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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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Presentation on theme: "Valvular Heart Disease ADRIEL E. GUERRERO, MD, FPCP, FPCC Training Officer Section of Cardiology, Dept of Medicine The Medical City."— Presentation transcript:

1 Valvular Heart Disease ADRIEL E. GUERRERO, MD, FPCP, FPCC Training Officer Section of Cardiology, Dept of Medicine The Medical City

2 Mitral Stenosis

3 Diagnostic Features of 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

4 Chest Xray MS

5 Common Etiologies of MS Rheumatic Heart Disease Congenital Heart disease Congenital MS Lutembachers syndrome (MS and ASD) Mitral Annular Calcification (elderly)

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7 Mitral Pathophysiology Obstruction to LV filling Increase LA pressure RV Failure

8 Natural History of MS Pulmonary Hypertension Fibrous thickening of alveolar and pulmo capillary walls Thrombi and Emboli Left atrial appendage Increased: AF, older patients, reduced CO Pulmonary Infections, IE,

9 Natural History of Mitral Stenosis MS - blue MR - purple

10 Differential Diagnosis of MS Atrial Septal Defect RVE and accentuated pulmo markings Widely split S2 (fixed)VS Opening snap; diastolic flow across the TV No LAE Left Atrial Myxoma Obstructing LA emptying, tumor-plop Mitral Regurgitation Systolic murmur; LVH Aortic Regurgitation (Austin Flint) Apical middiastolic murmur of AR. Becomes louder on handgrip and decreases with amyl nitrate

11 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 (embolization, permanent AF) Heart Rate Controlling drugs To lengthen diastolic LV filling Digitalis in Atrial Fibrillation; Beta-blockers in sinus rhythm Nondihydropyridine Calcium Antagonists

12 Mitral Valvotomy Indicated in symptomatic patients with isolated MS (<1.0 cm 2 /m 2 ) 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

13 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

14 Mitral Stenosis

15 Percutaneous Trans-septal Mitral Commissurotomy

16 Star Edwards Caged Ball Valve

17 Medtronic Hall Valve (Bjork- Shiley)

18 St Jude Bileaflet Valve

19 Carpentier Edwards Porcine Valve

20 Carpentier Edwards Pericardial Valve

21 Mitral Regurgitation Frequent in males History: Easy Fatigue then exertional Dyspnea PE: Characteristic holosystolic murmur at the apex with radiation to the axilla

22 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

23 Mitral Regurgitation

24 NORMAL

25 Pathophysiology of Mitral Regurgitation

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28 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

29 Medical Treatment for MR Restrict Physical activities Reduce sodium intake and enhance sodium excretion (diuretics) Increase forward cardiac output Vasodilators (ACEI) and digitalis Anticoagulants and leg binders to decrease likelihood of venous thrombi and pulmonary emboli Endocarditis prophylaxis

30 Surgical Treatment of MR Non-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 45mm MV replacement for markedly shrunken, deformed, calcified leaflets MV repair (reconstruction) with annuloplasty Lessens problem on long term anticoagulation and thromboembolism For ruptured chordae, annular dilatation and IE Not suitable for Mr due to myxomatous degeneration and patients with calcified annulus

31 Natural History of Unoperated MR

32 Late Survival Rates after Surgical Correction in MR (pre-op EF)

33 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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35 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

36 Mitral Valve Prolapse Mismatch between elongated MV and LV cavity

37 Laboratory Exams ECG – non specific STTW changes, PVCs Echo – demonstrates systolic displacement of MVL and quantifies Mitral Regurgitation and LV function

38 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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40 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

41 Aortic Stenosis 80% with symptomatic AS are males Age-related degenerative calcific AS – most common cause of AS in Adults

42 Common Etiologies of AS Valvular (90% of all cases) Rheumatic heart disease Degenerative calcification (elderly) Bicuspid AV stenosis/ Congenital heart disease Subvalvular (9%) Hypertrophic Obstructive Cardiomyopathy (HOCM) Discrete Supravalvular (<1%) Infancy

