Valvular Heart Disease Valvular Heart Disease and the Cardiac Examand the Cardiac Exam

20092009

OverviewOverview Clinical syndromesClinical syndromes Overview of cardiac murmurs and maneuversOverview of cardiac murmurs and maneuvers Left sided valvular lesionsLeft sided valvular lesions

– Aortic stenosis and sclerosisAortic stenosis and sclerosis– Mitral stenosis Mitral stenosis

Rheumatic fever prophylaxisRheumatic fever prophylaxis– Acute and chronic aortic regurgitationAcute and chronic aortic regurgitation– Acute and chronic mitral regurgitationAcute and chronic mitral regurgitation

Right sided valvular lesionsRight sided valvular lesions– Tricuspid valve diseaseTricuspid valve disease

Prosthetic valvesProsthetic valves Endocarditis prophylaxisEndocarditis prophylaxis QuestionsQuestions

General AppearanceGeneral Appearance Marfan SyndromeMarfan Syndrome

– Tall, long extremitiesTall, long extremities– Associated with:Associated with: aortic root aortic root

dilitation, MV prolapsedilitation, MV prolapse AcromegalyAcromegaly

– Large stature, coarse facial Large stature, coarse facial features, “spade” handsfeatures, “spade” hands

– Associated with:Associated with: Cardiac Cardiac hypertrophyhypertrophy

Turner SyndromeTurner Syndrome– Web neck, hypertelorism, Web neck, hypertelorism,

short statureshort stature– Associated with:Associated with: Aortic Aortic

coarctation, pulmonary coarctation, pulmonary stenosisstenosis

Pickwickian SyndromePickwickian Syndrome– Severe obesity, Severe obesity,

somnolencesomnolence– Associated with:Associated with:

Pulmonary hypertensionPulmonary hypertension

Fredreich ataxiaFredreich ataxia– Lurching gait, hammertoe, Lurching gait, hammertoe,

pes cavuspes cavus– Associated with:Associated with:

hypertrophic hypertrophic cardiomyopathycardiomyopathy

Duchenne type muscular Duchenne type muscular dystrophydystrophy– Pseudohypertrophy of the Pseudohypertrophy of the

calvescalves– CardiomyopathyCardiomyopathy

Ankylosing spondylitisAnkylosing spondylitis– Straight back syndrome, stiff Straight back syndrome, stiff

(“poker”) spine(“poker”) spine– Associated with:Associated with: AI, CHB AI, CHB

(rare)(rare) Lentigines (LEOPARD Lentigines (LEOPARD

syndrome)syndrome)– Brown skin macules that do Brown skin macules that do

not increase with sunlightnot increase with sunlight– Associated with:Associated with: HOCM, PS HOCM, PS

““Spade” hands in acromegalySpade” hands in acromegaly

General Appearance- 2General Appearance- 2 Hereditary hemorrhagic Hereditary hemorrhagic

telangiectasia (Osler-telangiectasia (Osler-Weber-Rendu)Weber-Rendu)– Small capillary hemangiomas Small capillary hemangiomas

on the face or mouthon the face or mouth– Associated with:Associated with: Pulmonary Pulmonary

arteriovenous fistulaarteriovenous fistula LupusLupus

– Butterfly rash on face, Butterfly rash on face, Raynaud phenomenon- hands, Raynaud phenomenon- hands, Livedo reticularisLivedo reticularis

– Associated with:Associated with: Verrucous Verrucous endocarditis, Myocarditis, endocarditis, Myocarditis, PericarditisPericarditis

PheochromocytomaPheochromocytoma– Pale diaphoretic skin, Pale diaphoretic skin,

neurofibromatosis- café-au-lait neurofibromatosis- café-au-lait spotsspots

– Associated with:Associated with: Catecholamine-induced Catecholamine-induced secondary dilated CMsecondary dilated CM

SarcoidosisSarcoidosis– Cutaneous nodules, Cutaneous nodules,

erythema nodosumerythema nodosum– Associated with:Associated with: Secondary Secondary

cardiomyopathy, heart cardiomyopathy, heart block block

Tuberous SclerosisTuberous Sclerosis– Angiofibromas (face; Angiofibromas (face;

adenoma sebaceum)adenoma sebaceum)– Associated with:Associated with:

