Valvular Heart Disease Valvular Heart Disease

Ronald D’Agostino, D.O., F.A.C.C., F.A.C.P. Director of Non-Invasive Cardiology

Long Island Cardiovascular and Internal Medicine Manhasset, N.Y.

Calcified Ao Valve 2nd to acquired AoV Stenosis

Severely calcified tricuspid valve from an elderly patient

Phonogram of a 20yoa women with moderate AoV congenital Phonogram of a 20yoa women with moderate AoV congenital stenosis with a bicuspid valve, presenting with an ejection click, stenosis with a bicuspid valve, presenting with an ejection click, increased A2 and systolic ejection murmurincreased A2 and systolic ejection murmur

Phonogram of a 20yoa male with severe non-calcified AoVS. Seen Phonogram of a 20yoa male with severe non-calcified AoVS. Seen here is a paradoxical splitting of S2, late systolic ejection murmur here is a paradoxical splitting of S2, late systolic ejection murmur and prominent S4. The LV is noted to have a low volume and a and prominent S4. The LV is noted to have a low volume and a slow up swing of the carotid pulse.slow up swing of the carotid pulse.

Apexcardiogram of the severe AoVS showing a Apexcardiogram of the severe AoVS showing a sustained “a” wave, causing a palpable S4 gallop (the sustained “a” wave, causing a palpable S4 gallop (the non-compliant ventricle)non-compliant ventricle)

70yoa male with sever AoVS, note the absence of both the ejection click and Ao second sound (circled). Also there is a slow up swing of the carotid pulse.

The window to the inner world – The Eyes– Note the multiple

calcific emboli in the retina of this elderly patient presenting with amaurosis fugax

– Patient was Dx with severe acquired AoVS

Catheter gradients are reported as peak to peak pressure differences

This is not a true measurement of pressure drop off across the AoV because they do not occur at the same time

Echocardiogram is ideal for pressure drop off across the valve

The two should be used together to evaluate the patient for validation studies

Peak to Peak pressure diff Pressure Drop off

Percutanous valvuloplasty with a prophylactic RV Percutanous valvuloplasty with a prophylactic RV Pacemaker to combat bradycardia during the procedurePacemaker to combat bradycardia during the procedure

Ross Ross ProcedureProcedure

Survival in the elderly (ave age of 60) after a AoV Survival in the elderly (ave age of 60) after a AoV replacement (AVR)replacement (AVR)

Pt with Marfan’s syndromePt with Marfan’s syndrome

Marfan’s with type-A Ao Marfan’s with type-A Ao dissection dissection

Growth the heart Growth the heart musclemuscle

A – Infant’s heart weighing about 15gm and LV is 7gm

B – Adult’s weighing 300gm and 100gm respectively

C – Athlete's is 500gms and 200gm

D – Concentric Hypertrophy – 650gms and 400gms

E – Decompensated Eccentric Hypertrophy – 900gms and 500gms – fewer myocytes are noted, replaced by fibrotic scar tissue

rr hh

Pulse and Reflected wave Pulse and Reflected wave velocities in an elastic Aovelocities in an elastic Ao

What about in a stiff aorta?What about in a stiff aorta?

Pre and Post op CXR of a patient with AoV Regurgitation

Note the decrease in long and short diameters from the Starr-Edwards valve replacement procedure

Typical LVH associated with AoVR with a strain pattern Typical LVH associated with AoVR with a strain pattern and tall T-wavesand tall T-waves

LV wall stress can be reduced with ACE-I or hydralazines, but only ACE-I are noted to decrease LV mass index and improve EF’s more effectively

% Survival Rates% Survival Rates

Patient with Patient with overt overt pulmonary pulmonary edema. Note edema. Note the the characteristic characteristic “batwing “batwing sign”sign” on the on the CXR – fluid CXR – fluid distributiondistribution

