valvular heart disease: an update in management bruce w. andrus md dhmc cardiology symposium...

Valvular Heart Disease:Valvular Heart Disease:An Update in ManagementAn Update in Management

Bruce W. Andrus MDBruce W. Andrus MD

DHMC Cardiology SymposiumDHMC Cardiology Symposium

December 2002December 2002

Learning ObjectivesLearning Objectives

• Locate and review ACC/AHA guidelinesLocate and review ACC/AHA guidelines

• Review timing of surgery in VHDReview timing of surgery in VHD

• Consider role of medicine in VHDConsider role of medicine in VHD

• Discuss impact of VHD on operative riskDiscuss impact of VHD on operative risk

• Revisit endocarditis prophylaxisRevisit endocarditis prophylaxis

Outline

• Case Presentations (with audience Case Presentations (with audience participation)participation)

• Specific Valve LesionsSpecific Valve Lesions• Physiologic principles/natural historyPhysiologic principles/natural history

• ImagesImages

• Guidelines Guidelines

• Cases RevisitedCases Revisited

Audience Response TestAudience Response Test

What did you have for breakfast?What did you have for breakfast?

A) cereal or bagelA) cereal or bagel

B) donuts or danishB) donuts or danish

C) eggs, bacon, and/or sausageC) eggs, bacon, and/or sausage

D) a foil wrapped energy barD) a foil wrapped energy bar

E) none of the aboveE) none of the above

Case 1Case 1

• JB, a 45 yo contractor, presents with a cc of JB, a 45 yo contractor, presents with a cc of increasing dyspnea over the past 6 months. increasing dyspnea over the past 6 months. Able to climb stairs, but very tired climbing Able to climb stairs, but very tired climbing scaffolding. Occ pounding in chest/neck.scaffolding. Occ pounding in chest/neck.

• Denies cp, syncope.Denies cp, syncope.

• PMH significant only for htn. No PMH significant only for htn. No rheumatic fever, anorexigen use, IE.rheumatic fever, anorexigen use, IE.

Case 1Case 1

• On Exam:On Exam:• Brawny, mildly overweight, no distress.Brawny, mildly overweight, no distress.

• HR 80 regular, BP 160/50.HR 80 regular, BP 160/50.

• Rapidly collapsing pulse, subtle head noddingRapidly collapsing pulse, subtle head nodding

• Apical impulse hyperdynamic, diffuse and laterally Apical impulse hyperdynamic, diffuse and laterally displaced. Diastolic thrill at base.displaced. Diastolic thrill at base.

• Soft S1, soft S2, ejection sound at base (diaphragm), Soft S1, soft S2, ejection sound at base (diaphragm), +S3 at apex (bell), descrescendo murmur leaning +S3 at apex (bell), descrescendo murmur leaning forward in expiration.forward in expiration.

Case 1Case 1

• CXR: CXR: • enlarged LV, widened mediastinum.enlarged LV, widened mediastinum.

• Echo: Echo: • dilated LV (ESD 57 mm, EDD 80 mm), EF dilated LV (ESD 57 mm, EDD 80 mm), EF

50%.50%.

• bicuspid aortic valve, 4+ AR, mildly dilated Asc bicuspid aortic valve, 4+ AR, mildly dilated Asc Ao. Ao.

Case 1Case 1

As the next step in management, would youAs the next step in management, would you

A) start beta blocker for htn and repeat echo A) start beta blocker for htn and repeat echo in 6 mosin 6 mos

B) start long acting nifedipineB) start long acting nifedipine

C) refer for surgery nowC) refer for surgery now

D) start diuretic and see in 1 month D) start diuretic and see in 1 month

Case 2Case 2

• MB, a 50 yo woman, native of India, now MB, a 50 yo woman, native of India, now working as a medical technologist in your working as a medical technologist in your hospital.hospital.

• Makes appt to discuss frequent episodes of Makes appt to discuss frequent episodes of “bronchitis”, declining exercise tolerance and “bronchitis”, declining exercise tolerance and occasional episodes of hemoptysis.occasional episodes of hemoptysis.