RhabdomyomaRhabdomyoma MyxedemaMyxedema

– Coarse, dry skin, thinning Coarse, dry skin, thinning of lateral eyebrows, of lateral eyebrows, hoarseness of voicehoarseness of voice

– Associated with:Associated with: Pericardial Pericardial effusion, LV dysfunctioneffusion, LV dysfunction

Grading the Intensity of Cardiac Grading the Intensity of Cardiac MurmursMurmurs

Grade 1Grade 1– Murmur heard with stethoscope, but not at firstMurmur heard with stethoscope, but not at first

Grade 2Grade 2– Faint murmur heard with stethoscope on chest wallFaint murmur heard with stethoscope on chest wall

Grade 3Grade 3– Murmur hears with stethoscope on chest wall, louder Murmur hears with stethoscope on chest wall, louder

than grade 2 but without a thrillthan grade 2 but without a thrill Grade 4Grade 4

– Murmur associated with a thrillMurmur associated with a thrill Grade 5Grade 5

– Murmur heard with just the rim held against the chestMurmur heard with just the rim held against the chest Grade 6Grade 6

– Murmur heard with the stethoscope held away and in Murmur heard with the stethoscope held away and in from the chest wallfrom the chest wall

Cardiac MurmursCardiac Murmurs

Most mid systolic murmurs of grade 2/6 Most mid systolic murmurs of grade 2/6 intensity or less are benignintensity or less are benign– Associated with physiologic increases in blood Associated with physiologic increases in blood

velocity:velocity: PregnancyPregnancy ElderlyElderly

In contrast, the following murmurs are In contrast, the following murmurs are usually pathologic:usually pathologic:– Systolic murmurs grade 3/6 or greater in Systolic murmurs grade 3/6 or greater in

intensityintensity– Continuous murmursContinuous murmurs– Any diastolic murmurAny diastolic murmur

ManeuverManeuver Hemodynamic Hemodynamic EffectEffect

Murmur EffectMurmur Effect

Normal respirationNormal respiration Transient Transient ↑↑ in venous in venous filling during inspirationfilling during inspiration

↑↑ right-sided murmursright-sided murmurs

Passive leg elevationPassive leg elevation ↑↑ venous return venous return (transient (transient ↑↑ in LV size in LV size and preload)and preload)

↑↑ right-sided murmurs, right-sided murmurs, ↓↓murmur of HOCM and murmur of HOCM and MVPMVP

Stand to squatStand to squat ↑↑ venous return venous return (transient (transient ↑↑ in LV size in LV size and preload)and preload)

↑↑ right-sided murmurs, right-sided murmurs,

↓↓murmur of HOCM and murmur of HOCM and MVPMVP

Squat to standSquat to stand ↓↓ venous return venous return (transient (transient ↓↓ in LV size in LV size and preload)and preload)

↑↑ murmur of HOCM, murmur of HOCM, moves midsystolic click moves midsystolic click of MVP closer to S1 and of MVP closer to S1 and ↑↑ MVP murmur, MVP murmur, ↓ ↓ AS AS murmurmurmur

ValsalvaValsalva ↓↓ venous return venous return (transient (transient ↓↓ in LV size, in LV size, preload, and relative preload, and relative systemic hypotension)systemic hypotension)

↑↑ murmur of HOCM, murmur of HOCM, moves midsystolic click moves midsystolic click of MVP closer to S1, and of MVP closer to S1, and ↓↓ murmur of MVP murmur of MVP

Isometric handgrip Isometric handgrip exerciseexercise

↑↑ afterloadafterload ↑↑ murmur of MR and murmur of MR and VSD, VSD, ↓↓the murmur of the murmur of HOCM, HOCM, ↓↓AS murmurAS murmur

Inhaled amyl nitrateInhaled amyl nitrate ↓↓ afterloadafterload ↓↓ murmur of MR and murmur of MR and VSD, no change in AS VSD, no change in AS murmurmurmur

Diagnostic TestingDiagnostic Testing

ECHOCARDIOGRAMECHOCARDIOGRAM Exercise testingExercise testing

– To assess the clinical severity of valvular heart diseaseTo assess the clinical severity of valvular heart disease Those with inconsistent resting hemodynamics Those with inconsistent resting hemodynamics Equivocal history of symptomsEquivocal history of symptoms

– Exercise testing in AS patientsExercise testing in AS patients Should be ended promptly if:Should be ended promptly if:

