valvular heart disease adriel e. guerrero, md, fpcp, fpcc training officer section of cardiology,...
TRANSCRIPT
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Valvular Heart Disease
ADRIEL E. GUERRERO, MD, FPCP, FPCC
Training Officer
Section of Cardiology, Dept of Medicine
The Medical City
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Mitral Stenosis
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Diagnostic Features of MS@
2/3 are females; Pure MS are generally rheumatic
History:Exertional Dyspnea, PND, Orthopnea and Hemoptysis
PE:Opening snap, loud S1, diastolic rumble at the apex
ECG and Chest Xray:
Evidence of left atrial enlargement with normal left ventricular size; RVH in later stages
2DECHO
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Chest Xray MS
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Common Etiologies of MS
Rheumatic Heart Disease
Congenital Heart diseaseCongenital MSLutembachers syndrome (MS and ASD)
Mitral Annular Calcification (elderly)
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Mitral Stenosis@
Pathophysiology
Obstruction to LV filling
Increase LA pressure
RV Failure
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Natural History of MS
Pulmonary HypertensionFibrous thickening of alveolar and pulmo capillary
walls
Thrombi and EmboliLeft atrial appendage Increased: AF, older patients, reduced CO
Pulmonary Infections, IE,
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Natural History of Mitral Stenosis
MS - blue
MR - purple
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Differential Diagnosis of MSAtrial Septal Defect
RVE and accentuated pulmo markingsWidely split S2 (fixed)VS Opening snap; diastolic flow across the TVNo LAE
Left Atrial MyxomaObstructing LA emptying, tumor-plop
Mitral RegurgitationSystolic murmur; LVH
Aortic Regurgitation (Austin Flint)Apical middiastolic murmur of AR. Becomes louder on handgrip and
decreases with amyl nitrate
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Treatment of MS
Penicillin Prophylaxis of B-hemolytic Streptococcal Infections to prevent Rheumatic Fever and IE
Sodium restriction, oral diuretics
Oral Anticoagulation (Warfarin) INR target 2-3.1 (embolization, permanent AF)
Heart Rate Controlling drugsTo lengthen diastolic LV fillingDigitalis in Atrial Fibrillation; Beta-blockers in sinus
rhythmNondihydropyridine Calcium Antagonists
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Mitral Valvotomy
Indicated in symptomatic patients with isolated MS (<1.0 cm2/m2)
Ideal for mobile, thin leaflets with no or little calcium without extensive subvalvular thickening and with no or mild MR
Open valvotomy – mortality rate is 2%
50% of all patients require reoperation by 10 years.
Pregnant – carried out if pulmonary congestion occurs despite intensive medical treatment
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Mitral Valve Replacement
MS with significant MR
Distorted valves from previous transcatheter or operative manipulation
Operative Mortality is 6%
Long term complications of valve replacement
Overall 10 year survival is 70%Poor Recovery
Old patients Marked disability Depressed Cardiac index
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Mitral Stenosis
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Percutaneous Trans-septal Mitral Commissurotomy
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Star Edwards Caged Ball Valve
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Medtronic Hall Valve (Bjork-Shiley)
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St Jude Bileaflet Valve
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Carpentier Edwards Porcine Valve
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Carpentier Edwards Pericardial Valve
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Mitral Regurgitation
Frequent in males
History:Easy Fatigue then exertional Dyspnea
PE:Characteristic holosystolic murmur at the apex with
radiation to the axilla
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Common Etiologies of MR
MV leaflet abnormality Rheumatic heart disease Myxomatous alteration (including MVP) Infective Endocarditis
Mitral annulus dilatation of any cause Dilated Cardiomyopathy IHD with dilated LV
Ruptured chordae tendinae Trauma Myocardial Infarction
Papillary muscle disorder Ischemic Heart Disease
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Mitral Regurgitation
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NORMAL
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Pathophysiology of Mitral Regurgitation
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Pathophysiology of Mitral Regurgitation
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Pathophysiology of Mitral Regurgitation
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Laboratory Examination
La enlargement; RAE maybe present if pulmonary HPN is severe
Atrial Fibrillation
LVH
ECG
2DECHO – most accurate non-invasive technique
