1. Causes of Heart Valve Dysfunction
Congenital defects (bicuspid aortic valve)
Infections (rheumatic fever and bacterial endocarditis
Coronary artery disease (papillary muscle rupture)
Senile calcification (most common)
Tricuspid or Pulmonary = right heart failure
Aortic or Mitral = left heart failure
Mitral Valve .. Keep inr=
Aortic Valve.. Keep inr= 2-3
Bioprosthetic= use aspirin
Mechanical prosthetic= warfarin

2. Aortic Stenosis Age 75-84= 35% have aortic senile stenosis
Aortic Stenosis results from the accumulation of calcium with the cusps of the valve and is the most predominant form of Valve Disorders. Age is the primary fisk factor, but hypertension, hyperlipidemia, male sex can also play a role.
Classic symptoms: syncope, angina, and heart failure- occur when the left ventricle can no longer overcome the excessive afterload imposed by the malfunctioning aortic valve.
Clinical manifestations begin when the aortic valve area has decreased to less than 1 cm2
Surgery is indicated when the patient is in stage C2 whith reduced EF < 50% or are in stage D.
Age 75-84= 35% have aortic senile stenosis
Age over 85= 48% have aortic senile stenosis

3. Mitral Valve Stenosis
Mitral stenosis occurs far less than aortic stenosis. 80% of Mitral Valve stenosis are caused from rheumatic heart disease, whereas only 3% are from senile calcification.
Classic Symptoms include dyspnea, hemoptysis, thromboembolism, AF, and right sided heart failure.
Physiologic problems: increased pressure within the left atrium, pulmonary vasculature, and right side of the heart
MR (Mitral regurgitation) can be caused from Mitral valve prolapse.

4. Diagnostics Transthoracic echocardiograpy
Transesophageal echocardiography
Coronary angiography
Cardiac magnetic resonance imaging
STAGE A – Normal – symptoms-absent
STAGE B- Progression- mild to moderate grade lesion—symptoms=absent
STAGE C- severe grade lesion – symptoms absent
STAGE D= severe grade lesion and SYMPTOMATIC.
In general, stage A and B – lifetime coagulation
Surgery is required for EJ < 50% who are in Stage D.

5. Types of Valves
BIOPROSTHETICS= deteriorate with time more than mechanical. Mitral Valves deteriorate after about 5 years and aortic after about 8 years. For 61-75yo, the probability of being alive after AVR was 30.9% vs 16.1% after MVR. Bioprosthetics are recommended in patients > 70 YO, or in pts who can’t take warfarin, or who have a short life expectancy–----- recommend lifelong aspirin 81 mg q day
PROSTHETICS= Recommended in patients < 60 YO. Require lifelong warfarin and antiplatelet medications. (incidence of major embolism or death between warfarin & aspirin 100mg vs warfarin alone was 1.9% vs 8.5%) Mitral prosthetic valves are more thromoembolic than aortic.
GUIDELINES: ACCP GUIDELINES ACC /AHA
Bioprosthetics asa mg q day for at least 3 months mg asa-warfarin
INR= 2-3 for first 3 months
Mechanical AVR Warfarin INR goal= warfarin INR 2-3 low risk high risk
Aortic valve repair. Asa mg q day no addressed.
Bioprosthetic MVR Warfarin INR 2-3 x 3 mo, then asa warfarin inr=3-3 x 3 month
Mechanical MVR Warfarin inr= 2.5= warfarin
Mitral valve repair asa 81 mg x 3 months Consider warfarin inr= 2-3 x 3 months
Ring placement
Mitral valve

6. Heart Valves
Remember: We treat only MECHANICAL PROSTHETIC VALVES with anticoagulants. (Bioprosthetics valves.. Treat with warfarin x 3 months.. Then aspirin)
ONLY ANTICOAGULANT FOR VALVES IS WARFARIN
RE-ALIGN STUDY
actually found an increased risk of stroke and bleeding in patients with mechanical heart valve treated with dabigatran compared with warfarin (Eikelboom 2013). Additionally,a subanalysis of ENGAGE AF-TIMI 48
found a higher rate of ischemic stroke in patients treated with edoxaban 60 mg daily