– Cardiac symptoms provokedCardiac symptoms provoked– Decrease or minimal increase (<20 mmHg) in blood pressureDecrease or minimal increase (<20 mmHg) in blood pressure

Prior history of angina, congestive heart failure, or Prior history of angina, congestive heart failure, or exertional syncope absolute contraindications to exercise exertional syncope absolute contraindications to exercise testingtesting

Cardiac catheterizationCardiac catheterization– Usually not needed for primary evaluationUsually not needed for primary evaluation

Aortic StenosisAortic Stenosis

Most common cause is calcific degenerationMost common cause is calcific degeneration– Active disease process with risk factors of male sex, Active disease process with risk factors of male sex,

smoking, HTN, DM, older age, hypercholesterolemiasmoking, HTN, DM, older age, hypercholesterolemia 2% of the general population have bicuspid aortic 2% of the general population have bicuspid aortic

valvesvalves– Symptomatic or severe AS occurs earlier (age 40-60 Symptomatic or severe AS occurs earlier (age 40-60

years)years) AS less commonly from rheumatic heart disease AS less commonly from rheumatic heart disease

valvulitisvalvulitis– Invariably MV involved firstInvariably MV involved first– Associated AV involvement in <1/2 patientsAssociated AV involvement in <1/2 patients

AV sclerosisAV sclerosis– Valve thickening without obstructionValve thickening without obstruction– Present in >20% of people >65 yearsPresent in >20% of people >65 years– Associated with 50% increased risk of MI and CV deathAssociated with 50% increased risk of MI and CV death

Progression of Aortic SclerosisProgression of Aortic Sclerosis

Hemodynamic progression usually slowHemodynamic progression usually slow– Average rate of increase in aortic jet velocity of Average rate of increase in aortic jet velocity of

0.3 m/s per year0.3 m/s per year– Increase in mean transaortic gradient of 7 Increase in mean transaortic gradient of 7

mmHgmmHg– Decrease in AVA of 0.1 cmDecrease in AVA of 0.1 cm22 per year per year

Severe ASSevere AS– Aortic jet velocity > 4 m/sAortic jet velocity > 4 m/s– Mean transvalvular pressure gradient > 50 Mean transvalvular pressure gradient > 50

mmHgmmHg– AVA < 1.0 cm2AVA < 1.0 cm2

Pathophysiology of Aortic StenosisPathophysiology of Aortic Stenosis

Obstruction of LV outflow increases Obstruction of LV outflow increases intracavitary systolic pressures and leads intracavitary systolic pressures and leads to LV pressure overloadto LV pressure overload

Initial compensatory mechanism is Initial compensatory mechanism is myocardial hypertrophy with preservation myocardial hypertrophy with preservation of systolic functionof systolic function

Diastolic function impaired as a Diastolic function impaired as a consequence of increased wall thickness consequence of increased wall thickness and abnormal myocardial relaxationand abnormal myocardial relaxation

Increased wall stress and afterload causes Increased wall stress and afterload causes eventual decrease in ejection fractioneventual decrease in ejection fraction

PseudostenosisPseudostenosis

Occurs in patients with impaired systolic Occurs in patients with impaired systolic function and aortic stenosisfunction and aortic stenosis– Unable to generate transvalvular gradientUnable to generate transvalvular gradient

Careful diagnostic testing with dobutamine Careful diagnostic testing with dobutamine infusion protocols can aid in differentiating infusion protocols can aid in differentiating between true AS and pseudostenosisbetween true AS and pseudostenosis

If the calculated AVA increases with If the calculated AVA increases with augmentation of cardiac output, then augmentation of cardiac output, then pseudostenosis presentpseudostenosis present

If AVA does not increase with dobutamine, If AVA does not increase with dobutamine, then obstruction fixed and true AS presentthen obstruction fixed and true AS present

Clinical Presentation of Aortic Clinical Presentation of Aortic StenosisStenosis

Cardinal symptoms:Cardinal symptoms:– AnginaAngina

Occurs in >50% of patients, not sensitive due to prevalence Occurs in >50% of patients, not sensitive due to prevalence of CADof CAD

– SyncopeSyncope– CHFCHF

Sudden cardiac death rare, <1% per yearSudden cardiac death rare, <1% per year In earlier stages, AS presentation more subtleIn earlier stages, AS presentation more subtle

