitral stenosis management guidelines60
Mitral StenosisManagement Guidelines

Indications for MVR (class I and IIa)

  • Symptomatic pts (NYHA class III and IV) with MVA < 1.5 cm2 unsuitable for PMBV
  • NYHA class I and II pts with MVA < 1.0 cm2 and PASP >60 at rest unsuitable for PMBV
acute mitral regurgitation physiology and natural history
Acute Mitral RegurgitationPhysiology and Natural History
  • Abrupt volume load---no time for adaptation
  • Sudden  in forward stroke volume
  • Sudden  in LA volume/pressure   PV pressure
  • Rapidly fatal
acute mitral regurgitation management guidelines
Acute Mitral RegurgitationManagement Guidelines

Medical Stabilization (while gathering OR team)

  • If normotensive: nitroprusside
  • If hypotensive: nitroprusside + dobutamine

or

intra-aortic balloon pump (IABP)

chronic mitral regurgitation physiology and natural history
Chronic Mitral RegurgitationPhysiology and Natural History
  • Gradual development allows adaptation
  • LA dilatation and increase in compliance
  • LV dilatation and  EF (via  preload and  afterload)  maintenance of forward SV
  • Compensation often adequate for vigorous exercise
  • May last many years
chronic mitral regurgitation physiology and natural history64
Chronic Mitral RegurgitationPhysiology and Natural History
  • Eventually, volume overload  LV decompensation
  • Preop LVEF (>60%) and LVESD (<45 mm) are primary predictors of postop survival
slide65

Wisenbaugh T, et al: Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation. Circulation 89:191, 1994.

chronic mitral regurgitation management guidelines
Chronic Mitral RegurgitationManagement Guidelines

Initial evaluation

  • History
  • Physical Exam
  • ECG
  • CXR
  • Echo
  • ± Exercise echo
chronic mitral regurgitation management guidelines67
Chronic Mitral RegurgitationManagement Guidelines

Scheduled Follow-up*

Instruct all pts to report any cv symptoms

office intervalecho interval

Mild MR 12 mos if sxs

Moderate MR 12 mos 1-2 yrs

Severe MR 6-12 mos 6-12 mos**

*assumes no symptoms and no sequellae

** consider exercise echo

chronic mitral regurgitation management guidelines68
Chronic Mitral RegurgitationManagement Guidelines

Medical Therapy

  • No generally accepted rx in asymptomatic pts
  • No long term studies suggesting benefit of afterload reduction in absence of hypertension
  • ACEi if hypertensive
  • AF requires rate control, anticoagulation and 1 attempt at restoration of SR
chronic mitral regurgitation management guidelines69
Chronic Mitral RegurgitationManagement Guidelines

Surgical Options

  • Mitral valve repair
  • Mitral valve replacement with preservation of subvalvular apparatus
  • Mitral valve replacement with excision of subvalvular apparatus
  • MVR with CABG (in ischemic MR)
slide70

Rozich JD et al: Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation; mechanisms for differences in postoperative ejection performance. Circulation 86:1718, 1992.

chronic mitral regurgitation management guidelines71
Chronic Mitral RegurgitationManagement Guidelines

Indications for Surgery (class I and IIa)

  • Symptomatic pts with severe MR and an LV appearing “less than hopeless” (EF > 30, ESD < 55 mm)*
  • Asymptomatic pts with moderate or severe MR and any of the following: EF 30-60%, ESD > 45 mm, AF, PASP > 50 at rest, PASP > 60 with exercise

*consider if chordal preservation appears very likely