Top – myxomatous MVTop – myxomatous MVBottom – Nl MVBottom – Nl MV

Phonogram of severe FMV Phonogram of severe FMV and MVRand MVR

Echo of an FMP with MVP in Echo of an FMP with MVP in diastolediastole

Note the MV prolapsing into the LANote the MV prolapsing into the LA

LV cineangiography in the RAO LV cineangiography in the RAO and LAO projectionand LAO projection

LV Ventriculogram of a pt with MRLV Ventriculogram of a pt with MR

It’s not just the heartIt’s not just the heart

S/S of FMV/MPV is a dynamic inter-relationship between the Cardiac, Neuroendocrine and Autonomic Nervous System

Phonogram with simultaneous ECG of a pt post MV Phonogram with simultaneous ECG of a pt post MV repair – note the absence of a murmur (pre-op below) repair – note the absence of a murmur (pre-op below)

Quick, what’s this ECG Quick, what’s this ECG showing?showing?

B-S Single Tilting DiskB-S Single Tilting Disk

M-H Single Tilting Disk – M-H Single Tilting Disk – Contains Contains

a Teflon sewing ring, titanium housing and carbon a Teflon sewing ring, titanium housing and carbon coated diskscoated disks

St. Jude Bi-leaflet Tilting DiskSt. Jude Bi-leaflet Tilting Disk

C-E Stented porcine C-E Stented porcine Bioprosthesis Bioprosthesis

Hancock II Stented Hancock II Stented BioprosthesisBioprosthesis

C-E Stented Pericardial C-E Stented Pericardial BioprosthesisBioprosthesis

Toronto Stentless Porcine Toronto Stentless Porcine ValveValve

Ausculatory Finding With Prosthetic ValvesAusculatory Finding With Prosthetic Valves

The St. Jude Heart Valve has regurgitant flow that is perpendicular to the valve

Regurgitation is noted at the disk margins and the extremes of the closure line

Prosthetic valves are prone to Prosthetic valves are prone to perforate perforate

TEE of an endocarditis originating from the TEE of an endocarditis originating from the prosthetic valveprosthetic valve

Another ViewAnother View

Any one know what Any one know what Dressler’s syndrome is?Dressler’s syndrome is?

Vegetations on a MV 2Vegetations on a MV 2ndnd to Infective to Infective Endocarditis from Endocarditis from H. FluH. Flu

Strep. Sanguis (or any pathogen) can cause occlusive coronary Strep. Sanguis (or any pathogen) can cause occlusive coronary

embolization of the coronary ostiumembolization of the coronary ostium

Subungual Subungual hemorrhages hemorrhages (splinter (splinter hemorrhages)hemorrhages) are indicative of are indicative of AcuteAcute infective infective endocarditis endocarditis

If you see needle tracks – think infective endocarditis If you see needle tracks – think infective endocarditis ((tricuspid perforation is common with IVDAtricuspid perforation is common with IVDA))

Does everybody see the vegetation on the Does everybody see the vegetation on the posterior leaflet, in this patient with severe posterior leaflet, in this patient with severe

MVP?MVP?

HMO's    Two doctors and an HMO manager died and lined

up at the Pearly Gates for admission to Heaven.  St. Peter asked them to identify themselves.

    One doctor stepped forward and said, "I was a pediatric spine surgeon and helped kids overcome

their deformities."    St. Peter said, " You can enter."

    The second doctor said, "I was a psychiatrist. I helped people rehabilitate themselves."

    St. Peter also invited him in.    The third applicant stepped forward and said, "I

was an HMO manager and I helped people get cost-effective health care."

    St. Peter said, "You can come in too."    As the HMO manager walked by, St. Peter quietly

added, "But you can only stay three days... After that you can go to hell.