CXR – LAE and LVE
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Medical Treatment for MR
Restrict Physical activities
Reduce sodium intake and enhance sodium excretion (diuretics)
Increase forward cardiac outputVasodilators (ACEI) and digitalis
Anticoagulants and leg binders to decrease likelihood of venous thrombi and pulmonary emboli
Endocarditis prophylaxis
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Surgical Treatment of MRNon-surgical candidates: asymptomatic, or exercise
limited to strenuous exertion, normal LV function
Surgery for severe MR even if asymptomatic or when LV dysfunction is progressive (declining <60%) and/or LV ESD on echo is >45mm
MV replacement for markedly shrunken, deformed, calcified leaflets
MV repair (reconstruction) with annuloplastyLessens problem on long term anticoagulation and
thromboembolismFor ruptured chordae, annular dilatation and IENot suitable for Mr due to myxomatous degeneration and
patients with calcified annulus
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Natural History of Unoperated MR
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Late Survival Rates after Surgical Correction in MR
(pre-op EF)
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Mitral Valve Prolapse
Barlow’s syndrome, floppy-valve syndrome, systolic click-murmur syndrome, billowing mitral leaflet syndrome
Excessive or redundant mitral leaflet tissue. Posterior MV leaflet is more affected than the AMVL
May lead to excessive stress on the papillary muscles leading to dysfunction. Rupture of chordae tendineae with progressive annular dilatation and calcification
Ventricular arrythmias
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Clinical Features
Females (14-30 years old)
Clinical course is often benign
Increased familial incidence – autosomal dominant
Most common cause of isolated severe MR requiring surgical treatment in North America
Arrythmias (PVCs, SVTs, VTs) – palpitations, lightheadedness and syncope. Sudden death is rare
Chest pain substernal, prolonged, unrelated to exertion
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Mitral Valve Prolapse
Mismatch between elongated MV and LV cavity
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Laboratory Exams
ECG – non specific STTW changes, PVCs
Echo – demonstrates systolic displacement of MVL and quantifies Mitral Regurgitation and LV function
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Treatment of MVP
IE prophylaxis
Beta-blockers sometimes relieve chest pain
For severe symptomatic MR, MV repair or rarely replacement is indicated
Antiplatelets for patients with TIA, anticoagulation if recurrent TIAs
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Survival Rates of MVP patients at baseline risk factors
Primary Risk Factors
Mod-severe MR; EF <50%
Secondary Risk Factors
Mild-mod MR; LA > 40
Flail leaflet; AF; age > 50
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Aortic Stenosis
80% with symptomatic AS are males
Age-related degenerative calcific AS – most common cause of AS in Adults
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Common Etiologies of AS
Valvular (90% of all cases)Rheumatic heart diseaseDegenerative calcification (elderly)Bicuspid AV stenosis/ Congenital heart disease
Subvalvular (9%)Hypertrophic Obstructive Cardiomyopathy (HOCM)Discrete
Supravalvular (<1%) Infancy
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NORMAL AORTIC VALVE
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Aortic Stenosis - Rheumatic
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Aortic Stenosis - Degenerative
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Aortic Stenosis - Bicuspid
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Pathophysio of AS
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Pathophysio of AS
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Aortic Stenosis
History:Cardinal symptoms
Exertional Dyspnea Angina Pectoris Syncope
PECarotid upstroke slowly rising and reduced in
amplitude in severe cases; Systolic ejection murmur radiating to the carotid arteries
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Laboratory Exam
LV hypertrophy is the key finding
ECG
2DECHO – estimate valve area, LV size and function
Cardiac catheterizationPresence or absence of concomittant CAD
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Natural History of Severe AS
Death most commonly occurs in the 7th and 8th decade
Average time from onset of symptoms to death:Angina – 3 yearsSyncope – 3 yearsHeart Failure – 1.5 – 2 years
Sudden death 10-20% in AS patients 60 years old and above
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Medical Treatment for AS
Severe AS (<0.5 cm2/m2)Avoid strenuous physical activities even if asymptomatic
Sodium restriction
Cautious administration of diuretics and digitalis in CHF
Nitroglycerin to relieve angina
Statins (HMGCoA reductase inhibitors) slows down progression of calcification (?)