43 NORMAL AORTIC VALVE

44 Aortic Stenosis - Rheumatic

45 Aortic Stenosis - Degenerative

46 Aortic Stenosis - Bicuspid

47 Pathophysio of AS

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49 Aortic Stenosis History: Cardinal symptoms Exertional Dyspnea Angina Pectoris Syncope PE Carotid upstroke slowly rising and reduced in amplitude in severe cases; Systolic ejection murmur radiating to the carotid arteries

50 Laboratory Exam LV hypertrophy is the key finding ECG 2DECHO – estimate valve area, LV size and function Cardiac catheterization Presence or absence of concomittant CAD

51 Natural History of Severe AS Death most commonly occurs in the 7 th and 8 th decade Average time from onset of symptoms to death: Angina – 3 years Syncope – 3 years Heart Failure – 1.5 – 2 years Sudden death 10-20% in AS patients 60 years old and above

52 Medical Treatment for AS Severe AS (<0.5 cm 2 /m 2 )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

53 Surgery in Aortic Stenosis Indications for Surgery Severe Aortic Stenosis ( < 0.6 cm 2 /m 2 ) 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 yrs Mechanical prosthesis – hemorrhage fm anticoagulation

54 Management Strategy for Severe Aortic Stenosis

55 Percutaneous Balloon Aortic Valvuloplasty Preferred in children and young adults with congenital, noncalcific AS High “restenosis” rate in calcific AS “bridge to operation”

56 Percutaneous Transcatheter Placement of AV prosthesis

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60 Aortic Regurgitation Etiology Primary Valve Disease Rheumatic – 2/3 of patients Infective Endocarditis Trauma Bicuspid valve Primary Aortic Root Disease Degenerative heart disease Syphilis Marfan’s syndrome Ankylosing Spondylitis Aortic Aneurysm with dissection Systemic hypertension Giant Cell arteritis

61 Pathophysio of AR

62 Aortic Regurgitation History: Easy fatigue then exertional dyspnea (diminished cardiac reserve) – orthopnea, PND and excessive diaphoresis PE: Wide pulse pressure with bounding pulses Diastolic decresendo murmur at the base of the heart Midsystolic ejection murmur at base of the heart Austin Flint murmur – soft, low pitched rumbling middiastolic bruit at the apex

63 Peripheral Signs of Chronic AR Corrigan’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

64 Differential Diagnosis of a Bounding Pulse Cardiac Causes Aortic Regurgitation Patent Ductus Arteriosus Non-Cardiac Causes Arteriovenous Fistula Fever Thyrotoxicosis Pregnancy

65 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 years.

66 Laboratory Exam LV Hypertrophy 2DECHO + myocardial contractility and function Cardiac catheterization and angiography Magnitude of AR and status of LV function

67 Survival without Surgery in Chronic AR

68 Medical Treatment of AR Salt restriction Diuretics Vasodilators (ACEI) Nitrates not as helpful in relieving angina Syphilitic aortitis – penicillin tx

69 Surgical Treatment of AR Definitive 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 mL/m 2 ( 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

70 Post-operative Survival in AR

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72 Tricuspid Stenosis

73 Treatment of TS Medical Tx Intensive salt restriction, diuretic tx Surgical Tx Definitive tx Diastolic pressure gradient >4 mmHg Tricuspid orifice < 1.5 to 2.0 cm Open heart repair/prosthesis (preferably large bioprosthetic valve)

74 Tricuspid Regurgitation

75 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

76 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.

77 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.1Patient has MS mild, AS severe, MR mild Ans.AS is the dominant lesion B. The lesion that causes the most corresponding chamber enlargement is usually the predominant lesion Ex.2Patient has AR moderate, MS moderate, Severely dilated LV, slightly dilated LA Ans.AR is the predominant lesion

78 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.

79 THANK YOU!!!


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