1. Treatment and Management of Valvular Heart disease
Gardar Sigurdsson, MD
Associate Professor Department of Internal Medicine & Radiology
University Iowa

2. Conflict of interest Medical Imaging Applications, LLC
Advanced Calcium Scoring Screening, LLC

4. Who needs a cardiologist?
General cardiology
Asymptomatic moderate to severe stenosis
Asymptomatic moderate to severe regurgitation
Valve clinic UIHC
Symptomatic moderate or severe stenosis
Symptomatic moderate or severe regurgitation
Asymptomatic severe regurgitation LVEF < 60%

5. Treatment/Management Valve dz
Medical therapy
Limited data, limited research
Surgical therapy – “open heart surgery”
Mechanical valves, Bioprosthetic valves, repair
Percutaneous/Transluminal therapy
Balloon valvuloplasty, TAVR, Mitral clip, TMVR
Anticoagulation
Endocarditis prophylaxis

6. Medical therapy Watchful waiting for optimal timing of surgery
Surgery risk substantial with MVR (less with AVR)
Stenosis
Symptom key for timing of surgery
Regurgitation
Imaging for ventricular dilatation or systolic dysfunction

7. Symptoms Shortness of breath Syncope / Chest pain

8. AS survival based on symptoms

9. Mitral stenosis Dyspnea Orthopnea Leg swelling Pulmonary hypertension
Atrial fibrillation
Pregnancy

10. “Leaky valves are sneaky”
Incidental murmur
Endocarditis
Atrial fibrillation or flutter
Dyspnea on exertion or other heart failure symptoms (too late for surgery?)

11. Medical therapy Aortic stenosis Mitral valve stenosis
Avoid hypotension
Mitral valve stenosis
Supportive with rate control, diuretics
Mitral valve regurgitation
No medical therapy, unless hypertensive
Aortic valve regurgitation
Randomized trial negative

12. Aortic valve regurgitation trials
1994 ”Afterload reduction”
2005 Control group
Scognamiglio et al. NEJM 1994
Evangelista et al. NEJM 2005

13. Annual echocardiograms
Routine annual surveillance of mod-severe regurgitation without change in clinical status
Maybe every 6 months if recent change in size
Routine annual surveillance of moderate to severe stenosis without change in status
If mild stenosis ≥ 3 years but uncertain for regurgitation
2011 ASE guidelines

15. BNP – aortic valve stenosis
Heart Nov;92(11): Epub 2006 Jun 1.
Prognostic value of N-terminal pro-B-type natriuretic peptide for conservatively and surgically treated patients with aortic valve stenosis.
Weber M1, Hausen M, Arnold R, Nef H, Moellman H, Berkowitsch A, Elsaesser A, Brandt R, Mitrovic V, Hamm C.
Author information
Abstract
OBJECTIVE:
To evaluate the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with aortic stenosis being treated conservatively or undergoing aortic valve replacement (AVR).
METHODS:
159 patients were followed up for a median of 902 days. 102 patients underwent AVR and 57 were treated conservatively. NT-proBNP at baseline was raised in association with the degree of severity and of functional status.
RESULTS:
During follow up 21 patients (13%) died of cardiac causes or required rehospitalisation for decompensated heart failure. NT-proBNP at baseline was higher in patients with an adverse outcome than in event-free survivors (median 623 (interquartile range ) pg/ml v 1054 ( ) pg/ml, p = 0.028). This difference was even more obvious in conservatively treated patients (331 ( ) pg/ml v 1102 ( ) pg/ml, p = 0.002). Baseline NT-proBNP independently predicted an adverse outcome in the entire study group and in particular in conservatively treated patients (area under the curve (AUC) = 0.65, p = and AUC = 0.82, p = 0.002, respectively) but not in patients undergoing AVR (AUC = 0.544). At a cut-off value of 640 pg/ml, baseline NT-proBNP was discriminative for an adverse outcome.
CONCLUSION:
NT-proBNP concentration is related to severity of aortic stenosis and provides independent prognostic information for an adverse outcome. However, this predictive value is limited to conservatively treated patients. Thus, the data suggest that assessing NT-proBNP may have incremental value for selecting the optimal timing of valve replacement.
Weber et al. Heart 2006

