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Overview of Valvular Heart Disease January 28, 2006 David R. Richards, DO, FACC, FASE MidOhio Cardiology and Vascular Consultants Director, Heart Disease Management Program Riverside Hospital
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Valve Disease: general concepts Etiology and natural history Physical findings Therapy –types of surgical therapy –indications for surgery –indications for anticoagulation –antibiotic prophylaxis
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Etiology of valve disease “Secondary” valve disease “Primary” valve disease
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Etiology of valve disease “Secondary” valve disease –Hypertension –CAD –Cardiomyopathy “Primary” valve disease
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Etiology of valve disease “Secondary” valve disease “Primary” valve disease –Calcific aortic stenosis –Rheumatic valve disease –Mitral prolapse / myxomatous mitral disease –Primary aortic regurgitation –Infective endocarditis
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Diseases primary degenerative rheumatic endocarditis myxomatous congenital secondary CAD / cardiomyopathy Mechanisms Aortic stenosis Mitral stenosis Mitral regurg. Aortic regurg. Tricuspid regurg
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Mechanisms of Valve Disease
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Valvular Emergencies Acute Endocarditis Papillary Muscle Rupture Flail Mitral Leaflet Prosthetic Valve Thrombosis / Dehiscence
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65 y.o. female with MVR and acute CHF
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S/P thrombolytic therapy
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S/P bioprosthetic valve replacement
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Valve disease: Diagnosis Physical exam suggests diagnosis Transthoracic Echo (TTE) confirms mechanism and severity of lesion Transesophageal Echo (TEE) usually reserved to: plan surgery confirm borderline diagnosis/severity
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2 D Echocardiography
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Transesophageal Echo (TEE)
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S1S1 S2S2 systole diastole MV closure AV closure
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S1S1 S2S2 Mild AS Severe ASMitral regurgMVP
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S1S1 S2S2 Mitral Stenosis Severe AR Mild AR
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Valve disease: Management Medical therapy ineffective –except: vasodilators for AR Surgical therapy curative Surgery for symptoms or LV dysfunction Surgical trends: –minimally invasive surgery –valve repair –homograft use
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Mechanical Prostheses
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2D Echo: normal mechanical MV
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Heterografts: Porcine
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Aortic Homograft
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TEE: aortic homograft
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Mitral Annuloplasty Ring
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Prosthetic Valves: selection Bioprosthetic Mechanical Homograft No Coumadin needed Less thromboembolic complications Lifelong cure No Coumadin needed Potential lifelong integrity Lifespan 10-15 yrs. Lifelong Coumadin 1% annual comp. Rate Limited availability ? Late failure Technically challenging ProsCons
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Prosthetic Valves: selection Bioprosthetic Mechanical Homograft Elderly pts.(lifespan < 15 yrs. Contraindication to Coumadin Elderly who already need Coumadin All other patients Young patients with Aortic Valve disease
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Prosthetic Valves: types of dysfunction Stenosis –degenerative –thrombosis Regurgitation –Paravalvular –Transvalvular Endocarditis Mechanical Failure
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Prosthetic Valve Endocarditis
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Valve disease: Management Endocarditis prophylaxis High-risk patient High-risk procedure + = prophylaxis
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Endocarditis prophylaxis High-risk patient High-risk procedure + *Congenital disease *Prior endocarditis *Prosthetic valves Acquired valve disease MVP with MR Dental GU GI Resp
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Antibiotic Regimens Oral, Dental, Upper Resp Procedures: Amoxicillin 2.0 gm p.o. Alternative: –Clindamycin 600 mg p.o. –Cephalexin, Azithromycin GU, GI Procedures: Ampicillin and Gentamycin Alternative: Vancomycin
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Case 1 36 year old male presents with palpitations. No past history. No meds. Sibling has heart murmur. Exam: normal S1, S2. No murmur. Soft mid-systolic click. EKG: normal except for PACs.