– DyspneaDyspnea– Decreased exercise toleranceDecreased exercise tolerance

Rarely, AS diagnosed in the setting of GI bleedingRarely, AS diagnosed in the setting of GI bleeding– Heyde’s syndromeHeyde’s syndrome

Bleeding caused by AVMBleeding caused by AVM Concurrent AS occurs at prevalence rate of 15-25%Concurrent AS occurs at prevalence rate of 15-25% Associated with an acquired von Willebrand syndrome due Associated with an acquired von Willebrand syndrome due

to disruption of vW multimers through a diseased AVto disruption of vW multimers through a diseased AV

Management of Aortic StenosisManagement of Aortic Stenosis

Prognosis in asymptomatic disease excellent Prognosis in asymptomatic disease excellent Conservative approach with monitoring for Conservative approach with monitoring for

symptoms recommendedsymptoms recommended When severe stenosis present-When severe stenosis present-

– 38% of asymptomatic patients develop symptoms within 38% of asymptomatic patients develop symptoms within 2 years2 years

– 79% are symptomatic within 3 years79% are symptomatic within 3 years Once symptoms occur, AVR neededOnce symptoms occur, AVR needed LV dysfunction and severe AS have increased LV dysfunction and severe AS have increased

perioperative mortality with AVRperioperative mortality with AVR– But outcomes still favorable with surgeryBut outcomes still favorable with surgery

Nitroprusside may transiently improve cardiac Nitroprusside may transiently improve cardiac function as a bridge to valve replacement function as a bridge to valve replacement – Does not supplant AVR in symptomatic patientsDoes not supplant AVR in symptomatic patients

Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51

Aortic Valve ReplacementAortic Valve Replacement

Prophylatic AVR in asymptomatic patients not Prophylatic AVR in asymptomatic patients not routinely performed due to surgical risksroutinely performed due to surgical risks– Thromboembolism, bleeding associated with Thromboembolism, bleeding associated with

anticoagulation, prosthetic valve dysfunction, and anticoagulation, prosthetic valve dysfunction, and endocarditis endocarditis

– Occurs at a rate of 2-3% annuallyOccurs at a rate of 2-3% annually– Only should be considered:Only should be considered:

If other cardiac surgery (such as CABG) plannedIf other cardiac surgery (such as CABG) planned Severe LVH or systolic dysfunctionSevere LVH or systolic dysfunction Women contemplating pregnancyWomen contemplating pregnancy Patients remote from health carePatients remote from health care

Surgical valve replacement with operative Surgical valve replacement with operative morbidity and mortality of 10%morbidity and mortality of 10%

Percutaneous balloon aortic valvotomy rarely usedPercutaneous balloon aortic valvotomy rarely used

Mitral StenosisMitral Stenosis

Usually associated with history of Usually associated with history of rheumatic feverrheumatic fever

>40% of cases of RHD result in >40% of cases of RHD result in mitral stenosismitral stenosis– Women affected more than men (2:1)Women affected more than men (2:1)

Presentation 20-40 years after the Presentation 20-40 years after the initial episode of rheumatic feverinitial episode of rheumatic fever– If infected at a young age, latent period If infected at a young age, latent period

is a few yearsis a few years

Clinical Presentation of Mitral Clinical Presentation of Mitral StenosisStenosis

Significant MS leads to Significant MS leads to ↑↑LA pressure and pulm HTNLA pressure and pulm HTN Symptoms include dyspnea with Symptoms include dyspnea with ↑↑ cardiac demand cardiac demand

– ExerciseExercise– PregnancyPregnancy

Survival excellent with asymptomatic or minimally Survival excellent with asymptomatic or minimally symptomatic patientssymptomatic patients– >80% survival at 10 years>80% survival at 10 years

Survival in symptomatic patients much worseSurvival in symptomatic patients much worse– 10 year survival drops to 15% or lower (if pulm HTN present)10 year survival drops to 15% or lower (if pulm HTN present)

Findings consistent with severe MS:Findings consistent with severe MS:– Transvalvular diastolic pressure gradient >10 mmHgTransvalvular diastolic pressure gradient >10 mmHg– MVA <1.0 cm2MVA <1.0 cm2– Severe pulmonary hypertension (>60 mmHg)Severe pulmonary hypertension (>60 mmHg)

