overview of valvular heart disease january 28, 2006 david r. richards, do, facc, fase midohio...
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Overview of Valvular Heart
DiseaseJanuary 28, 2006
David R. Richards, DO, FACC, FASEMidOhio Cardiology and Vascular Consultants
Director, Heart Disease Management Program Riverside Hospital
Valve Disease: general concepts
• Etiology and natural history• Physical findings• Therapy
– types of surgical therapy– indications for surgery– indications for anticoagulation– antibiotic prophylaxis
Etiology of valve disease
• “Secondary” valve disease– Hypertension– CAD– Cardiomyopathy
• “Primary” valve disease
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
Diseasesprimary
• degenerative• rheumatic• endocarditis• myxomatous• congenital
secondary• CAD / cardiomyopathy
Mechanisms
• Aortic stenosis• Mitral stenosis• Mitral regurg.• Aortic regurg. • Tricuspid regurg
Mechanisms of Valve Disease
Rheumatic Post-inflammatorythickening andcalcification
Mitral StenosisAortic StenosisMitral Regurg
Degenerative Age-relatedcalcification andfibrosis
Aortic StenosisMitral Regurg
Myxomatous Redundant andfloppy leaflets
Mitral RegurgAortic Regurg
Endocarditis Leafletdestruction
Mitral RegurgAortic Regurg
Valvular Emergencies
• Acute Endocarditis
• Papillary Muscle Rupture
• Flail Mitral Leaflet
• Prosthetic Valve Thrombosis / Dehiscence
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
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
Prosthetic Valves: selection
• Bioprosthetic
• Mechanical
• Homograft
• No Coumadin needed• Less thromboembolic
complications
• Lifelong cure
• No Coumadin needed• Potential lifelong
integrity
Lifespan 10-15 yrs.
Lifelong Coumadin1% annual comp. Rate
Limited availability? Late failureTechnically challenging
Pros Cons
Prosthetic Valves: selection
• Bioprosthetic
• Mechanical
• Homograft
• Elderly pts.(lifespan < 15 yrs.• Contraindication to Coumadin
• Elderly who already need Coumadin• All other patients
• Young patients with Aortic Valve disease
Prosthetic Valves:types of dysfunction
• Stenosis– degenerative– thrombosis
• Regurgitation– Paravalvular– Transvalvular
• Endocarditis• Mechanical Failure
Valve disease: Management
• Endocarditis prophylaxis
High-riskpatient
High-riskprocedure+ = prophylaxis
Endocarditis prophylaxis
High-riskpatient
High-riskprocedure+
•*Congenital disease•*Prior endocarditis •*Prosthetic valves •Acquired valve disease•MVP with MR
•Dental•GU•GI•Resp
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
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.
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
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
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
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
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
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
Aortic Stenosis
• Most common etiology is degenerative calcific disease (age < 50, bicuspid AV or rheumatic)
• Classic Triad: Chest Pain, Dyspnea, Syncope
• Reduced exercise capacity may be earliest symptom (use exercise test)
• Surgery indicated for– any symptoms– LV dilation or dysfunction (EF <50%, ESD > 50mm)– NOT for specific valve area
Case 4
• 35 y.o. male found to have heart murmur. No symptoms.
• Exam: – ejection click– 2/4 diastolic murmur
Aortic Regurgitation
• Most common etiology is degenerative (age < 50, bicuspid AV or rheumatic)
• Reduced exercise capacity may be earliest symptom (use exercise test)
• Surgery indicated for– any symptoms– LV dilation or dysfunction (EF <50%, ESD >
50mm)
Case 5
• 10 years later, patient develops acute fever, weakness. Patent reports severe dyspnea at rest.
• Exam: BP 80/50, HR 110, bilateral crackles, soft diastolic murmur, S4 gallop
Case 4
•Echo: bicuspid AV with vegetation, severe AR,dilated LV with EF 30%
•antibiotics, diuretics, & pressors areinitiated. The patient initially stabilizes, but within 24 hours develops recurrent hypotensionand respiratory failure.
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