Acquired Valvular Heart Disease: Causes, Complications & Management

1. ACQUIRED VALVULAR HEART DISEASE Iwona Świątkiewicz Katedra i Klinika Kardiologii i Chorób Wewnętrznych Collegium Medicum w Bydgoszczy

2. AVHD – acquired valvular heart disease • LV – left ventricle • LA – left atrium • RV – right ventricle • RA – right atrium • HF – heart failure • AF – atrial fibrillation • AV – aortic valve • MV – mitral valve • EF – ejection fraction • MR - mitral regurgitation • TR – tricuspid regurgitation • LVEDP – LV end-diastolic pressure • LVED(S)V(D) – LV end-diastolic (systolic)volume (diameter) • SV – stroke volume • CO – cardiac output

3. Left ventricular end-diastolic volume (LVEDV): 110-120 ml • Left ventricular end-systolic volume (LVESV): 40-50 ml • Left ventricular stroke volume (LVSV): 70-80 ml • Left ventricular ejection fraction (LVEF): 58-73% • Cardiac output (CO): at rest about 5 l (on exertion 20-25 l)

4. Left ventricular end-diastolic pressure (LVEDP): 6-12 mm Hg • Left ventricular end-systolic pressure (LVESP): 90-140 mm Hg • Left atrial pressure (mean): 6-11 mm Hg • Right atrial pressure (mean): 1-5 mm Hg • Right ventricular end-diastolic/end-systolic pressure : 2-7/20-30 mm Hg • Pressure in pulmonary artery (diastolic/peak systolic/mean): 4-13/16-30/9-18 mm Hg • Pulmonary wedge pressure: 5-12 mmHg • Aortic pressure (diastolic/peak systolic/mean): 70-90/90-140/70-110 mmHg • Pulmonary load: 0,8-1,1 (0,3-1,6) acc. Wood’s

5. Acquired valvular heart disease - definition The dysfunction of heart due to the presence of acquired abnormal structure and/or function of the valve

6. Acquired valvular heart disease – primary (structural) - due to the changes in the structure of valve

7. Acquired valvular heart disease – secondary (functional) - due to the changes in the function of valve caused by abnormalities in the structure of other elements of the heart

20. Causes of death in acquired valvular heart disease • Congestive heart failure • Sudden cardiac death • Arrythmia • Stroke • Infective endocarditis • Death in the periintervention period (because of the complications of interventional/surgical treatment)

21. Left ventricle in acquired valvular heart diseases • Volume and/or pressure overload • Remodelling • Dysfunction – decides about prognosis

22. Remodelling of left ventricle • Left ventricular hypertrophy (LVH) • Left ventricular enlargement • Spheric shape of left ventricle • Increased wall stress of left ventricle

23. Left ventricular hypertrophy • Left ventricular eccentric hypertrophy (volume overload) • Left ventricular concentric hypertrophy (pressure overload)

24. T = p X R² / ThT – LV wall stressp – LV pressureR – LV radiusTh – LV wall thickness

25. AORTIC STENOSIS

26. Aortic stenosis • the third most frequent cardiovascular disease • Aortic valve replacement • – the second most frequent cardiosurgical procedure

27. Aortic valve - physiology Aortic valve area (AVA): 2–4 cm2 Peak velocity of aortic flow: 1,0–1,7 m/s Left ventricular pressure: end-systolic (140-90 mm Hg) end-diastolic (do 12 mm Hg) Peak pressure gradient across aortic valve < 20 mmHg

29. Bicuspid aortic valve Most frequent congenital defect in adults More frequent in male (4x) Positive family history With other cardiovascular defects (CoA, PDA) 30% patients – cardiovascular complications (valvular and/or vascular)

30. Bicuspid aortic valve Valvular complications Aortic stenosis Aortic regurgitation Infective endocarditis – prevention !!! Vascular complications Dilatation/aneurysma Dissecting aneurysm

31. Aortic stenosis - patophysiology Aortic valve area < 1 cm2 Left ventricular outflow obstruction during systole • LV systolic pressure LV pressure overload ↓ LV concentric hypertrophy → normalisation of LV wall stress

32. Aortic stenosis - patophysiology Compensation preventing cardiac output decrease: •  LV systolic pressure , •  antegrade velocity across the narrowed valve, •  systolic pressure gradient across aortic valve (between LV and aorta), • LV concentric hypertrophy , •  LV contractility, •  LV ejection time. Unchanged cardiac output at rest Decreased cardiac output on exertion  symptoms (angina, syncope)  LV end-diastolic pressure caused by LVH  symptoms on exertion (dyspnea, fatigue)

33. Aortic stenosis - patophysiology • LV contractility (caused by increased wall stress)  ↓ LV cardiac output  symptoms (syncope, angina) • LV end- systolic volume • LV end-diastolic pressure  symptoms (dyspnea, fatigue) LV heart failure  symptoms (dyspnea in rest)

34. Aortic stenosis - history • Asymptomatic for many years • First symptoms in calcified bicuspid valve at age of 50-60 years, and in degenerative tricuspid valve at age of 70-80 years • First symptoms associated with exertion, • Angina (5 years to death), • Syncope (3 years), • Dyspnea (2 years).

