Some Essentials of Valvular Heart Disease CCU lecture series

Case 1 56 YO M presents for DOE 6 months 56 YO M presents for DOE 6 months Denies CP, syncope, palpitations Denies CP, syncope, palpitations PMH significant for hypercholesterolemia PMH significant for hypercholesterolemia Had “murmur since I was a child” Had “murmur since I was a child” Mother died of heart failure in 60s Mother died of heart failure in 60s Non-smoker Non-smoker

Case 1 HR 66 BP 120/85 HR 66 BP 120/85 Neck: No bruits Neck: No bruits Chest: CTA Chest: CTA CVS: RRR, harsh 3/6 SEM radiating to carotids CVS: RRR, harsh 3/6 SEM radiating to carotids Abdomen: Soft, NT Abdomen: Soft, NT Ext: No c/c/e Ext: No c/c/e

Aortic Stenosis Obstruction most commonly located at the level of the aortic valve Obstruction most commonly located at the level of the aortic valve May be congenital or acquired (most common) May be congenital or acquired (most common) Calcific AS is associated with traditional risk factors for atherosclerosis (smoking, high LDL, HTN) Calcific AS is associated with traditional risk factors for atherosclerosis (smoking, high LDL, HTN) Also seen in ESRD, Pagets, SLE, alkaptonuria Also seen in ESRD, Pagets, SLE, alkaptonuria

Pathophysiology Aortic stenosis generally develops gradually, leading to LV hypertrophy Aortic stenosis generally develops gradually, leading to LV hypertrophy As stenosis progresses, LVEDP begins to increase – LV function usually remains normal until late in disease process As stenosis progresses, LVEDP begins to increase – LV function usually remains normal until late in disease process Diastolic dysfunction may also contribute to symptom onset Diastolic dysfunction may also contribute to symptom onset

Clinical Features 3 classic symptoms of severe AS 3 classic symptoms of severe AS 1) DOE 2) Syncope 3) Angina

Physical Exam Pulse Pulse Heart sounds (second heart sound) Heart sounds (second heart sound) Murmur Murmur Other clinical manifestations (bleeding, embolic events, CAD) Other clinical manifestations (bleeding, embolic events, CAD)

Testing EKG EKG CXR CXR Echo Echo Cardiac catheterization Cardiac catheterization CT/MRI? CT/MRI?

Catheterization findings

Cardiac MRI and CT

Grading Severity of AS

Low Gradient AS

Indications for Surgery

Treatment No effective medical therapy for what is primarily a mechanical obstruction No effective medical therapy for what is primarily a mechanical obstruction Aortic valve replacement is standard of care Aortic valve replacement is standard of care Mechanical vs. Bioprosthetic valves Mechanical vs. Bioprosthetic valves The Ross procedure The Ross procedure Aortic root replacement? Aortic root replacement?

Balloon Valvuloplasty 31 patients >90 years old who underwent balloon valvuloplasty from patients >90 years old who underwent balloon valvuloplasty from Patients all had severe symptomatic AS and were deemed high risk for surgery Patients all had severe symptomatic AS and were deemed high risk for surgery Mean STS score was 18.5% Mean STS score was 18.5%

Results 25 patients underwent retrograde BAV, 6 anterograde 25 patients underwent retrograde BAV, 6 anterograde Mean AVA increased from 0.52 to 0.92 cm² Mean AVA increased from 0.52 to 0.92 cm² Mean NYHA Class increased from 3.4 to 1.8 Mean NYHA Class increased from 3.4 to day mortality was 9.7% 30 day mortality was 9.7%

CoreValve 86 patients with symptomatic severe AS, >80 years old and high risk for cardiac surgery enrolled 86 patients with symptomatic severe AS, >80 years old and high risk for cardiac surgery enrolled Percutaneous AV replacement attempted with 18 and 21 French systems Percutaneous AV replacement attempted with 18 and 21 French systems

Results Acute device success was 88% Acute device success was 88% Successful implantation led to a significant reduction in gradient Successful implantation led to a significant reduction in gradient Aortic regurgitation remained unchanged Aortic regurgitation remained unchanged Procedural mortality was 6% Procedural mortality was 6% 30 day mortality was 12% 30 day mortality was 12%

