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Valvular Heart Disease Valvular Heart Disease and the Cardiac Examand the Cardiac Exam
20092009
OverviewOverview Clinical syndromesClinical syndromes Overview of cardiac murmurs and maneuversOverview of cardiac murmurs and maneuvers Left sided valvular lesionsLeft sided valvular lesions
– Aortic stenosis and sclerosisAortic stenosis and sclerosis– Mitral stenosis Mitral stenosis
Rheumatic fever prophylaxisRheumatic fever prophylaxis– Acute and chronic aortic regurgitationAcute and chronic aortic regurgitation– Acute and chronic mitral regurgitationAcute and chronic mitral regurgitation
Right sided valvular lesionsRight sided valvular lesions– Tricuspid valve diseaseTricuspid valve disease
Prosthetic valvesProsthetic valves Endocarditis prophylaxisEndocarditis prophylaxis QuestionsQuestions
General AppearanceGeneral Appearance Marfan SyndromeMarfan Syndrome
– Tall, long extremitiesTall, long extremities– Associated with:Associated with: aortic root aortic root
dilitation, MV prolapsedilitation, MV prolapse AcromegalyAcromegaly
– Large stature, coarse facial Large stature, coarse facial features, “spade” handsfeatures, “spade” hands
– Associated with:Associated with: Cardiac Cardiac hypertrophyhypertrophy
Turner SyndromeTurner Syndrome– Web neck, hypertelorism, Web neck, hypertelorism,
short statureshort stature– Associated with:Associated with: Aortic Aortic
coarctation, pulmonary coarctation, pulmonary stenosisstenosis
Pickwickian SyndromePickwickian Syndrome– Severe obesity, Severe obesity,
somnolencesomnolence– Associated with:Associated with:
Pulmonary hypertensionPulmonary hypertension
Fredreich ataxiaFredreich ataxia– Lurching gait, hammertoe, Lurching gait, hammertoe,
pes cavuspes cavus– Associated with:Associated with:
hypertrophic hypertrophic cardiomyopathycardiomyopathy
Duchenne type muscular Duchenne type muscular dystrophydystrophy– Pseudohypertrophy of the Pseudohypertrophy of the
calvescalves– CardiomyopathyCardiomyopathy
Ankylosing spondylitisAnkylosing spondylitis– Straight back syndrome, stiff Straight back syndrome, stiff
(“poker”) spine(“poker”) spine– Associated with:Associated with: AI, CHB AI, CHB
(rare)(rare) Lentigines (LEOPARD Lentigines (LEOPARD
syndrome)syndrome)– Brown skin macules that do Brown skin macules that do
not increase with sunlightnot increase with sunlight– Associated with:Associated with: HOCM, PS HOCM, PS
““Spade” hands in acromegalySpade” hands in acromegaly
General Appearance- 2General Appearance- 2 Hereditary hemorrhagic Hereditary hemorrhagic
telangiectasia (Osler-telangiectasia (Osler-Weber-Rendu)Weber-Rendu)– Small capillary hemangiomas Small capillary hemangiomas
on the face or mouthon the face or mouth– Associated with:Associated with: Pulmonary Pulmonary
arteriovenous fistulaarteriovenous fistula LupusLupus
– Butterfly rash on face, Butterfly rash on face, Raynaud phenomenon- hands, Raynaud phenomenon- hands, Livedo reticularisLivedo reticularis
– Associated with:Associated with: Verrucous Verrucous endocarditis, Myocarditis, endocarditis, Myocarditis, PericarditisPericarditis
PheochromocytomaPheochromocytoma– Pale diaphoretic skin, Pale diaphoretic skin,
neurofibromatosis- café-au-lait neurofibromatosis- café-au-lait spotsspots
– Associated with:Associated with: Catecholamine-induced Catecholamine-induced secondary dilated CMsecondary dilated CM
SarcoidosisSarcoidosis– Cutaneous nodules, Cutaneous nodules,
erythema nodosumerythema nodosum– Associated with:Associated with: Secondary Secondary
cardiomyopathy, heart cardiomyopathy, heart block block
Tuberous SclerosisTuberous Sclerosis– Angiofibromas (face; Angiofibromas (face;
adenoma sebaceum)adenoma sebaceum)– Associated with:Associated with:
RhabdomyomaRhabdomyoma MyxedemaMyxedema
– Coarse, dry skin, thinning Coarse, dry skin, thinning of lateral eyebrows, of lateral eyebrows, hoarseness of voicehoarseness of voice
– Associated with:Associated with: Pericardial Pericardial effusion, LV dysfunctioneffusion, LV dysfunction