• PMH neg. for htn, tobacco use, dm, PMH neg. for htn, tobacco use, dm, dyslipidemia, obesity.dyslipidemia, obesity.

Case 2Case 2

• On exam:On exam:• Thin, pleasant woman. Comfortable looking.Thin, pleasant woman. Comfortable looking.

• HR 96 irreg, irreg. BP 146/88.HR 96 irreg, irreg. BP 146/88.

• JVP 7 cm H20. Bibasilar insp crackles.JVP 7 cm H20. Bibasilar insp crackles.

• Apical impulse not displaced.Apical impulse not displaced.

• S1 varies in intensity, nl S2. Opening snap S1 varies in intensity, nl S2. Opening snap

and diastolic rumble shortly following S2.and diastolic rumble shortly following S2.

Case 2Case 2

• Echo:Echo:• Thickened and immobile mitral valve. No Thickened and immobile mitral valve. No

calcification. Minimal fusion of subvalvular calcification. Minimal fusion of subvalvular apparatus.apparatus.

• Moderately enlarged LA.Moderately enlarged LA.

• Doppler evidence of stenosis with estimated Doppler evidence of stenosis with estimated pressure gradient of 8 m Hg and MVA of 1.7 pressure gradient of 8 m Hg and MVA of 1.7 cmcm22..

Case 2Case 2

Which of the following would you do next?Which of the following would you do next?

A) begin asa for stroke prophylaxisA) begin asa for stroke prophylaxis

B) begin warfarinB) begin warfarin

C) start metoprolol C) start metoprolol

D) B and CD) B and C

E) begin Coenzyme Q10E) begin Coenzyme Q10

Case 2Case 2

Which of the following would you next Which of the following would you next pursue?pursue?

A) closely observe, repeat echo in 6 mosA) closely observe, repeat echo in 6 mos

B) refer for mitral valve replacementB) refer for mitral valve replacement

C) refer for percutaneous balloon vavuloplastyC) refer for percutaneous balloon vavuloplasty

D) schedule for exercise echocardiographyD) schedule for exercise echocardiography

Case 3Case 3

• EA, an 84 yo widow and retired english EA, an 84 yo widow and retired english teacher, sees you for vague chest discomfort teacher, sees you for vague chest discomfort and a near syncopal episode while climbing and a near syncopal episode while climbing stairs with groceries.stairs with groceries.

• Longstanding “benign” murmur.Longstanding “benign” murmur.

• PMH: htn, mild hyperlipidemia, OA, familial PMH: htn, mild hyperlipidemia, OA, familial tremor. On HCTZ 12.5 mg qD and atenolol tremor. On HCTZ 12.5 mg qD and atenolol 25 mg BID.25 mg BID.

Case 3Case 3

• On exam:On exam:• thin, elderly woman neatly dressed.thin, elderly woman neatly dressed.

• HR 60. BP 155/76 both arms. BMI 19.HR 60. BP 155/76 both arms. BMI 19.

• JVP ~11 cm H2O. Carotid upstrokes brisk.JVP ~11 cm H2O. Carotid upstrokes brisk.

• Fine bibasilar crackles. Fine bibasilar crackles.

• Apical impulse sustained. Thrill at RUSB. Nl S1 Apical impulse sustained. Thrill at RUSB. Nl S1 and harsh late peaking sys murmur at RUSB and harsh late peaking sys murmur at RUSB obscuring S2. Musical sounding sys murmur at obscuring S2. Musical sounding sys murmur at apex. Valsalva strain and standing diminish apex. Valsalva strain and standing diminish murmur. Handgrip increases murmur.murmur. Handgrip increases murmur.