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Case 1 Initial management should include: A.antibiotic prophylaxis B.2D echo C. beta-blockade D.EP study
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Case 1: 2D echo Findings:Posterior Leaflet Prolapse Mild (1+) Regurgitation
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Case 1 Further management should include: A.antibiotic prophylaxis B.yearly 2D echo to follow MR C. Holter monitor D.empiric beta-blockade
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Case 1 Further management should include: A.antibiotic prophylaxis B.yearly 2D echo to follow MR C. Holter monitor D.empiric beta-blockade
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Mitral Valve Prolapse A form of myxomatous valve disease symptoms may be from: –mitral regurgitation –hyperadrenergic state May progress to “surgical” MR Often familial Overdiagnosed clinically
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Severe Posterior Leaflet Prolapse
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Case 2 56 year old male with known heart murmur and MVP for 20 years. 3 days prior to admission, he had acute onset dyspnea and orthopnea. Exam: pulse 110. 3/6 holosystolic murmur at apex. Bilateral crackles. Labs: Troponin negative EKG: sinus tachy CXR: pulmonary edema
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Case 2 Potential Causes of CHF include all except: A.Endocarditis on pre-existing myxomatous mitral valve B.Flail mitral leaflet due to ruptured chordae tendinae C. Papillary muscle rupture from acute MI D.LV dysfunction from chronic MR
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Case 2 Potential Causes of CHF include all except: A.Endocarditis on pre-existing myxomatous mitral valve B.Flail mitral leaflet due to ruptured chordae tendinae C. Papillary muscle rupture from acute MI D.LV dysfunction from chronic MR
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Case 2: TEE Findings:Severe MV prolapse Flail Posterior Leaflet Severe (4+) MR
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Case 2 Flail Mitral Leaflet: A.is a rare but potentially life- threatening cause of severe MR B.is most commonly a result of endocarditis C. is often amenable to valve repair D.is best initially managed with medical therapy
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Case 2 Flail Mitral Leaflet: A.is a rare but potentially life- threatening cause of severe MR B.is most commonly a result of endocarditis C. is often amenable to valve repair D.is best initially managed with medical therapy
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Flail Mitral Valve Leaflet A complication of myxomatous valve disease: rupture of chordae tendinae Rarely from endocarditis, rheumatic, etc Presents as severe MR with CHF Accurately diagnosed with TEE High untreated mortality Accounts for 30 to 50 % of MV surgery Highly amenable to valve repair
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Mitral Regurgitation Etiology: Chronic _ Myxomatous valve disease (MVP) –LV dysfunction, prior MI –Endocarditis, rheumatic disease Etiology: Acute –Papillary muscle rupture s/p AMI –Chordal rupture (flail leaflet) –Acute endocarditis Accurately diagnosed with TEE (mechanism, severity, reparability) Surgery indicated for symptoms or LV dilatation/dysfunction No role for med therapy
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Case 3 53 y.o. female with chronic dyspnea. Atrial fib for 12 years. Exam: –4/6 blowing systolic murmur at apex with harsh component at LSB –harsh diastolic rumbling murmur –reduced S2, loud opening snap –prominent JVD
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Case 3: 2D echo Findings:Rheumatic changes of MV Severe MS, Moderate AS Moderate MR
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Case 3 Potential complications expected in this patient include all except: A.Endocarditis B.Chronic Atrial Fibrillation C. CVA D.CHF due to LV dysfunction E.Pulmonary Hypertension
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Case 3 Potential complications expected in this patient include all except: A.Endocarditis B.Chronic Atrial Fibrillation C. CVA D.CHF due to LV dysfunction E.Pulmonary Hypertension
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Mitral Valve Stenosis A complication of acute rheumatic fever Valve disease occurs 20 yrs after initial acute illness Presents as exertional dyspnea and murmur Complications: A.Fib., emboli, refractory pulmonary hypertension Therapy: Commisurotomy or valve replacement
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Case 3b 72 y.o. female with dyspnea. Exam: –2/4 systolic murmur –Normal S1 and S2
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Case 3b
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Normal Aortic Valve Calcific Aortic Stenosis
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Aortic Stenosis Most common etiology is degenerative calcific disease (age < 50, bicuspid AV or rheumatic ) Classic Triad: Chest Pain, Dyspnea, Syncope Reduced exercise capacity may be earliest symptom (use exercise test) Surgery indicated for –any symptoms –LV dilation or dysfunction (EF 50mm) –NOT for specific valve area
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Case 4 35 y.o. male found to have heart murmur. No symptoms. Exam: –ejection click –2/4 diastolic murmur
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Case 4: 2D Echo Findings: Moderate AR Bicuspid AV Normal LV size and function
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Case 4 Echo: moderate AR, bicuspid AV, normal LV Exercise EKG: normal exercise capacity All are appropriate except: A.p.o. nifedipine B.yearly 2D echo C.surgery, if echo shows mild LV cavity dilation D.surgery, if mild symptoms develop E.endocarditis prophylaxis
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Case 4 Echo: moderate AR, bicuspid AV, normal LV Exercise EKG: normal exercise capacity All are appropriate except: A.p.o. nifedipine B.yearly 2D echo C.surgery, if echo shows mild LV cavity dilation D.surgery, if mild symptoms develop E.endocarditis prophylaxis
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Aortic Regurgitation Most common etiology is degenerative (age < 50, bicuspid AV or rheumatic ) Reduced exercise capacity may be earliest symptom (use exercise test) Surgery indicated for –any symptoms –LV dilation or dysfunction (EF 50mm)
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Case 5 10 years later, patient develops acute fever, weakness. Patent reports severe dyspnea at rest. Exam: BP 80/50, HR 110, bilateral crackles, soft diastolic murmur, S4 gallop
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Case 5: 2D Echo
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Case 4 Echo: bicuspid AV with vegetation, severe AR, dilated LV with EF 30% antibiotics, diuretics, & pressors are initiated. The patient initially stabilizes, but within 24 hours develops recurrent hypotension and respiratory failure.
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Case 4 Which strategy is appropriate: A.continue antibiotics, no surgery B.antibiotics, with surgery after completed course, when blood sterile C.antibiotics, with surgery in several days D.antibiotics, with surgery within 24 hours
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Case 4 Which strategy is appropriate: A.continue antibiotics, no surgery B.antibiotics, with surgery after completed course, when blood sterile C.antibiotics, with surgery in several days D.antibiotics, with surgery within 24 hours
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25 y.o woman with fatigue Findings: MV mass ? Myxoma
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Overview of Valvular Heart Disease August 10, 2005 Kgrewal@mocvc.com
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