Valve SurgeryValve Surgery

Aortic StenosisAortic Stenosis

Indications for surgery:– Hemodynamically severe AS with or without

symptoms High risk of sudden death immediate surgery indicated

– Hemodynamically mild to moderate AS with symptoms

1/3 will die within 4 years Prompt surgery indicated

Indications for Surgery for Indications for Surgery for Severe Aortic StenosisSevere Aortic Stenosis

All Symptomatic Patients:

Normal LV: ASAP LV Dysfunction: Urgent Heart Failure: Emergent

Asymptomatic Patients:

All patients with AVA <0.75cm2

All patients with AVA 0.76-1.0cm2

Painless Ischemia Significant arrhythmias Severe LVH LV dysfunction

Aortic InsufficiencyAortic Insufficiency

Latent period to cardiac decompensation. Once deterioration begins LV fails rapidly

Sudden death is not common– Symptoms = prompt surgery– No symptoms = follow closely for decreased

LV function

Aortic Valve SurgeryAortic Valve Surgery

Repair:– Not often done. No long term results. – Replacement is procedure of choice

Replacement:– Procedure of choice– Mechanical Valve– Tissue Valve

Choosing a ValveChoosing a Valve

Ideal artifical valve would:– Be easy to implant– Last forever– Allow blood to flow easily thru central opening

& prevent reverse flow when closed– Be made from material that would not damage

cells or promote blood clot formation– Be easy to obtain

Selecting a ValveSelecting a Valve

When selecting a replacement valve the surgeon must:– Weigh the advantages & disadvantages of each

valve type.– Know patient’s lifestyle, age, size, medical

history & ability to tolerate anticoagulation

Caged Ball ValveCaged Ball Valve(Starr-Edwards)(Starr-Edwards)

Metal ball cage with struts mounted on ringInside cage is hollow metal or plastic ball

(poppet)The forward motion of blood forces the

poppet into the cage.Blood flows thru the cage & around poppet

Ball-CageBall-Cage

Advantages:– Durability

Disadvantages:– Prone to clot formation– Blood flow thru &

around poppet can cause clots to break free & enter blood stream

– Requires long-term anticoagulation

Tilting Disc ValveTilting Disc Valve

Made of pyrolytic carbonMobile lens-shaped disc attached to cirular

ring by 2 transverse struts.Disc tilts open 60-80 degrees allowing

blood to flow around the disc

Tilting DiscTilting Disc

Advantages:– Durability– Less blood flow

obstruction than caged-ball

Disadvantages:– Prone to clot formation– Long term

anticoagulation required

Bi-Leaflet ValveBi-Leaflet Valve

Newest mechanical valveMost common valve in USA2 pivoting semicircular discs mounted

directly to sewing ring. Discs open perpendicularly

Blood flows thru ring & around discs When closed the discs lie flat, preventing

regurgitant blood flow

Bi-Leaflet ValveBi-Leaflet Valve

Advantages:– Durability– Approximates normal

valve function

Disadvantages:– Prone to clot formation

(less than other mechanical valves)

– Requires long term anticoagulation

Tissue ValvesTissue Valves

Porcine Xenograft:

– Aortic valve of pig, harvested intact, preserved & mounted on sewing ring. When in place, blood flows almost unobstructed thru central opening.

Porcine XenograftPorcine Xenograft

Advantages:– No anticoagulation

required

Disadvantages:– Limited durability– Increased failure after

5-7 years

Pericardial XenograftPericardial Xenograft

Obtained from calf pericardium.3 leaflets formed from preserved

pericardium & mounted on Dacron frame. Blood flow is virtually unobstructed.Advantages & disadvantages same as

porcine xenograft

HomograftHomograft

Frozen AV of human cadaver. Harvested valve is thawed, trimmed & sewn

into place. No mounting material is needed

HomograftHomograft

Advantages:– Excellent

hemodynamics– Little risk of clot

formation– Rare need for

anticoagulation

Disadvantages:– Difficult to obtain– Limited durability– Only for AVR

Pulmonary AutograftPulmonary Autograft

Ross Procedure:– Subtitution of patient’s pulmonary valve for the

aortic valve.– Only replacement that is truly alive &

potentially able to last a normal lifetime without blood thinners

– Has been shown to grow with the rest of the body in young children

AVRAVR

Median SternotomyCPBValve exposure/inspection of valve & root

surrounding to determine extent of diseaseValve is sizedChosen valve is sewn into placeWean from CPB