Case 3Case 3

• ECG:ECG:• LAD, LA abn, mild IVCD (QRS 110 ms), LAD, LA abn, mild IVCD (QRS 110 ms),

asymmetric T wave inversion in V5 and V6asymmetric T wave inversion in V5 and V6

• Echo:Echo:• dilated LA, normal LV chamber size, moderate dilated LA, normal LV chamber size, moderate

LVHLVH

• normal LV systolic functionnormal LV systolic function

• calcified Ao valve, estimated valve area 0.6 cmcalcified Ao valve, estimated valve area 0.6 cm22

Case 3Case 3

How would you manage her?How would you manage her?

A) refer for EP study and possible ICDA) refer for EP study and possible ICD

B) begin atorvastatin 80 mg qDB) begin atorvastatin 80 mg qD

C) refer for consideration of valvuloplastyC) refer for consideration of valvuloplasty

D) refer for coronary arteriography in D) refer for coronary arteriography in anticipation of AVRanticipation of AVR

E) initiate Hospice referral, palliative careE) initiate Hospice referral, palliative care

Case 4Case 4

• RD, a 73 yo retired insurance salesman, RD, a 73 yo retired insurance salesman, sees you because a urologist evaluating him sees you because a urologist evaluating him for erectile dysfunction heard a murmur.for erectile dysfunction heard a murmur.

• Denies SOB, chest pain or syncope but is Denies SOB, chest pain or syncope but is very sedentary. Has notice some fatigue very sedentary. Has notice some fatigue and dependent edema.and dependent edema.

• Diagnosed with MVP 25 yrs ago.Diagnosed with MVP 25 yrs ago.

Case 4Case 4

• On exam:On exam:• obese, loquacious man with petite wifeobese, loquacious man with petite wife

• HR 86. BP 170/94. BMI 45.HR 86. BP 170/94. BMI 45.

• JVP 12 cm H2O. Nl carotid upstrokesJVP 12 cm H2O. Nl carotid upstrokes

• diminished bs, no crackles diminished bs, no crackles

• apical impulse not palpableapical impulse not palpable

• Neither S1 or S2 are well heard, obscured by a Neither S1 or S2 are well heard, obscured by a holosystolic blowing murmur at apex and left holosystolic blowing murmur at apex and left parasternal borderparasternal border

Case 4Case 4

• ECG:ECG:• SR, RAD, LA abn, R>S in V1, NSSTT abnSR, RAD, LA abn, R>S in V1, NSSTT abn

• CXR:CXR:• LA and LV enlargementLA and LV enlargement

• Echo:Echo:• severe LA enlargement, mild LV dilatation severe LA enlargement, mild LV dilatation

(ESD 45mm), nl LVEF (60%), pulmonary (ESD 45mm), nl LVEF (60%), pulmonary hypertensio (est PASP 55 mmHg)hypertensio (est PASP 55 mmHg)

Case 4Case 4

How would you manage this gentleman?How would you manage this gentleman?

A) begin ACE inhibitorA) begin ACE inhibitor

B) begin digoxin for inotropic supportB) begin digoxin for inotropic support

C) refer for exercise echoC) refer for exercise echo

D) refer for consideration of MV repairD) refer for consideration of MV repair

E) A and DE) A and D

Case 4Case 4

Does this man need endocarditis prophylaxis Does this man need endocarditis prophylaxis for a dental extraction?for a dental extraction?

A) yesA) yes

B) only if the tooth is infectedB) only if the tooth is infected

C) only if local anaesthetic will be usedC) only if local anaesthetic will be used

D) noD) no

Aortic StenosisAortic StenosisPhysiologic Principles-Natural HistoryPhysiologic Principles-Natural History

• Normal aortic valve area is 3.0 - 4.0 cmNormal aortic valve area is 3.0 - 4.0 cm22

• Circulation affected when valve area is reduced Circulation affected when valve area is reduced by ~ 75% (i.e. 0.75 - 1.0 cmby ~ 75% (i.e. 0.75 - 1.0 cm22))

valve area (cmvalve area (cm sq)sq) mean gradient (mm mean gradient (mm Hg)Hg)**

MildMild > 1.5> 1.5 < 25< 25

ModerateModerate 1.0 - 1.51.0 - 1.5 25 - 5025 - 50

SevereSevere < 0.75< 0.75 > 50> 50

* assumes normal cardiac output


• Primary adaptation is concentric hypertrophyPrimary adaptation is concentric hypertrophy