Management of Mitral StenosisManagement of Mitral Stenosis

Atrial fibrillationAtrial fibrillation– Prevalence >30% in symptomatic patients and Prevalence >30% in symptomatic patients and

associated with poorer long term outcomeassociated with poorer long term outcome– Warfarin indicated:Warfarin indicated:

In patients with AF and MSIn patients with AF and MS Patients without history of AF but with MS and Patients without history of AF but with MS and

embolic CVAembolic CVA

– In patients with prior history of AF who have In patients with prior history of AF who have mitral valve surgery, decreased postoperative mitral valve surgery, decreased postoperative AF observed if MAZE performed concominantlyAF observed if MAZE performed concominantly

Mitral Valve RepairMitral Valve Repair Percutaneous valvotomyPercutaneous valvotomy

– Therapeutic intervention of choice if:Therapeutic intervention of choice if: LAA thrombus excludedLAA thrombus excluded MR less than moderateMR less than moderate Valvular characteristics favorableValvular characteristics favorable

– Pliable leaflets, minimal commisural fusion, minimal Pliable leaflets, minimal commisural fusion, minimal valvular or subvalvular calcificationvalvular or subvalvular calcification

– Pulmonary HTN not contraindication to valvotomyPulmonary HTN not contraindication to valvotomy– Major complications include: severe MR (1-8%), Major complications include: severe MR (1-8%),

systemic embolization (1-3%), and tamponade (1-systemic embolization (1-3%), and tamponade (1-2%)2%) Periprocedural mortality- 1%Periprocedural mortality- 1%

Surgical commissurotomy or MVR can be Surgical commissurotomy or MVR can be performed in unfavorable anatomyperformed in unfavorable anatomy

Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51

Rheumatic Fever ProphylaxisRheumatic Fever Prophylaxis Primary prophylaxisPrimary prophylaxis

– If living in an endemic area, with pharyngitis and a If living in an endemic area, with pharyngitis and a +test for group A strep or positive throat culture+test for group A strep or positive throat culture

– Given once, may be repeated as needed:Given once, may be repeated as needed: PCN G 1.2 million U IM or PCN V 500 mg TID x 10dPCN G 1.2 million U IM or PCN V 500 mg TID x 10d Azithromycin 500 mg on day 1, 250 mg daily for 4dAzithromycin 500 mg on day 1, 250 mg daily for 4d

Secondary prophylaxisSecondary prophylaxis– PCN G 1.2 million units IM every 4 weeks or PCN V PCN G 1.2 million units IM every 4 weeks or PCN V

250 mg PO BID or erythromycin 250 mg BID250 mg PO BID or erythromycin 250 mg BID RHD without carditis-RHD without carditis- At least 5 years or until >21 y of At least 5 years or until >21 y of

ageage RHD with carditis, no valvular HD-RHD with carditis, no valvular HD- At least 10 y or well At least 10 y or well

into adulthoodinto adulthood RHD with carditis and valvular HD-RHD with carditis and valvular HD- At least 10 years At least 10 years

from last episode or until patient is older than 40 yearsfrom last episode or until patient is older than 40 years

Acute Aortic RegurgitationAcute Aortic Regurgitation Causes of acute aortic regurgitation:Causes of acute aortic regurgitation:

– Aortic dissectionAortic dissection– Valve distruction from endocarditisValve distruction from endocarditis– Traumatic ruptureTraumatic rupture

Classic physical exam findings may be absent in Classic physical exam findings may be absent in the acute presentationthe acute presentation– Diastolic murmur may not be present due to sudden Diastolic murmur may not be present due to sudden

increase of LVEDPincrease of LVEDP TTE, along with TEE, cath, CT or MRI may be used TTE, along with TEE, cath, CT or MRI may be used

for diagnosisfor diagnosis Surgical AV repair or replacement should be Surgical AV repair or replacement should be

performed emergentlyperformed emergently Afterload reducing medications and inotropes Afterload reducing medications and inotropes

may help to acutely stabilize the patientmay help to acutely stabilize the patient IABP contraindicatedIABP contraindicated

Acute Mitral RegurgitationAcute Mitral Regurgitation

Most often occurs in:Most often occurs in:– Chordae tendineae rupture due to Chordae tendineae rupture due to

myxomatous valve disease or endocarditismyxomatous valve disease or endocarditis– Myocardial infarction with papillary muscle Myocardial infarction with papillary muscle

dysfunction or rupturedysfunction or rupture Symptoms almost always occurSymptoms almost always occur

