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)

2. Aortic 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 50-100mg q day for at least 3 months 75-100mg asa-warfarin INR= 2-3 for first 3 months Mechanical AVR Warfarin INR goal= 2-3 warfarin INR 2-3 low risk 2.5-3.5 high risk Aortic valve repair. Asa 50-100 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=3.5 warfarin 2.5-3.5 Mitral valve repair asa 81 mg x 3 months Consider warfarin inr= 2-3 x 3 months Ring placement Mitral valve

6. Management of suspected prosthetic valve thrombosis

7. 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%

8. 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 bioprothetics…… 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.

9. 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