overview of valvular heart disease january 28, 2006 david r. richards, do, facc, fase midohio...
TRANSCRIPT
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
• “Primary” valve disease
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
65 y.o. female with MVR and acute CHF
65 y.o. female with MVR and acute CHF
65 y.o. female with MVR and acute CHF
S/P thrombolytic therapy
S/P bioprosthetic valve replacement
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
2 D Echocardiography
Transesophageal Echo (TEE)
S1 S2
systole diastole
MV closure
AV closure
S1 S2
Mild AS
Severe AS
Mitral regurg
MVP
S1 S2
Mitral Stenosis
Severe AR
Mild AR
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
Mechanical Prostheses
2D Echo: normal mechanical MV
Heterografts: Porcine
Aortic Homograft
TEE: aortic homograft
Mitral Annuloplasty Ring
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
Prosthetic Valve Endocarditis
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.
Case 1: 2D echo
Findings: Posterior Leaflet ProlapseMild (1+) Regurgitation
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
Severe Posterior Leaflet Prolapse
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
Case 2: TEE
Findings: Severe MV prolapseFlail Posterior LeafletSevere (4+) MR
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
Case 3: 2D echo
Findings: Rheumatic changes of MVSevere MS, Moderate ASModerate MR
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
Case 3b
• 72 y.o. female with dyspnea.• Exam:
– 2/4 systolic murmur– Normal S1 and S2
Case 3b
Case 3b
Normal Aortic Valve Calcific Aortic Stenosis
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
Case 4: 2D Echo
Findings: Moderate ARBicuspid AV Normal LV size and function
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 5: 2D Echo
Case 5: 2D Echo
Case 5: 2D Echo
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.
25 y.o woman with fatigue
Findings: MV mass ? Myxoma