– Dyspnea and pulmonary edemaDyspnea and pulmonary edema Systolic function may occur normal or Systolic function may occur normal or

hyperdynamichyperdynamic IABP or afterload reducing drugs to IABP or afterload reducing drugs to

temporize temporize Surgical intervention for treatmentSurgical intervention for treatment

Chronic Valvular RegurgitationChronic Valvular Regurgitation

Cardiac chamber size and function have time to Cardiac chamber size and function have time to compensate for dysfunctioncompensate for dysfunction– May allow patients to remain asymptomatic for a long May allow patients to remain asymptomatic for a long

timetime Both preload and afterload increasesBoth preload and afterload increases Once increase in cardiac output insufficientOnce increase in cardiac output insufficient→ →

systolic function declines systolic function declines →→ pulmonary HTN may pulmonary HTN may develop and symptoms developdevelop and symptoms develop

LV enlargement and progressive systolic LV enlargement and progressive systolic dysfunction are associated with significant dysfunction are associated with significant morbidity and mortalitymorbidity and mortality

Serial echocardiography and evaluation by a Serial echocardiography and evaluation by a cardiologist is indicated cardiologist is indicated

Chronic Aortic RegurgitationChronic Aortic Regurgitation Occurs most often in bicuspid AVOccurs most often in bicuspid AV Other causes include ascending aortic aneurysm and Other causes include ascending aortic aneurysm and

Marfan’s DiseaseMarfan’s Disease Risk factors for poorer outcome:Risk factors for poorer outcome:

– AgeAge– Cardiac symptomsCardiac symptoms– Atrial fibrillationAtrial fibrillation– LV enlargementLV enlargement– Lower LVEFLower LVEF

Asymptomatic patients with normal LV size and function do Asymptomatic patients with normal LV size and function do not require prophylatic surgerynot require prophylatic surgery

Surgery should be considered if:Surgery should be considered if:– LVESD LVESD >> 55 mm 55 mm– Ejection fraction <60%Ejection fraction <60%– Symptoms developSymptoms develop

Oral afterload reduction (nifedipine or ACE-I) may slow rate of Oral afterload reduction (nifedipine or ACE-I) may slow rate of LV dilationLV dilation

Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51

Chronic Mitral RegurgitationChronic Mitral Regurgitation

Often caused by myxomatous disease or MVPOften caused by myxomatous disease or MVP– Myxomatous mitral valve disease with progressive Myxomatous mitral valve disease with progressive

MR associated with poor long term outcomeMR associated with poor long term outcome Higher risk of arrhythmias and sudden cardiac deathHigher risk of arrhythmias and sudden cardiac death

– Mitral valve prolapse occurs in ~2% of the general Mitral valve prolapse occurs in ~2% of the general populationpopulation Consists of the buckling of the mid portion of the valve Consists of the buckling of the mid portion of the valve

leaflets into the LAleaflets into the LA Usually asymptomatic, but may be associated with Usually asymptomatic, but may be associated with

palpitations or chest discomfortpalpitations or chest discomfort Prognosis usually benignPrognosis usually benign Antibiotic prophylaxis now not indicatedAntibiotic prophylaxis now not indicated

Chronic Mitral RegurgitationChronic Mitral Regurgitation

Other causes include secondary or Other causes include secondary or acquired leaflet dysfunctionacquired leaflet dysfunction– EndocarditisEndocarditis– Rheumatic heart diseaseRheumatic heart disease– Annular tethering from LV dilationAnnular tethering from LV dilation– Tethering of the chordal apparatus from Tethering of the chordal apparatus from

ischemic heart diseaseischemic heart disease– Rare cause: Fenfluramine and phentermine, Rare cause: Fenfluramine and phentermine,

also associated with AIalso associated with AI Compensatory increase in LV chamber size Compensatory increase in LV chamber size

initially allows for increase in total stroke initially allows for increase in total stroke volume and restoration or total forward volume and restoration or total forward cardiac outputcardiac output

Treatment of Chronic Mitral Treatment of Chronic Mitral RegurgitationRegurgitation

Mitral valve repair preferred over mitral Mitral valve repair preferred over mitral valve replacementvalve replacement– Avoids risk of anticoagulationAvoids risk of anticoagulation– Preservation of subvalvular apparatusPreservation of subvalvular apparatus