• Latent phase usually lasts decadesLatent phase usually lasts decades

• Risk of sudden death is very low during this phaseRisk of sudden death is very low during this phase

• Rate of progression ranges from 0-0.3 cmRate of progression ranges from 0-0.3 cm22/yr. /yr. (average rate is 0.12 cm(average rate is 0.12 cm22/yr)/yr)

• 50% of patients with severe AS do not progress50% of patients with severe AS do not progress

• Cannot predict who will progressCannot predict who will progress


Bonow et al. Valvular Guidelines. Circ


• Once symptoms develop, Once symptoms develop, average survival is 2-3 yrsaverage survival is 2-3 yrs

• With LV systolic With LV systolic dysfunction, there may be dysfunction, there may be increased risk of sudden increased risk of sudden death and permanent LV death and permanent LV dysfunction dysfunction

Ross J Jr, Braunwald E: Aortic stenosis. Circulation 38[Suppl V]:61, 1968

Aortic StenosisAortic StenosisManagement GuidelinesManagement Guidelines

Initial Diagnostic TestingInitial Diagnostic Testing

• Lipids, renal fxn, Ca, P---all patientsLipids, renal fxn, Ca, P---all patients

• CXR, ECG, Echocardiography---all patientsCXR, ECG, Echocardiography---all patients

• Cardiac catheterization with angiographyCardiac catheterization with angiography• If clinical and echo data are discordantIf clinical and echo data are discordant

• To assess coronary circulation prior to surgeryTo assess coronary circulation prior to surgery


Initial Diagnostic Testing (cont.)Initial Diagnostic Testing (cont.)

• Treadmill stress testingTreadmill stress testing•Dangerous in symptomatic ptsDangerous in symptomatic pts

•Not useful for dx of CADNot useful for dx of CAD

•May be used to assess functional significance of May be used to assess functional significance of severe AS in pts who deny symptoms (e.g. bp severe AS in pts who deny symptoms (e.g. bp response)response)


Scheduled Follow-upScheduled Follow-up

office intervaloffice interval echo intervalecho interval

Mild ASMild AS 12 mos12 mos 5 yrs5 yrs

Moderate ASModerate AS 6 mos6 mos 2 yrs2 yrs

Severe ASSevere AS 6 mos6 mos 1 yr1 yr


Low Gradient ASLow Gradient AS

• Special caseSpecial case

• Minimal valve mobility and low cardiac outputMinimal valve mobility and low cardiac output

• Calculated valve area is small but pressure Calculated valve area is small but pressure gradient is also smallgradient is also small

• Functional vs. fixed AS?Functional vs. fixed AS?

• Consider dobutamine stress test (DSE) to clarifyConsider dobutamine stress test (DSE) to clarify

ACC Classification of ACC Classification of RecommendationsRecommendations

Class I:Class I:

Conditions for which there is evidence and/or general agreement that a Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. given procedure or treatment is useful and effective.

Class IIClass II::

Conditions for which there is conflicting evidence and/or a divergence of Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.opinion about the usefulness/efficacy of a procedure or treatment.

IIa. Weight of evidence/opinion is in favor of usefulness/efficacyIIa. Weight of evidence/opinion is in favor of usefulness/efficacy

IIb. Usefulness/efficacy is less well established by evidence/opinion.IIb. Usefulness/efficacy is less well established by evidence/opinion.

Class III:Class III:

Conditions for which there is evidence and/or general agreement that the Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be procedure/treatment is not useful/effective, and in some cases may be harmful.harmful.