Steps in Aortic Valve Replacement:

Risk Factors for Survival After Risk Factors for Survival After AVRAVR

Increased ageDecreased LV functionCADEndocarditisMismatch of prosthesis & body sizeNYHA Functional statusAscending Aortic Aneurysm

Mitral StenosisMitral Stenosis

Indications for surgery:– Surgery not usually recommended in

asymptomatic patients– Patients with few symptoms that are otherwise

healthy should have surgery– Patients with severe MS should have surgery

Mitral InsufficiencyMitral Insufficiency

Indications for surgery are more complex than for Mitral Stenosis

Patients with MR become symptomatic only after LV function has been severely & irreversibly damaged (at which time surgical results are much less favorable)

Mitral Valve RepairMitral Valve Repair

Able to perform repair when:– Prominent opening snap, no valve calcification– Pliable leaflets, commissural fusion– Normal chordae & papillary muscle

Closed CommissurotomyClosed Commissurotomy

First mitral valve surgery to be performedFirst performed 1923; suggested as early as

1898Rarely performed today

Operative TechniqueOperative Technique

Left Antero-lateral thoracotomy Pericardial sac opened longitudinally Suture & tourniquet placed @ base of left atrial

appendage which is clamped & opened. Surgeon’s index finger is intoduced thru opening &

clamp removed so that the LA & MV can be digitally explored.

Transventricular dilator introduced thru small incision in LV

Closed Mitral Closed Mitral CommissurotomyCommissurotomy

Advantages:– Simple– Rapid– Cost-effective– Low likelihood of

ending in valve replacement

Disadvantages:– Restenosis rate varies

greatly– Not “exact science”– Limited use– High risk of intra-op

embolism

Open CommissurotomyOpen Commissurotomy

Median Sternotomy/CPBWide atrial incision made/valve exposedAnnulus, leaflets, commissures, chords &

papillary muscles examined & analyzedMV observed thru open atrium as ventricle is

filled under pressureDecision then made regarding reconstruction

or valve replacement

Mitral Valve Surgery

Open CommissurotomyOpen Commissurotomy

Advantages:– Relatively safe– Preferred to valve

replacement

Disadvantages:– Median Sternotomy– CPB

Ring AnnuloplastyRing Annuloplasty

The role of the ring annuloplasty is to:– Correct/prevent further annular dilatation– Increase leaflet coaptation– Reinforce annulus following repair– Keep tension off fragile suture lines

(scaffolding)– Restore the size & shape of valve orifice

VALVE ANNULOPLASTY

ValvuloplastyValvuloplasty

Used to relieve valvular stenosis in selected patients

Local anesthesia/mild sedationBalloon passed thru narrowed valve &

inflated.Provides long-term improvement in patients

with MS. Limited relief in AS

Mitral stenosis: catheter balloon commissurotomy

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Indications for Valve Indications for Valve ReplacementReplacement

EndocarditisAcute Ischemic Mitral RegurgeRheumatic Heart DiseaseDegeneration of valve

Mitral Valve ReplacementMitral Valve Replacement

Chest Wall Incisions:– Median Sternotomy (most common)– Right thoracotomy - (isolated for re-op MVR)– Left thoracotomy - rarely used

Mitral Valve ReplacementMitral Valve Replacement

Median Sternotomy (most common incision) CPB Mitral valve exposed & examined to determine

how much tissue to remove. Preservation of chordae tendonae

Valve is sized using sizing tool New valve is sewn into place, suture line

inspected, CPB weaned & chest closed

Chordal PreservationChordal Preservation

Evidence suggests that preservation of Chordae & posterior leaflet of MV is important in maintaining the normal LV function