7. Management of suspected prosthetic valve thrombosis

8. Disruption of VKA
- Don’t need to stop warfarin for minor procedures such as cataract removal or dental procedures.
ACCP recommends parenteral bridging during warfarin initation. Start 6 hrs after procedure
Reduced thrombosis from 6.1 to 2%

9. Transcatheter Aortic Valve Replacement
1 year mortality for TAVR vs traditional surgery was 24.2% vs 26.8% with complications, rate of death at 1 year was 30.7% for TAVR and 50.7% for standard surgery.
TAVR are bioprosthetics…… recommend 6 months of dual antiplatelet (aspirin and clopidogrel) followed by long term ASA 81 mg. New onset AF can effect as many as 30% of TAVR pts. Strokes are much higher in the AF population.

10. Mitral vs Aortic
Mitral valve disorders occur far less than aortic. 80% of
Mitral stenosis is caused by rheumatic heart disease. vs only
3% are due from senile calcification

11. For Atrial Fibrillation Management
Scoring system
Interpretation
ATRIAL FIB- untreated is assoc with 5% chance of stroke per year.. Treated with warfarin, there is a 64% risk reduction in stroke and systemic embolism and a 25% reduction in mortality.
DOACs have been shown to be as effective
as warfarin for stroke prevention in patients with AF and are associated with less intracranial hemorrhage and reduced
all-cause mortality. However, the DOACs, except apixaban,
are associated with a 25% increase in risk of GI bleeding
CHA2DS2VASc has replaced CHAD2

12. Use of D-dimer to stop/continue anticoagulant
Utility of D-dimer Testing
D-dimer testing performed several weeks after 3-6 months of
warfarin therapy has been completed is a strategy identified to
predict the likelihood of recurrent VTE and the need for continuing
anticoagulation. A positive D-dimer (typically >0.5 mg/dL)
at the time of warfarin discontinuation or shortly thereafter was
shown in several meta-analyses to identify patients at higher
risk of developing recurrent VTE (Bruinstroop 2009; Douketis
2010; Marcucci 2013; Verhovsek 2008), independent of the timing
of D-dimer testing, patient age, and the assay cut point used
(Douketis 2010). A low D-dimer value in this setting may identify
patients at low risk of recurrence who can discontinue warfarin,
whereas a positive D-dimer test may identify patients with
a persistent prothrombotic tendency. However, one consideration
to note is that D-dimer is an acute-phase reactant that is
nonspecific and may be elevated by other conditions

13. Comparisons Pearls For Initial treatment of VTE.
Use Parenteral Anticoag FIRST..
Then edoxaban or dabigatran or
Start Rivaroxaban or Apixaban
Without parenteral anticoags.
Apixaban is the drug of choice
In Renal Failure.
Last 3 agents have CYP3A4 drug
Interactions

14. Reversal Agents For Anticoagulants
Idarucizumab (Praxbind) was recently granted accelerated
approval by the FDA for patients on dabigatran warranting anticoagulation
reversal for emergent procedure or life-threating and
uncontrolled bleeding. This agent is a humanized monoclonal antibody
fragment with >350-fold preferential binding to dabigatran
Andexanet alfa is a recombinant modified human factor
Xa decoy protein that binds to and sequesters with high
specificity direct and indirect factor Xa inhibitors (apixaban,
edoxaban, rivaroxaban, LMWH, fondaparinux)
Ciraparantag (formerly known as aripazine and PER977),
is a water-soluble synthetic molecule designed to bind to
LMWH and UFH; it has been shown to bind in a similar way to
fondaparinux, direct thrombin inhibitors, and direct factor Xa
inhibitors, inhibiting their anticoagulant effect in animal studies.