Valvular Heart Disease and Heart FailureIwan N BoestanDepartement Cardiology and VascularAirlangga University-Dr.Soetomo General Hospital

Epidemiology of Valvular Heart DiseaseDeveloped countries, the causes:Congenital abnormalitiesDegenerative processesMyocardial ischemiaInfectionsPostinflammatory conditionsTrauma

Clinical ManifestationStenotic valve lesions:Need a long latent periodCorrelates with severity of stenosis

Regurgitant valve lesions:Present in acute or chronic stagesCorrelates less-well with extent of regurgitation

Interested Points:Medical treatment as alternative realistic option in high risk patients for surgical interventionHigh exciting advance in medical treatment to delaying and avoiding for surgical correctionValvular lesions is mechanical disease, need interventions for defintive therapy

Stenotic valve lesions:Require little additional therapy when symptom-free

Need mechanical intervention (non-surgical / surgical correction)

Aortic Stenosis Congenital abnormalities/Bicuspid Aortic Valve

Mitral StenosisRheumatic Heart Disease/Postinflammatory conditions

Regurgitant valve lesions:The purposes:alleviate symptomspreserve ventricular functionMild-moderate disease: medical therapy periodic follow-upSevere disease: closed clinical follow upfrequent serial echocardiography

Regurgitant valve lesions:No medical therapy is proven to effectively treat Almost need surgical correction for defintive treatment Surgical approach:RepairReplacement

Repair Vs. ReplacementRepair: better clinical and long-term outcome than replacement preserve continuity of mitral annulus and papillary muscles

Replacement: better results with maintenance patency of chordae

Medical treatment in regurgitant valve lesionsMitral regurgitationDepend on etiologyDiuretics are useful for preload condition affected MRACE-I may favor in delaying progressifity of LV dilation and dysfunctionDigoxin, CCBs, blockers: to control atrial fibrillation

Medical treatment of Mitral RegurgitationFig. the relation between the cause of MR, drug induced changes in LV preload, and the degree of mitral regurgitation

Medical treatment in regurgitant valve lesionsAortic regurgitation:Vasodilators: reduce LV wall stress and decrease pressure gradient in aortic valve during diastolic phaseACE-I: reduce morbidity and mortality rate in hypertension and/or heart failure patientsDiuretics: favor in hypervolemic status and pulmonary congestionDigoxin: used in existing LV dysfunction and atrial fibrillation

Recommendation of treatment:In chronic mitral regurgitation:Depend uponstatus of left ventriclesymptomatic statustype of operation

Medical treatment in stenotic valve lesionsMitral stenosisDiuretics: relief pulmonary congestionCCBs, -blockers: lengthen diastolic filling timeDgoxin: control ventricular contraction in atrial fibrillation

Medical treatment in stenotic valve lesionsAortic stenosis:HMG CoA Reductase: delaying progressivity of calcific aortic stenosis (induce disease regression)ACE-I: induce LV regression with decrease RAA system activation. Start with low dose and tappering up to prevent hypotension

Case 58 y.o woman with SOB Has noticed significant DOE over last 1 years, progressiveNo chest pain or syncopeDiagnosed with valve lesion since 10 yrs ago

Case On ExamHR 74 regularBP 140/70 R=LJVP 6 cm ASA. Carotid pulse normal Apex sustained, normal positionAccentuated S1, single S2 Grade 3/6 DM at aortic Grade 3/6 SM @ apex

Case ECG:Sinus Rhythm with LV High Voltage

Echo:LVHnormal all chamber size, normal LV systolic and diastolic functionbicuspid Ao valve, estimated valve area 0.65-0.74 cm, Vmax 4.6 m/s, mean PG 55.5 mmHgmild mitral regurgitation

PLAX AS + MRSAX BICUSPID AV

CaseCoronary Angiographynormal coronary artery

Left Ventriculographybicuspid Ao Valvemoderate Ao Stenosis (PG LV-Ao 60 mmHg)severe mitral regurgitationEF : 67%

Case How would you manage this woman?

A) begin ACE inhibitorB) begin digoxin for inotropic supportC) begin diureticD) begin ARBE) begin Ca Channel Antagonist

CaseWhich of the following would you next pursue?

A) closely observe, repeat echo in 6 mosB) refer for mitral valve replacement/repairC) refer for aortic and mitral valve replacementD) schedule for exercise echocardiography

Case

Does this woman need endocarditis prophylaxis for a dental extraction?

A) yesB) only if the tooth is infectedC) only if local anaesthetic will be usedD) no