Recommendations for AVRRecommendations for AVR

Class IClass I

• Severe AS and symptomsSevere AS and symptoms

• Severe AS (with or without sxs) Severe AS (with or without sxs) andand need for CABG, need for CABG, other valve replacement or aortic surgeryother valve replacement or aortic surgery

Class IIaClass IIa

• Moderate AS and need for other cardiac surgeryModerate AS and need for other cardiac surgery

• Asymptomatic severe AS and diminished LVEF or Asymptomatic severe AS and diminished LVEF or hypotensive response to exercisehypotensive response to exercise


Recommendations for AVR (cont.)Recommendations for AVR (cont.)

Class IIbClass IIb• Asymptomatic AS and VT, severe LVH (>15mm)Asymptomatic AS and VT, severe LVH (>15mm)

or valve area <0.6 cmor valve area <0.6 cm22

Class IIIClass III• Asymptomatic AS with none of the aboveAsymptomatic AS with none of the above

Aortic RegurgitationAortic Regurgitation Physiologic Principles-Natural HistoryPhysiologic Principles-Natural History

• LV faces combined pressure and volume loadLV faces combined pressure and volume load

• Primary adaptation is dilatation (eccentric Primary adaptation is dilatation (eccentric hypertrophy)hypertrophy)

• Since this adaptation takes time, AR classified as Since this adaptation takes time, AR classified as acute or chronicacute or chronic

• Acute AR results in sudden increase in LVEDP Acute AR results in sudden increase in LVEDP >>> pulmonary edema and cardiogenic shock>>> pulmonary edema and cardiogenic shock


• Latent phase of AR, like AS, may last decadesLatent phase of AR, like AS, may last decades

• Decompensation whenDecompensation when

• LV systolic function begins to failLV systolic function begins to fail

• Progressive LV dilatation occursProgressive LV dilatation occurs

• Spherical geometry developsSpherical geometry develops

• Initially this is reversibleInitially this is reversible

• LV systolic function and ESD are the most important LV systolic function and ESD are the most important predictors of postop survival and LV functionpredictors of postop survival and LV function


• In asymptomatic pts with severe AS and nl In asymptomatic pts with severe AS and nl LV systolic function, progression is slowLV systolic function, progression is slow

• 4.3%/yr develop symptoms of LV systolic 4.3%/yr develop symptoms of LV systolic dysfunctiondysfunction

• 1.3%/yr progress to LV dysfunction without 1.3%/yr progress to LV dysfunction without symptoms†symptoms†

† pooled data from 7 series. 490 pts with mean follow-up of 6.4 yrs

Aortic RegurgitationAortic Regurgitation Management GuidelinesManagement Guidelines

Initial EvaluationInitial Evaluation

• ECGECG

• CXRCXR

• EchoEcho

• ETT (if pt asymptomatic but sedentary or if ETT (if pt asymptomatic but sedentary or if symptoms are equivocal)symptoms are equivocal)

Aortic RegurgitationAortic Regurgitation Management GuidelinesManagement Guidelines

Scheduled Follow-up (office and echo)Scheduled Follow-up (office and echo)

Severe AR without symptomsSevere AR without symptoms

• q 4-12 month depending on pace of change and q 4-12 month depending on pace of change and current LV ESD/EDDcurrent LV ESD/EDD

Moderate AR without symptomsModerate AR without symptoms

• 1st follow-up in 2-3 months to establish pace, 1st follow-up in 2-3 months to establish pace, then ~ q 12 monthsthen ~ q 12 months

Aortic RegurgitationAortic RegurgitationManagement GuidelinesManagement Guidelines

Vasodilator TherapyVasodilator Therapy

• Expected to Expected to afterload, afterload, stroke volume and stroke volume and

regurgitant volumeregurgitant volume

• Hemodynamic benefit shown with hydralazine and Hemodynamic benefit shown with hydralazine and nifedipine, less consistent results with ACEinifedipine, less consistent results with ACEi

• Improvement in clinical outcomes in trial of LA Improvement in clinical outcomes in trial of LA nifedipine vs. digoxin (need for AVR in 143 pts followed nifedipine vs. digoxin (need for AVR in 143 pts followed for 6 yrs--- 15% vs 34%)for 6 yrs--- 15% vs 34%)