Grading the Intensity of Cardiac Grading the Intensity of Cardiac MurmursMurmurs
Grade 1Grade 1– Murmur heard with stethoscope, but not at firstMurmur heard with stethoscope, but not at first
Grade 2Grade 2– Faint murmur heard with stethoscope on chest wallFaint murmur heard with stethoscope on chest wall
Grade 3Grade 3– Murmur hears with stethoscope on chest wall, louder Murmur hears with stethoscope on chest wall, louder
than grade 2 but without a thrillthan grade 2 but without a thrill Grade 4Grade 4
– Murmur associated with a thrillMurmur associated with a thrill Grade 5Grade 5
– Murmur heard with just the rim held against the chestMurmur heard with just the rim held against the chest Grade 6Grade 6
– Murmur heard with the stethoscope held away and in Murmur heard with the stethoscope held away and in from the chest wallfrom the chest wall
Cardiac MurmursCardiac Murmurs
Most mid systolic murmurs of grade 2/6 Most mid systolic murmurs of grade 2/6 intensity or less are benignintensity or less are benign– Associated with physiologic increases in blood Associated with physiologic increases in blood
velocity:velocity: PregnancyPregnancy ElderlyElderly
In contrast, the following murmurs are In contrast, the following murmurs are usually pathologic:usually pathologic:– Systolic murmurs grade 3/6 or greater in Systolic murmurs grade 3/6 or greater in
intensityintensity– Continuous murmursContinuous murmurs– Any diastolic murmurAny diastolic murmur
ManeuverManeuver Hemodynamic Hemodynamic EffectEffect
Murmur EffectMurmur Effect
Normal respirationNormal respiration Transient Transient ↑↑ in venous in venous filling during inspirationfilling during inspiration
↑↑ right-sided murmursright-sided murmurs
Passive leg elevationPassive leg elevation ↑↑ venous return venous return (transient (transient ↑↑ in LV size in LV size and preload)and preload)
↑↑ right-sided murmurs, right-sided murmurs, ↓↓murmur of HOCM and murmur of HOCM and MVPMVP
Stand to squatStand to squat ↑↑ venous return venous return (transient (transient ↑↑ in LV size in LV size and preload)and preload)
↑↑ right-sided murmurs, right-sided murmurs,
↓↓murmur of HOCM and murmur of HOCM and MVPMVP
Squat to standSquat to stand ↓↓ venous return venous return (transient (transient ↓↓ in LV size in LV size and preload)and preload)
↑↑ murmur of HOCM, murmur of HOCM, moves midsystolic click moves midsystolic click of MVP closer to S1 and of MVP closer to S1 and ↑↑ MVP murmur, MVP murmur, ↓ ↓ AS AS murmurmurmur
ValsalvaValsalva ↓↓ venous return venous return (transient (transient ↓↓ in LV size, in LV size, preload, and relative preload, and relative systemic hypotension)systemic hypotension)
↑↑ murmur of HOCM, murmur of HOCM, moves midsystolic click moves midsystolic click of MVP closer to S1, and of MVP closer to S1, and ↓↓ murmur of MVP murmur of MVP
Isometric handgrip Isometric handgrip exerciseexercise
↑↑ afterloadafterload ↑↑ murmur of MR and murmur of MR and VSD, VSD, ↓↓the murmur of the murmur of HOCM, HOCM, ↓↓AS murmurAS murmur
Inhaled amyl nitrateInhaled amyl nitrate ↓↓ afterloadafterload ↓↓ murmur of MR and murmur of MR and VSD, no change in AS VSD, no change in AS murmurmurmur
Diagnostic TestingDiagnostic Testing
ECHOCARDIOGRAMECHOCARDIOGRAM Exercise testingExercise testing
– To assess the clinical severity of valvular heart diseaseTo assess the clinical severity of valvular heart disease Those with inconsistent resting hemodynamics Those with inconsistent resting hemodynamics Equivocal history of symptomsEquivocal history of symptoms
– Exercise testing in AS patientsExercise testing in AS patients Should be ended promptly if:Should be ended promptly if:
– Cardiac symptoms provokedCardiac symptoms provoked– Decrease or minimal increase (<20 mmHg) in blood pressureDecrease or minimal increase (<20 mmHg) in blood pressure
Prior history of angina, congestive heart failure, or Prior history of angina, congestive heart failure, or exertional syncope absolute contraindications to exercise exertional syncope absolute contraindications to exercise testingtesting