The SALTIRE Study 155 patients with moderate to severe AS enrolled – randomized to 80 mg atorvastatin or placebo 155 patients with moderate to severe AS enrolled – randomized to 80 mg atorvastatin or placebo AV stenosis and calcification assessed by echocardiography and cardiac CT AV stenosis and calcification assessed by echocardiography and cardiac CT Primary endpoints changes in aortic jet velocity and AV calcium score Primary endpoints changes in aortic jet velocity and AV calcium score

SALTIRE LDL decreased to 62 mg/dl in the atorvastatin group, 131 in placebo LDL decreased to 62 mg/dl in the atorvastatin group, 131 in placebo No significant change in endpoints No significant change in endpoints

The Critically Ill AS patient Remember… Remember… 1) Atrial fibrillation is bad! 2) Vasopressor agents are preferable to inotropes for blood pressure support 3) Think IABP early 4) Always auscultate before you give NTG for chest pain!

Management Recommendations

Case Number 2 72 YO M in the emergency department has had CP x 5 days 72 YO M in the emergency department has had CP x 5 days Finally decides to come to the ED Finally decides to come to the ED Hypoxic on room air, rales 1/2 way up Hypoxic on room air, rales 1/2 way up Heart sounds difficult to appreciate Heart sounds difficult to appreciate Troponin is 44 Troponin is 44

EKG

Stat Echo performed…

Acute Mitral Regurgitation Three main mechanisms Flail leaflet due to mitral valve prolapse Flail leaflet due to mitral valve prolapse Chordae tendinae rupture due to trauma, infective endocarditis or rheumatic fever Chordae tendinae rupture due to trauma, infective endocarditis or rheumatic fever Papillary muscle dysfunction due to ischemia/infarction (what kind of infarction will more often present with acute MR?) Papillary muscle dysfunction due to ischemia/infarction (what kind of infarction will more often present with acute MR?)

Mitral Valve Anatomy

Pathophysiology Hemodynamic changes much more pronounced than in chronic MR due to lack of time for adaptation Hemodynamic changes much more pronounced than in chronic MR due to lack of time for adaptation The abrupt increase in left atrial pressure is transmitted to the pulmonary circulation The abrupt increase in left atrial pressure is transmitted to the pulmonary circulation Cardiac output falls and systemic vascular resistance increases Cardiac output falls and systemic vascular resistance increases

Clinical Manifestations Often present in cardiogenic shock and acute pulmonary edema Often present in cardiogenic shock and acute pulmonary edema Physical exam may reveal a hyperdynamic precordium (will the apex be displaced?) Physical exam may reveal a hyperdynamic precordium (will the apex be displaced?) The murmur The murmur Up to 50% of patients will not have an audible murmur at the time of evaluation Up to 50% of patients will not have an audible murmur at the time of evaluation

Testing Echocardiography mainstay of diagnosis Echocardiography mainstay of diagnosis Cardiac catheterization may be required for determination of the extent and severity of concomitant CAD Cardiac catheterization may be required for determination of the extent and severity of concomitant CAD Hemodynamics are characteristic Hemodynamics are characteristic

Mitral Regurgitation

Treatment Definitive treatment is surgical Definitive treatment is surgical Supportive measures include nitroprusside (what is the mechanism?) and possibly dobutamine for low cardiac output Supportive measures include nitroprusside (what is the mechanism?) and possibly dobutamine for low cardiac output IABP IABP

Class I Indications for MV Surgery in Severe MR Acute symptomatic MR Acute symptomatic MR Chronic severe MR with NYHA class II, III or IV in absence of severe LV dysfunction and/or LVESD>55 mm. Chronic severe MR with NYHA class II, III or IV in absence of severe LV dysfunction and/or LVESD>55 mm. Symptomatic or asymptomatic patients with mild/mod LV dysfunction (EF 30-60%) and end- systolic dimension >40 mm Symptomatic or asymptomatic patients with mild/mod LV dysfunction (EF 30-60%) and end- systolic dimension >40 mm MV repair recommended over replacement for majority of pts; pts should be referred to experienced surgical center. MV repair recommended over replacement for majority of pts; pts should be referred to experienced surgical center.

Surgery Surgical mortality can be as high as 50% - however mortality is uniformly worse without surgical intervention Surgical mortality can be as high as 50% - however mortality is uniformly worse without surgical intervention Valve repair is always preferable to replacement, if possible Valve repair is always preferable to replacement, if possible The success rates depend on the etiology of the valvular dysfunction The success rates depend on the etiology of the valvular dysfunction