• Dose titrated to achieve Dose titrated to achieve in SBP, not normalization in SBP, not normalization


Vasodilator Therapy IndicationsVasodilator Therapy Indications

Class I Class I

• Severe AR with symptoms or severe LV dilatation but Severe AR with symptoms or severe LV dilatation but contraindications to surgerycontraindications to surgery

• Severe AR without symptoms but LV dilatation and Severe AR without symptoms but LV dilatation and elevated SBPelevated SBP

• Any degree of AR with hypertensionAny degree of AR with hypertension• Persistent LV systolic dysfunction s/p Persistent LV systolic dysfunction s/p AVR (ACEi)AVR (ACEi)

• Short term therapy prior to AVRShort term therapy prior to AVR


Vasodilator Therapy IndicationsVasodilator Therapy Indications

Class IIIClass III

• Mild to mod AR without sxs and nl LV Mild to mod AR without sxs and nl LV functionfunction

• In lieu of AVR in pts without In lieu of AVR in pts without contraindicationscontraindications


Recommendations for AVR (chronic severe AR)Recommendations for AVR (chronic severe AR)

Class IClass I

• NYHA functional class III or IV sxsNYHA functional class III or IV sxs

• NYHA functional class II sxs NYHA functional class II sxs andand progressive LV progressive LV dilatation or declining LVEF on serial studiesdilatation or declining LVEF on serial studies

• CCS class II anginaCCS class II angina

• Mild or moderate reduction in EF (25-50%)Mild or moderate reduction in EF (25-50%)

• Need for CABG or surgery on other valvesNeed for CABG or surgery on other valves


Class IIaClass IIa

• NYHA class II sxs with nl LVEF (>50%) with stable EF, NYHA class II sxs with nl LVEF (>50%) with stable EF, LV size and exercise toleranceLV size and exercise tolerance

• Asymptomatic pts with nl LVEF but severe LV Asymptomatic pts with nl LVEF but severe LV dilatation (ESD > 55 mm or EDD > 75 mm)dilatation (ESD > 55 mm or EDD > 75 mm)

Class IIbClass IIb

• LVEF < 25%LVEF < 25%

• Asymptomatic pts with nl LVEF and progressive LV Asymptomatic pts with nl LVEF and progressive LV dilatation with ESD 50-55 mm or ESD 70-75 mmdilatation with ESD 50-55 mm or ESD 70-75 mm

Recommendations for Aortic ValveReplacement in Aortic Stenosis

Indication Class

Symptomatic patients with severe AS. I

Patients with severe AS undergoing coronaryartery bypass surgery.

I

Patients with severe AS undergoing surgery onthe aorta or other heart valves.

I

Patients with moderate AS undergoingcoronary artery bypass surgery or surgery onthe aorta or other heart valves (see sectionsIII.F. and VIII.D.).

IIa

Asymptomatic patients with severe AS and

LV systolic dysfunction IIa

Abnormal response to exercise (eg,hypotension)

IIa

Ventricular tachycardia IIb

Marked or excessive LV hypertrophy (>15 mm) IIb

Valve area <0.6 cm2 IIb

Prevention of sudden death in asymptomaticpatients with none of the findings listed underindication 5.

III

Mitral StenosisMitral StenosisPhysiology/Natural HistoryPhysiology/Natural History

• Normal MVA 4 -5 cmNormal MVA 4 -5 cm22

• Symptoms not apparent until area < 2.5 cmSymptoms not apparent until area < 2.5 cm22

valve area (cmvalve area (cm sq)sq) mean gradient (mmHg)mean gradient (mmHg)**

MildMild > 1.5> 1.5 < 5< 5

ModerateModerate 1.0 - 1.51.0 - 1.5 5 -105 -10

SevereSevere < 1.0< 1.0 > 10> 10

* assumes normal cardiac output


• Akin to severe diastolic dysfunctionAkin to severe diastolic dysfunction

• V = IR (electrical) V = IR (electrical)

• P = QR (hydraulic)P = QR (hydraulic)