No effect on long term survival
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Surgery in Aortic Stenosis
Indications for SurgerySevere Aortic Stenosis ( < 0.6 cm2/m2)
Symptomatic with LV dysfunction (LV Ejection Fraction <50%)
Expanding poststenotic aortic root (even if asymptomatic)Those who undergo CABG even if asymptomatic
Operative risk of Aortic Valve Replacement in asymptomatic severe AS is 4%. In frank CHF – 15 – 20%
10 year survival rate of patients with AVR = 60%30% of bioprosthesis fail in 10 yrsMechanical prosthesis – hemorrhage fm anticoagulation
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Management Strategy for Severe Aortic Stenosis
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Percutaneous Balloon Aortic Valvuloplasty
Preferred in children and young adults with congenital, noncalcific AS
High “restenosis” rate in calcific AS
“bridge to operation”
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Percutaneous Transcatheter Placement of AV prosthesis
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Percutaneous Transcatheter Placement of AV prosthesis
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Aortic RegurgitationEtiology
Primary Valve DiseaseRheumatic – 2/3 of patients Infective EndocarditisTraumaBicuspid valve
Primary Aortic Root DiseaseDegenerative heart diseaseSyphilisMarfan’s syndromeAnkylosing SpondylitisAortic Aneurysm with dissectionSystemic hypertensionGiant Cell arteritis
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Pathophysio of AR
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Aortic Regurgitation
History:Easy fatigue then exertional dyspnea (diminished
cardiac reserve) – orthopnea, PND and excessive diaphoresis
PE:Wide pulse pressure with bounding pulsesDiastolic decresendo murmur at the base of the
heartMidsystolic ejection murmur at base of the heartAustin Flint murmur – soft, low pitched rumbling
middiastolic bruit at the apex
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Peripheral Signs of Chronic ARCorrigan’s pulse: Pulses with abrupt distension and
quick collapse; water hammer pulse
De Musset’s sign: head bobbing
Traube’s sign: Pistol shot sound on the femoral artery
Duroziez’s sign: Systolic murmur heard over the femoral artery when compressed proximally
Muller’s sign: systoic pulsation of the uvula
Quincke’s sign: Capillary pulsation
Hill’s sign: Popliteal cuff SBP > brachial cuff SBP by 60mmHg
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Differential Diagnosis of a Bounding Pulse
Cardiac CausesAortic RegurgitationPatent Ductus Arteriosus
Non-Cardiac CausesArteriovenous FistulaFeverThyrotoxicosisPregnancy
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Symptomatology in AR
Symptoms depend on the onset of AR (acute/chronic)
Compensatory mechanisms LV dilatation Laplace Law ( myocardial wall tension = intracavitary
pressure x LV radius)
Deterioration of LV function precedes the development of symptoms
Chronic Severe AR may have a long latent period. Patients remain asymptomatic for as long as 10-15 years.
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Laboratory Exam
LV Hypertrophy
2DECHO + myocardial contractility and function
Cardiac catheterization and angiographyMagnitude of AR and status of LV function
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Survival without Surgery in Chronic AR
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Medical Treatment of AR
Salt restriction
Diuretics
Vasodilators (ACEI)Nitrates not as helpful in relieving angina
Syphilitic aortitis – penicillin tx
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Surgical Treatment of ARDefinitive treatment
Should be done before development of Heart Failure
Operation should be carried out even in Asymptomatic patients with progressive LV dysfunction and a left Ventricular Ejection Fraction < 55% or a LV end-systolic volume > 55 mL/m2 ( 55/55 rule)
AVR – mechanical or bioprosthesis
Operative mortality for isolated AVR is 4.3%
Patients with marked LVE and dysfunction OR mortality 10% Late operative mortality 5% per year
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Post-operative Survival in AR
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Post-operative Survival in AR
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Tricuspid Stenosis
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Treatment of TS
Medical Tx Intensive salt restriction, diuretic tx
Surgical TxDefinitive txDiastolic pressure gradient >4 mmHgTricuspid orifice < 1.5 to 2.0 cmOpen heart repair/prosthesis (preferably large
bioprosthetic valve)
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Tricuspid Regurgitation
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Treatment Considerations in TR
Isolated TR, in the absence of Pulmo HPN, is well tolerated and does not require operation
Functional TR (secondary to PHPN with MV disease) resolves with effective correction of the MV disease)
- annuloplasty
TVR for severe valve deformity
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Pulmonic Valve Disease
Pulmonic Regurgitation – most common acquired abnormality of the PV secondary to dilatation of the PV ring as a consequence of PHPN
Graham Steell murmur (high pitched decresendo, diastolic blowing murmur along the left sternal border- like AR)
Of little hemodynamic significance.
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Four Guidelines to Follow in Assessing Patients with Multiple Valvular Abnormalities
Guideline 1: Determine the Predominant Lesion A. The most severe lesion is usually the predominant
lesion
Ex.1 Patient has MS mild, AS severe, MR mildAns. AS is the dominant lesion
B. The lesion that causes the most corresponding chamber enlargement is usually the predominant lesion
Ex.2 Patient has AR moderate, MS moderate, Severely dilated LV, slightly dilated LA
Ans. AR is the predominant lesion
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Guideline No. 2: Left-sided lesions are more important that right-sided lesions. Therefore tailor your treatment more for the left-sided lesion.
Guideline No. 3: Significant stenotic lesions (MS or AS) should be given more serious attention compared to regurgitant lesions (MR or AR)
Guideline No. 4: In severe valvular disease, surgical correction of the mechanical defect should be given prime consideration. Response to medical treatment is poor.
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THANK YOU!!!