16. BNP – AS all patients Weber et al. Heart 2006
Heart Nov;92(11): Epub 2006 Jun 1.
Prognostic value of N-terminal pro-B-type natriuretic peptide for conservatively and surgically treated patients with aortic valve stenosis.
Weber M1, Hausen M, Arnold R, Nef H, Moellman H, Berkowitsch A, Elsaesser A, Brandt R, Mitrovic V, Hamm C.
Author information
Abstract
OBJECTIVE:
To evaluate the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with aortic stenosis being treated conservatively or undergoing aortic valve replacement (AVR).
METHODS:
159 patients were followed up for a median of 902 days. 102 patients underwent AVR and 57 were treated conservatively. NT-proBNP at baseline was raised in association with the degree of severity and of functional status.
RESULTS:
During follow up 21 patients (13%) died of cardiac causes or required rehospitalisation for decompensated heart failure. NT-proBNP at baseline was higher in patients with an adverse outcome than in event-free survivors (median 623 (interquartile range ) pg/ml v 1054 ( ) pg/ml, p = 0.028). This difference was even more obvious in conservatively treated patients (331 ( ) pg/ml v 1102 ( ) pg/ml, p = 0.002). Baseline NT-proBNP independently predicted an adverse outcome in the entire study group and in particular in conservatively treated patients (area under the curve (AUC) = 0.65, p = and AUC = 0.82, p = 0.002, respectively) but not in patients undergoing AVR (AUC = 0.544). At a cut-off value of 640 pg/ml, baseline NT-proBNP was discriminative for an adverse outcome.
CONCLUSION:
NT-proBNP concentration is related to severity of aortic stenosis and provides independent prognostic information for an adverse outcome. However, this predictive value is limited to conservatively treated patients. Thus, the data suggest that assessing NT-proBNP may have incremental value for selecting the optimal timing of valve replacement.
Weber et al. Heart 2006

17. NT-proBNP 640 in AS for CHF/death
Figure 2 Receiver operating characteristic curves for N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) as a predictor of cardiac death or rehospitalisation for decompensated heart failure. (A) All patients. (B) Only conservatively treated patients. (C) Only surgically treated patients.
Weber et al. Heart 2006

18. Echocardiogram – diastology/strain
Mentias et al. JACC 2016

19. A. Global longitudinal strain greater than -21. 7% B
A. Global longitudinal strain greater than -21.7% B. Exercise performance below 100% predicted for age/gender
Mentias et al. JACC 2016

20. Exercise capacity vs GLS
Mentias et al. JACC 2016

21. Mentias et al. JACC 2016

22. Who needs TEE? Mitral valve regurgitation Mitral stenosis
Flail or perforation
Repair versus replacement
Mitral clip
Mitral stenosis
Left atrial appendage thrombus
Mitral regurgitation

23. Myxomatous mitral valve with prolapse and/or flail

24. Classic Quadrangular resection of mitral valve and repair with annuloplasty ring

25. Aortic valve repair - rare

26. Percutaneous valvuloplasty for MS

27. Trans-septal procedures

29. “Therapy on a stick”

31. SAPIEN Platforms in PARTNER Device Evolution
Valve
Technology
SAPIEN
SAPIEN XT
SAPIEN 3
Sheath
Compatibility
Available
Valve Sizes
23 mm
26 mm
20 mm
29 mm
22-24F
16-20F
14-16F
29 mm
23 mm
26 mm

32. Unadjusted Clinical Events At 30 Days and 1 Year (AT)
TAVR
Surgery
Death
All-cause
1.1
4.0
7.4
13.0
Cardiovascular
0.9
3.1
4.5
8.1
Neurological Events
Disabling Stroke
1.0
4.4
2.3
5.9
All Stroke
2.7
6.1
4.6
8.2
All-cause Death and Disabling Stroke
2.0
8.0
8.4
16.6

33. Unadjusted Time-to-Event Analysis All-Cause Mortality and All Stroke (AT)10 20 30 40
P2A Surgery
SAPIEN 3 TAVR
18.8%
All-Cause Mortality / Stroke Rate (%)
10.8%
9.7%
3.7% 3 6 9 12
Months from Procedure
Number at risk:
P2A Surgery
944
805
786
757
743
S3 TAVR
1077
1012
987
962
930