Better postoperative LV function and long term survivalBetter postoperative LV function and long term survival When MR occurs in volume overloaded When MR occurs in volume overloaded

states, afterload reduction can be beneficialstates, afterload reduction can be beneficial– Dilated CM Dilated CM – CADCAD

Revascularization may improve dysfunction Revascularization may improve dysfunction of the papillary muscleof the papillary muscle

Biventricular pacing may improve LV Biventricular pacing may improve LV geometrygeometry

Timing of Intervention for Left-Sided Valvular Timing of Intervention for Left-Sided Valvular ConditionsConditions

Aortic StenosisAortic Stenosis Mitral StenosisMitral Stenosis Chronic Severe ARChronic Severe AR Chronic Severe Chronic Severe MRMR

Intervention:Intervention:

AVRAVRIntervention:Intervention:

Percutaneous Percutaneous valvotomy if anatomy valvotomy if anatomy amenable and amenable and <moderate MR, and no <moderate MR, and no LAA clot. Otherwise, LAA clot. Otherwise, open commissurotomy open commissurotomy or MVRor MVR

Intervention:Intervention:

Surgical AVR with aortic Surgical AVR with aortic root replacement if root replacement if neededneeded

Intervention:Intervention:

Surgical mitral valve Surgical mitral valve repair if anatomy repair if anatomy amenable. Otherwise, amenable. Otherwise, MVRMVR

IF:IF:

Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater, angina due to greater, angina due to AS, or syncope)AS, or syncope)

OROR

Patient has Patient has symptomatic severe AS symptomatic severe AS and needs other and needs other cardiothoracic surgery cardiothoracic surgery (i.e. CABG)(i.e. CABG)

IF:IF:

Patient has moderate or Patient has moderate or more severe MS (MVA < more severe MS (MVA < 1.5 cm1.5 cm22))

OROR

Pulmonary Pulmonary hypertrension at rest hypertrension at rest (PAP > 60 mmHg)(PAP > 60 mmHg)

OROR

Abnormal hemodynamic Abnormal hemodynamic response to exercise:response to exercise:

PAP > 60 mmHgPAP > 60 mmHg

Mean gradient > 15 Mean gradient > 15 mmHgmmHg

IF:IF:

Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater)greater)

OROR

EF <60%EF <60%

OR OR

ESD > 55 mmESD > 55 mm

OR OR

Abnormal hemodynamic Abnormal hemodynamic response to exerciseresponse to exercise

PAP increase by 25 PAP increase by 25 mmHgmmHg

IF:IF:

Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater)greater)

OROR

EF <60%EF <60%

OR OR

ESD > 45 mmESD > 45 mm

OR OR

Pulmonary hypertension Pulmonary hypertension or atrial fibrillationor atrial fibrillation

OTHERWISEOTHERWISE

Depending on the Depending on the severity of AS, at least severity of AS, at least annual clinical annual clinical evaluation with TTE to evaluation with TTE to monitor for symptom monitor for symptom onsetonset

OTHERWISEOTHERWISE

Clinical evaluation at Clinical evaluation at least annually, least annually, depending on the depending on the severity of the mitral severity of the mitral stenosisstenosis

OTHERWISEOTHERWISE

Repeat TTE at least Repeat TTE at least yearly, repeat clinical yearly, repeat clinical evaluation at least evaluation at least biannually depending biannually depending on the severity of the on the severity of the LV dilitiationLV dilitiation

OTHERWISEOTHERWISE

Repeat TTE yearly, Repeat TTE yearly, repeat clinical repeat clinical evaluation biannuallyevaluation biannually

Tricuspid Valve DiseaseTricuspid Valve Disease

Tricuspid stenosis is rareTricuspid stenosis is rare– Associated with rheumatic heart diseaseAssociated with rheumatic heart disease

TR usually occurs secondary to:TR usually occurs secondary to:– Pulmonary hypertensionPulmonary hypertension– RV chamber enlargement with annular dilatationRV chamber enlargement with annular dilatation– Endocarditis (associated with IV drug use)Endocarditis (associated with IV drug use)– Injury following pacer lead placementInjury following pacer lead placement

Other secondary causes: carcinoid, radiation Other secondary causes: carcinoid, radiation therapy, anorectic drug use, and traumatherapy, anorectic drug use, and trauma