35. Aortic stenosis Symptoms: - angina - exertional lightheadedness - syncope - heart failure - sudden cardiac death

36. Aortic stenosis - angina • Reasons: • - Coronary artery disease • Inadequate oxygen supply/demand • LV hypertrophy • coronary microciculation not increased • increase of vascular thickness and load • perivascular fibrosis • LV EDP increase • subendocardial ischaemia

37. Aortic stenosis - syncope • Reasons: • Inadequate brain perfusion: • - acute drop in blood pressure due to an inappropriate LV baroreceptor response • - ventricular arrhythmias

38. Aortic stenosis – reasons of death Heart failure 50-60% Infective endocarditis 15-20% SUDDEN DEATH 5-34% 65-80% pt - symptomatic 3-5% pt - asymptomatic

39. Aortic stenosis – physical examination (key features) • Apex beat displaced laterally and down • Loud single second heart sound (severe AS) or reverse splitting of second heart sound (moderate AS) • S4 gallop • Systolic murmur: timing - crescendo-decrescendo during systole; location - the loudest at the base (over the right second intercostal space); systolic thrill (in severe AS); radiation - to the carotides; typically AS first diagnosed based on the finding on a murmur on auscultation • Palpation of the carotid pulse contour and amplitude: pulsus tardus (peak aortic pressure later in systole) and parvus (decreased pulse amplitude) • Typical signs of heart failure (if hemodynamic decompensation occured)

40. Aortic stenosis –diagnostic approaches • - ECG (LVH) • Chest radiograph (poststenotic dilatation • of ascending aorta, calcifications of • aortic valve) • - Echocardiography

41. Aortic stenosis – echocardiography - morphology and mobility of AV leaflets - calcifications of AV - maximum velocity of aortic jet (vmax) - peak pressure gradient - meanpressure gradient - AV area (AVA) - contractility and LV ejection fraction - LV hypertrophy - assessment of other valves!!!

42. Severe aortic stenosis – echocardiographic criteria v maxMeanPG AVA >4,0 m/s >40 mmHg <1,0 cm2AVAI <0,6cm2/m2 ESC, 2012

43. Predictors of survival in adult patients with symptomatic aortic stenosis are stenosis severity expressed as jet velocity or transaortic gradient, functional status and LV systolic function.

44. Aortic stenosis -prognosis 50% increase of cardiovascular risk 5-year survival in symptomatic patients15-50%

45. MITRAL STENOSIS

46. Mitral valve - physiology Mitral valve area 4 – 6 cm2 Diastolic pressure gradient between LA and LV 1 – 3 mmHg Maximal velocity of mitral flow 0,6 – 1,3 m/s

47. Mitral stenosis - ethiology • - rheumatic • (fibrosis and thickening of leaflets; fusion of leaflet edges along commissures; fusion, thickening and shortening of chordae; superimposed calcific changes) • - myxoma in LA • massive calcifications in mitral annulus poreumatyczna

48. Mitral stenosis - pathophysiology Presence of mechanical obstruction at MV level (significant if MVA < 2,0 cm²)   diastolic transmitral pressure gradient between LA and LV  LA pressure • normal LV filling but  LA pressure

49. Mitral stenosis - pathophysiology MVA 1–1,5 cm²   transmitral gradient and LA pressure  LA enlargement  • Pulmonary venous pressure  dyspnea  • Pulmonary arterial pressure  RV pressure overload  RV hypertrophy  RV dilation + tricuspid functional regurgitation  Right heart failure

50. Mitral stenosis – clinical history • Acute rheumatic fever episode in past medical history (rare finding) • Slow but progressive decline in exercise capacity, fatigue • Symptoms of pulmonary congestion: dyspnea on exertion, shortness of breath, paroxysmal nocturnal dyspnea, pulmonary oedema • Symptoms of right heart failure: peripheral oedema, abdominal distention, decreased appetite • Hoarseness (Ortners’ s. – due to compression of the left recurrent laryngeal nerve by the enlarged LA) • Recurrent pulmonary infections, hemoptysis