34. Unadjusted Time-to-Event Analysis All-Cause Mortality (AT)10 20 30 40
P2A Surgery
SAPIEN 3 TAVR
All-Cause Mortality (%)
13.0%
4.0%
7.4%
1.1% 3 6 9 12
Months from Procedure
Number at risk:
P2A Surgery
944
859
836
808
795
S3 TAVR
1077
1043
1017
991
963

35. Unadjusted Time-to-Event Analysis All Stroke (AT)10 20 30 40
P2A Surgery
SAPIEN 3 TAVR
All Stroke (%)
8.2%
6.1%
4.6%
2.7% 3 6 9 12
Months from Procedure
Number at risk:
P2A Surgery
944
805
786
757
743
S3 TAVR
1077
1012
987
962
930

36. Other Unadjusted Clinical Outcomes At 30 Days and 1 Year (AT)
Events (%)
30 Days
1 Year
TAVR
(n = 1077)
Surgery
(n = 944)
Re-hospitalization
4.6
6.8
11.4
15.1 MI
0.3
1.9
1.8
3.1
Major Vascular Complication
6.1
5.4
---
AKI (Stage III)
0.5
3.3
Life-Threatening/Disabling Bleeding
46.7
New Atrial Fibrillation
5.0
28.3
5.9
29.2
New Permanent Pacemaker
10.2
7.3
12.4
9.4
Re-intervention
0.1
0.0
0.6
Endocarditis
0.2
0.8
0.7

37. Paravalvular Regurgitation 3-Class Grading Scheme (VI)
≥ Moderate
1.5%
Mild
39.8%
No. of echos
30 Days
1 Year
P2A Surgery
755
610
S3i TAVR
992
875

38. Mitral clip

40. MitraClip in MitraSWISS registry
Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome
Stefan Toggweiler1, Michel Zuber1,2, Daniel Sürder3, Patric Biaggi2,4, Christine Gstrein2, Tiziano Moccetti3, Elena Pasotti3, Oliver Gaemperli2, Francesco Faletra3, Iveta Petrova-Slater3, Jürg Grünenfelder2,4, Peiman Jamshidi1, Roberto Corti2,4, Giovanni Pedrazzini3, Thomas F Lüscher2 and Paul Erne1,2
Author affiliations
Abstract
Objective Analyse 2-year outcomes after MitraClip therapy and identify predictors of outcome.
Methods Consecutive patients (n=74) undergoing MitraClip therapy were included in the MitraSWISS registry and followed prospectively.
Results A reduction of mitral regurgitation (MR) to ≤ mild was achieved in 32 (43%) patients and to moderate in 31 (42%) patients; 16/63 (25%) patients with initially successful treatment developed recurrent moderate to severe or severe MR during the first year and only 1 patient did so during the second year. At 2 years, moderate or less MR was more frequently present in patients with a transmitral mean gradient <3 mm Hg at baseline (73% vs 23%, p < 0.01) and in patients with a left atrial volume index (LAVI) <50 mL/m2 at baseline (86% vs 52%, p=0.03). More than mild MR post MitraClip, N-terminal probrain natriuretic peptide ≥5000 ng/L at baseline, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were associated with reduced survival.
Conclusions A mean transmitral gradient <3 mm Hg at baseline, an LAVI <50 mL/m2, the absence of COPD and CKD, and reduction of MR to less than moderate were associated with favourable outcome. Given a suitable anatomy, such patients may be excellent candidates for MitraClip therapy. Between 1 and 2 years follow-up, clinical and echocardiographic outcomes were stable, suggesting favourable, long-term durability of the device.
Stefan Toggweiler et al. Open Heart 2014

41. Everest II trial - similar mortality Mitral valve surgery and mitral clip with similar mortality
1/3 patients with posterior leaflet
1/3 with anterior/bileaflet
1/3 with functional MR
4 years out the mortality is no different
Feldman et al. NEJM 2011