Complete excision is necessary in:– Endocarditis with infected tissue– Heavily calcified valvular apparatus

MVR FactsMVR Facts

MVR has higher mortality than AVR2 most important factors are LV function &

ageValves in mitral position degenerate faster

than aortic or tricuspid

Tricuspid & Mitral ValvesTricuspid & Mitral Valves

The tricuspid and mitral valves function as a unit because the atrium, fibrous rings, valvular tissue, chordae tendonae, papillary muscle and ventricular walls are connected.

Damage to any one of these 6 parts can alter the heart’s function significantly.

Valve Structure:

Causes of Valvular DiseaseCauses of Valvular Disease

Degenerative DiseaseRheumatic Heart DiseaseInfective EndocarditisComplication of Acute MI

Valve AreasValve Areas

– NORMAL VALUES

– Aortic Valve: 2.5-3.5cm2– Mitral Valve: 4-6cm2– Tricuspid Valve: 4-6cm2

MV Narrows

LAP Increases LA

Dilates

Pulmonary VascularPressure Incrreases

RV EnlargementRA Enlargement

Pathophysiology of Mitral Stenosis:

Dyspnea, Pulmonary Edema

RV Failure

JVD, Liver Engorgement,Ascites, Peripheral Edema

Clinical FindingsClinical Findingsin Mitral Stenosisin Mitral Stenosis

Atrial Dysrrhythmias Diastolic Murmur Symptoms start when

Valve area < 1.5cm2

Increased RAP, PAP, PAWP

Decreased CO/CI Fatigue, Dyspnea,JVD Hoarseness,

Dysphagia

Ruptured Papillary Muscle

Clinical Findings in Clinical Findings in Mitral InsufficiencyMitral Insufficiency

Atrial Dysrhythmias Systolic murmur Elevated RAP, PAP &

PAWP

Decreased CO/CI Fatigue Dyspnea Crackles Peripheral Edema

Aortic StenosisAortic Stenosis

Cause:– Rheumatic– Non-Rheumatic

CongenitalDegenerative

Aortic StenosisAortic Stenosis

Pathophysiology of AS:AV

StenosisIncreased

LVP LVH

DecreasedCO

Increased LAPLA

Dilatation

RV Failure

Clinical Findings of ASClinical Findings of AS

Chest Pain Syncope Fatigue Dyspnea Symptoms start with

valve area <1.0cm2

Increased PAP, PAWP Decreased

CO/CI/SVR Narrowed pulse

pressure Systolic Murmur

Aortic RegurgitationAortic Regurgitation

Rheumatic Non-rheumatic -

Valvular– Endocarditis– Congenital– Blunt Chest Trauma– Degeneration– Rheumatoid Arthritis– Systemic Lupus

Aortic:– Disease of ascending

aorta: Syphillis Marfan’s syndrome Aortic Dissection Dilatation of ascending

aorta

Aortic InsufficiencyAortic Insufficiency

Backward flow into LVDecreased COLV Dilatation & Hypertrophy DevelopIncreased LAP & PAP/PAWPOver Time - Right sided Heart Failure

Clinical Findings: AIClinical Findings: AI

Chest Pain Palpitations Diastolic Murmur Nodding of Head Fatigue Dyspnea

Elevated PAP/PAWP Decreased CO/CI Widened Pulse

Pressure

Tricuspid StenosisTricuspid Stenosis

Etiology: Congenital, RHD, NeoplasmAtrial Arrhythmias, RA EnlargementPulsatile JVD, Peripheral Edema, Ascites,

Hepatomegaly

Tricuspid InsufficiencyTricuspid Insufficiency

Etiology: Physiologic resulting from Left sided heart disease, Endocarditis, Neoplasm

S&S: Same as for TS, but less peripheral edema/more ascites, pulsatile liver