MEDICAL MANAGEMENT OF VALVULAR HEART DISEASE

DR BISWA RANJAN PATRARESIDENT OF MEDICINEP.G.I.M.E.R & DR. R.M.L HOSPITAL, NEW DELHI

MITRAL VALVE DISEASE

1. MITRAL STENOSIS2. MITRAL REGURGITATION

MITRAL STENOSISCAUSES 1. RHEUMATIC FEVER (99% OF CASES)

PATTERN OF VALVE INVOLVEMENT▪ Isolated MS-25%▪ Combined MS with MR- 40%▪ Aortic Valve -35%▪ Tricuspid Valve-6%

2. AS A COMPLICATION OF Malignant carcinoid disease SLE RA Mucopolysaccharidoses

3. METHYSERGIDE THERAPY

MEDICAL MANAGEMENTDIRECTED TOWARDS-

1. Prevention of recurrent rheumatic fever

2. Prevention and treatment of complications of MS

3. Monitoring disease progression to allow intervention at optimal time point

PREVENTION OF RHEUMATIC FEVER1. PRIMORDIAL PREVENTION2. PRIMARY PREVENTION3. SECONDARY PREVENTION

DRUG REGIME OF CHOICE FOR THE PRIMARY PREVENTION OF RHEUMATIC FEVER

DRUG REGIMEN OF CHOICE FOR SECONDARY PREVENTION OF RHEUMATIC FEVER

DURATION OF SECONDARY PROPHYLAXIS

PREVENTION AND TREATMENT OF COMPLICATIONS

INFECTIVE ENDOCARDITIS- risk 0.17/1000 patients. prophylaxis not

recommended.

SYSTEMIC EMBOLISM- anticoagulant therapy indicated in MS and AF (persistent or paroxysmal) any previous embolic events (even in sinus rhythm) documented left atrial thrombus. also may be considered in severe MS and sinus rhythm when

there is left atrial enlargement (dia>55 mm) or spontaneous contrast on echocardiography.

TARGET INR – 2-3

TREATMENT OF ARRHYTHMIAS Management of AF with AF is similar to

the management for AF of any cause.

However, it is more difficult to restore and maintain sinus rhythm due to pressure overload of the left atrium effects of rheumatic process on atrial

tissue and conducting system.

SEVERE MS(With persistant symptoms after intervention/ when intervention is

not possible )

Oral Diuretics Restriction of salt intake Digitalis- not benificial in sinus rhythm, useful in

slowing FVR in AF & in pt with Right sided HF For Hemoptysis- measures designed to reduce

pulmonary pressure Sedation assumption of upright posture aggressive diuresis

PERCUTANEOUS BALLOON MITRAL VALVOTOMY

PROCEDURE OF CHOICE .

RECOMENDATIONS-

1. Symptomatic patients with moderate to severe MS (MVA <1cm2/m2 or <1.5 cm2 in normal sized adults, with favorable valve morphology, no or mild MR and no evidence of LA thrombus.

2. Asymptomatic patients with very severe MS (<1cm2) with favorable valve anatomy.

3. Symptomatic patients in whom surgery carries a high risk of adverse outcomes, even when valve morphology not ideal

Wilkin's score- Favorable valve morphology

AORTIC STENOSIS Patient education, avoid vigorous physical activity. AVR- Severe AS pt with symptoms, EF<50%, asyptomatic pt

undergoing any heart surgery. also when symptoms/ fall in BP with exercise. Medical therapy- (class IIb) DIURETICS, ACEI- used with caution B BLOCKERS- should be avoided AF/Flutter- treated promptly with cardioversion Appropriate t/t for concurrent cardiac condition- HTN / CAD (class I) No benefits with lipid lowering drugs (class III)

TAVI

Transcatheter Aortic Valve Replacement Percutaneous/ transapical approach Alternative in patients with prohibitive surgical

risk and high surgical risk. TAVI resulted in substantial reduction in death,

hospitalisation & lead to significant relief of symptom

AORTIC REGURGITATION Pt education, avoid vigorous sports AVR-Symptomatic pt with severe AR, asymptomatic

pt with EF<50% or severe LV dilation ESD>50mm. Asymptomatic patients- t/t for systemic arterial

diastolic hypertension (class I) AF & bradyarrthymias poorly tolerated- promptly

treated Vasodilators for chronic AR with significant volume

overload- (class IIa)

REPEAT ECHO ??

Infective Endocarditis prophylaxis

THANK YOU