42. Everest II mortality at 4 years
Mauri et al. JACC 2013

43. COAPT trial ongoing for functional MR

44. TMVR with Tendyne device
The Valve Prosthesis En face (A) and longitudinal (B) views of the Tendyne transcatheter mitral valve (Tendyne Holdings, LLC, a subsidiary of Abbott Vascular, Roseville, Minnesota). The self-expanding prosthesis has an outer frame with a cuff (AC) that rests against the anterior left atrial wall and aorta. The inner frame (black arrows) houses the valve leaflets. The prosthesis is anchored to an epicardial pad (EP) by a tether (T).
The procedure is performed under general anesthesia through a left lateral mini-thoracotomy. The site for LV apical access and optimal coaxial alignment is derived from the pre-procedural cardiac CT and intraprocedural TEE as described earlier in the text. After pledgeted purse-string sutures are placed, a 34-F delivery sheath is inserted over a inch guidewire, ensuring there is no entanglement with the mitral subvalvular apparatus. The prosthesis is introduced through the sheath, partially unsheathed in the left atrium, aligned with the aortomitral continuity using TEE, and retracted until the cuff of the device rests on the floor of the left atrium (Figure 2). The remainder of the prosthesis is deployed within the annulus and secured with a braided, high-molecular-weight polyethylene tether that is attached to an epicardial pad (Figure 1). The tension of the tether is adjusted after deployment to optimize the seating of the prosthesis and to minimize movement of the device within the annulus (Figure 3). If the function of the prosthesis is not acceptable, or LVOT obstruction occurs, it can be recaptured and repositioned or fully retrieved. The procedure is performed without cardiopulmonary bypass and without rapid ventricular pacing. Left ventriculography may be performed to assess MR severity, but is not required for prosthesis placement. Post-procedurally, all patients were treated with aspirin (81 to 100 mg daily) or clopidogrel (75 mg daily), and were anticoagulated with heparin followed by warfarin for ≥3 months, with a target international normalized ratio of 2.5 to 3.5.
Muller et al. JACC 2017

45. Muller et al. JACC 2017

46. Muller et al. JACC 2017

47. Anticoagulation
Mechanical MVR or AVR w/risk factors (CHF/hypercoaguable states/older gen AVR)
Warfarin INR goal 3 plus aspirin low dose
Bridging with UFH or SC LMWH
Mechanical AVR without risk factors
Warfarin INR goal 2.5 plus aspirin low dose
No heparin bridge needed
Bioprosthetic MVR or AVR
3 Months Warfarin INR 2.5 -> Aspirin low dose
TAVR
Plavix and aspirin first 6 months
Nishimura RA, Otto CM, Bonow RO, et al AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57

48. Low dose Aspirin added to warfarin
Meta-analysis 13 studies involving 4122 participants from 1971 to 2011
reduced thromboembolism by 57% (OR 0.43, 95% CI )
increased risk of major hemorrhage by 58% (OR 1.58, 95% CI )
lowered mortality by 43% (odds ratio [OR] 0.57, 95% CI )
Cochrane Database Syst Rev. 2013

49. Anticoagulation Uptodate 2017
Chest guidelines suggest
TAVR: 3 months ASA/Plavix for TAVR
Mechanical valves, add aspirin only in those with low risk for bleeding
Uptodate 2017

50. Endocarditis Prosthetic valves Prior history of endocarditis
Congenital heart disease
Dental procedures/routine cleaning
Biopsy/incision respiratory mucosa
Ongoing infection of skin, GI or urinary tract
2014 AHA/ACC guideline

51. Antibiotic Prophylaxis
Oral Amoxicillin 2 gr
IM/IV Ampicillin 2 gr
Allergy to PCN:
Clindamycin 600mg PO or IV or IM
Oral azithromycin 500 mg
Oral Cephalexin 2 gr
IV/IM 1gr cefazolin/ceftriaxone

52. Learning points “Leaky is sneaky” and needs serial echo
BNP and GLS might help
TAVR now superior to AVR in intermediate risk patients (STS 4-8%)
Mitral clip with equal survival over 4 years
TMVR coming soon
Baby aspirin for AVR/MVR
Endocarditis prophylaxis not for everyone