• Q = P/RQ = P/Rvalvevalve


• LA pressure LA pressure PV pressure PV pressure interstitial interstitial edema edema ± alveolar flooding ± alveolar flooding

• Adaptations:Adaptations:

-pulmonary vascular constriction, intimal -pulmonary vascular constriction, intimal hyperplasia, medial hypertrophy hyperplasia, medial hypertrophy reversible reversible pulmonary hypertension pulmonary hypertension ± fixed pulm htn ± fixed pulm htn

-downregulation of neuroreceptors, -downregulation of neuroreceptors, lymphatic lymphatic drainagedrainage


• Latent (subclinical) phase in RHD 20-40 yrsLatent (subclinical) phase in RHD 20-40 yrs

• 10 yrs of symptoms before disabling10 yrs of symptoms before disabling

• With physically limiting symptomsWith physically limiting symptoms• 10 yr survival 0-15%10 yr survival 0-15%

• 10-20% systemic embolism10-20% systemic embolism

• 30-40% develop AF30-40% develop AF

• With onset of severe pulm hypertensionWith onset of severe pulm hypertension• Mean survival < 3 yrsMean survival < 3 yrs

Mitral StenosisMitral StenosisManagement GuidelinesManagement Guidelines

Initial EvaluationInitial Evaluation

• HistoryHistory

• PhysicalPhysical

• ECGECG

• CXRCXR

• EchocardiogramEchocardiogram

• ± Exercise echocardiogram± Exercise echocardiogram


Medical TherapyMedical Therapy

• Rheumatic fever prophylaxisRheumatic fever prophylaxis

• Infective endocarditis prophylaxisInfective endocarditis prophylaxis

• Limitation of strenuous physical activitiesLimitation of strenuous physical activities

• Control of HR (negative chronotropes)Control of HR (negative chronotropes)

• Na restriction, intermittent diuretic useNa restriction, intermittent diuretic use

• Prompt management of AFPrompt management of AF


Interventional and Surgical OptionsInterventional and Surgical Options

• Percutaneous mitral balloon valvotomy Percutaneous mitral balloon valvotomy (PMBV)(PMBV)

• Closed commissurotomy (obselete)Closed commissurotomy (obselete)

• Open commissurotomyOpen commissurotomy

• Mitral valve replacementMitral valve replacement


Indications for PMBV (class I and IIa)Indications for PMBV (class I and IIa)

• Suitable anatomy, no LA clot, ≤ mild MR Suitable anatomy, no LA clot, ≤ mild MR

• Symptomatic pts (NYHA class II-IV) with Symptomatic pts (NYHA class II-IV) with MVA <1.5 cmMVA <1.5 cm22

• Asymptomatic pts with MVA <1.5 cmAsymptomatic pts with MVA <1.5 cm2 2 and and PASP 50 mmHg at rest, 60 with exercisePASP 50 mmHg at rest, 60 with exercise


Indications for MVR (class I and IIa)Indications for MVR (class I and IIa)

• Symptomatic pts (NYHA class III and IV) Symptomatic pts (NYHA class III and IV) with MVA < 1.5 cmwith MVA < 1.5 cm2 2 unsuitable for PMBVunsuitable for PMBV

• NYHA class I and II pts with MVA < 1.0 cmNYHA class I and II pts with MVA < 1.0 cm2 2

and PASP >60 at rest unsuitable for PMBV and PASP >60 at rest unsuitable for PMBV

Acute Mitral RegurgitationAcute Mitral RegurgitationPhysiology and Natural HistoryPhysiology and Natural History

• Abrupt volume load---no time for Abrupt volume load---no time for adaptationadaptation

• Sudden Sudden in forward stroke volume in forward stroke volume

• Sudden Sudden in LA volume/pressure in LA volume/pressure PV PV pressurepressure

• Rapidly fatalRapidly fatal

Acute Mitral RegurgitationAcute Mitral RegurgitationManagement GuidelinesManagement Guidelines

Medical Stabilization (while gathering OR team)Medical Stabilization (while gathering OR team)