Primary causes: Marfan’s syndrome and Primary causes: Marfan’s syndrome and congenital disorders such as Ebstein’s anomaly congenital disorders such as Ebstein’s anomaly and AV canal malformationand AV canal malformation

Echo is diagnostic in most casesEcho is diagnostic in most cases

Tricuspid RegurgitationTricuspid Regurgitation

Severe tricuspid regurgitation is difficult to Severe tricuspid regurgitation is difficult to treat and carries a poor overall clinical treat and carries a poor overall clinical outcomeoutcome

Symptoms are manifestations of systemic Symptoms are manifestations of systemic venous congestionvenous congestion– AscitesAscites– Pedal edemaPedal edema

Surgical intervention usually considered if Surgical intervention usually considered if other cardiac surgery plannedother cardiac surgery planned

Surgical options include valvular Surgical options include valvular annuloplasty or replacementannuloplasty or replacement– If replacement planned, bioprosthetic valve If replacement planned, bioprosthetic valve

preferredpreferred

Prosthetic Valves- MechanicalProsthetic Valves- Mechanical

Three types:Three types:– Ball-cage valveBall-cage valve– Single tilting disk valveSingle tilting disk valve– Bileaflet valveBileaflet valve

Durable but require life long anticoagulationDurable but require life long anticoagulation For operative procedures, warfarin typically For operative procedures, warfarin typically

is discontinued for 48-72 hours and is discontinued for 48-72 hours and restarted postop as soon as possible, restarted postop as soon as possible, except for:except for:– Mechanical mitral prosthesisMechanical mitral prosthesis– Atrial fibrillationAtrial fibrillation– Prior thromboembolic eventsPrior thromboembolic events

Ball-cage valve

Single tilting disk valve

Bileaflet valve

Prosthetic Valves- BiologicalProsthetic Valves- Biological Biological ValvesBiological Valves

– Composed of autologous or xenograft Composed of autologous or xenograft biological material mounted on stents and a biological material mounted on stents and a sewing ringsewing ring

– Warfarin therapy not required due to lower Warfarin therapy not required due to lower thromboembolic potentialthromboembolic potential

– Valve durability less when compared to Valve durability less when compared to mechanical valvesmechanical valves

– Newer stentless valves with increased Newer stentless valves with increased longevitylongevity

Anticoagulation Guidelines for Anticoagulation Guidelines for Mechanical ValvesMechanical Valves

Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51

Prosthetic Valve ComplicationsProsthetic Valve Complications Common complications include:Common complications include:

– Structural valve deteriorationStructural valve deterioration– Valve thrombosisValve thrombosis– EmbolismEmbolism– BleedingBleeding– EndocarditisEndocarditis

Endocarditis prophylaxis required for patients with all types Endocarditis prophylaxis required for patients with all types of prosthetic valvesof prosthetic valves

Suspect valve dehiscence or dysfunction in:Suspect valve dehiscence or dysfunction in:– Acute CHF in the immediate postop periodAcute CHF in the immediate postop period– New cardiac symptomsNew cardiac symptoms– Embolic phenomenaEmbolic phenomena– Hemolytic anemiaHemolytic anemia– New murmursNew murmurs

TEE is the diagnostic procedure of choiceTEE is the diagnostic procedure of choice Postop TTE should be done 2-3 months after surgeryPostop TTE should be done 2-3 months after surgery

Valve ThrombosisValve Thrombosis

Incidence with mechanical prosthesis of 2-4 % per Incidence with mechanical prosthesis of 2-4 % per yearyear

Suspect in patients with new murmur, change in Suspect in patients with new murmur, change in cardiopulmonary symptoms, or an embolic eventcardiopulmonary symptoms, or an embolic event

Diagnosis based on clinical presentation, TTE/TEE, Diagnosis based on clinical presentation, TTE/TEE, and fluroscopyand fluroscopy

In small thrombus, treatment with heparin may be In small thrombus, treatment with heparin may be adequateadequate

Optimal treatment for left sided thrombosis is Optimal treatment for left sided thrombosis is emergency surgeryemergency surgery

Consider thrombolytic therapy for right sided Consider thrombolytic therapy for right sided thrombosis or if surgery cannot be performed with thrombosis or if surgery cannot be performed with left sided diseaseleft sided disease

Endocarditis ProphylaxisEndocarditis Prophylaxis

2007 AHA Prevention of Infective Endocarditis Guidelines