• If normotensive: nitroprussideIf normotensive: nitroprusside

• If hypotensive: nitroprusside + dobutamineIf hypotensive: nitroprusside + dobutamine

oror

intra-aortic balloon pump (IABP)intra-aortic balloon pump (IABP)

Chronic Mitral RegurgitationChronic Mitral RegurgitationPhysiology and Natural HistoryPhysiology and Natural History

• Gradual development allows adaptationGradual development allows adaptation

• LA dilatation and increase in complianceLA dilatation and increase in compliance

• LV dilatation and LV dilatation and EF (via EF (via preload and preload and afterload) afterload) maintenance of forward SV maintenance of forward SV

• Compensation often adequate for vigorous Compensation often adequate for vigorous exerciseexercise

• May last many yearsMay last many years

Chronic Mitral RegurgitationChronic Mitral RegurgitationPhysiology and Natural HistoryPhysiology and Natural History

• Eventually, volume overload Eventually, volume overload LV LV decompensationdecompensation

• Preop LVEF (>60%) and LVESD (<45 mm) Preop LVEF (>60%) and LVESD (<45 mm) are primary predictors of postop survival are primary predictors of postop survival

Wisenbaugh T, et al: Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation. Circulation 89:191, 1994.

Chronic Mitral RegurgitationChronic Mitral RegurgitationManagement GuidelinesManagement Guidelines

Initial evaluationInitial evaluation

• HistoryHistory

• Physical ExamPhysical Exam

• ECGECG

• CXRCXR

• EchoEcho

• ± Exercise echo± Exercise echo


Scheduled Follow-up*Scheduled Follow-up*Instruct all pts to report any cv symptomsInstruct all pts to report any cv symptoms

office intervaloffice interval echo intervalecho interval

Mild MRMild MR 12 mos12 mos if sxsif sxs

Moderate MRModerate MR12 mos12 mos 1-2 yrs1-2 yrs

Severe MRSevere MR 6-12 mos6-12 mos 6-12 mos**6-12 mos**

*assumes no symptoms and no sequellae** consider exercise echo

•Chronic Mitral RegurgitationChronic Mitral RegurgitationManagement GuidelinesManagement Guidelines

Medical TherapyMedical Therapy

• No generally accepted rx in asymptomatic ptsNo generally accepted rx in asymptomatic pts

• No long term studies suggesting benefit of No long term studies suggesting benefit of afterload reduction in absence of hypertensionafterload reduction in absence of hypertension

• ACEi if hypertensiveACEi if hypertensive

• AF requires rate control, anticoagulation and AF requires rate control, anticoagulation and 1 attempt at restoration of SR1 attempt at restoration of SR


Surgical OptionsSurgical Options

• Mitral valve repairMitral valve repair

• Mitral valve replacement with Mitral valve replacement with preservationpreservation of subvalvular apparatusof subvalvular apparatus

• Mitral valve replacement with Mitral valve replacement with excisionexcision of of subvalvular apparatussubvalvular apparatus

• MVR with CABG (in ischemic MR)MVR with CABG (in ischemic MR)

Rozich JD et al: Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation; mechanisms for differences in postoperative ejection performance. Circulation 86:1718, 1992.


Indications for Surgery (class I and IIa)Indications for Surgery (class I and IIa)

• Symptomatic pts with severe MR and an LV Symptomatic pts with severe MR and an LV appearing “less than hopeless” (EF > 30, appearing “less than hopeless” (EF > 30, ESD < 55 mm)*ESD < 55 mm)*

• Asymptomatic pts with moderate or severe Asymptomatic pts with moderate or severe MR and any of the following: EF 30-60%, MR and any of the following: EF 30-60%, ESD > 45 mm, AF, PASP > 50 at rest, PASP ESD > 45 mm, AF, PASP > 50 at rest, PASP > 60 with exercise> 60 with exercise

*consider if chordal preservation appears very likely

valvular heart disease: an update in management bruce w. andrus md dhmc cardiology symposium...

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