Cardiac catheterizationCardiac catheterization– Usually not needed for primary evaluationUsually not needed for primary evaluation
Aortic StenosisAortic Stenosis
Most common cause is calcific degenerationMost common cause is calcific degeneration– Active disease process with risk factors of male sex, Active disease process with risk factors of male sex,
smoking, HTN, DM, older age, hypercholesterolemiasmoking, HTN, DM, older age, hypercholesterolemia 2% of the general population have bicuspid aortic 2% of the general population have bicuspid aortic
valvesvalves– Symptomatic or severe AS occurs earlier (age 40-60 Symptomatic or severe AS occurs earlier (age 40-60
years)years) AS less commonly from rheumatic heart disease AS less commonly from rheumatic heart disease
valvulitisvalvulitis– Invariably MV involved firstInvariably MV involved first– Associated AV involvement in <1/2 patientsAssociated AV involvement in <1/2 patients
AV sclerosisAV sclerosis– Valve thickening without obstructionValve thickening without obstruction– Present in >20% of people >65 yearsPresent in >20% of people >65 years– Associated with 50% increased risk of MI and CV deathAssociated with 50% increased risk of MI and CV death
Progression of Aortic SclerosisProgression of Aortic Sclerosis
Hemodynamic progression usually slowHemodynamic progression usually slow– Average rate of increase in aortic jet velocity of Average rate of increase in aortic jet velocity of
0.3 m/s per year0.3 m/s per year– Increase in mean transaortic gradient of 7 Increase in mean transaortic gradient of 7
mmHgmmHg– Decrease in AVA of 0.1 cmDecrease in AVA of 0.1 cm22 per year per year
Severe ASSevere AS– Aortic jet velocity > 4 m/sAortic jet velocity > 4 m/s– Mean transvalvular pressure gradient > 50 Mean transvalvular pressure gradient > 50
mmHgmmHg– AVA < 1.0 cm2AVA < 1.0 cm2
Pathophysiology of Aortic StenosisPathophysiology of Aortic Stenosis
Obstruction of LV outflow increases Obstruction of LV outflow increases intracavitary systolic pressures and leads intracavitary systolic pressures and leads to LV pressure overloadto LV pressure overload
Initial compensatory mechanism is Initial compensatory mechanism is myocardial hypertrophy with preservation myocardial hypertrophy with preservation of systolic functionof systolic function
Diastolic function impaired as a Diastolic function impaired as a consequence of increased wall thickness consequence of increased wall thickness and abnormal myocardial relaxationand abnormal myocardial relaxation
Increased wall stress and afterload causes Increased wall stress and afterload causes eventual decrease in ejection fractioneventual decrease in ejection fraction
PseudostenosisPseudostenosis
Occurs in patients with impaired systolic Occurs in patients with impaired systolic function and aortic stenosisfunction and aortic stenosis– Unable to generate transvalvular gradientUnable to generate transvalvular gradient
Careful diagnostic testing with dobutamine Careful diagnostic testing with dobutamine infusion protocols can aid in differentiating infusion protocols can aid in differentiating between true AS and pseudostenosisbetween true AS and pseudostenosis
If the calculated AVA increases with If the calculated AVA increases with augmentation of cardiac output, then augmentation of cardiac output, then pseudostenosis presentpseudostenosis present
If AVA does not increase with dobutamine, If AVA does not increase with dobutamine, then obstruction fixed and true AS presentthen obstruction fixed and true AS present
Clinical Presentation of Aortic Clinical Presentation of Aortic StenosisStenosis
Cardinal symptoms:Cardinal symptoms:– AnginaAngina
Occurs in >50% of patients, not sensitive due to prevalence Occurs in >50% of patients, not sensitive due to prevalence of CADof CAD
– SyncopeSyncope– CHFCHF
Sudden cardiac death rare, <1% per yearSudden cardiac death rare, <1% per year In earlier stages, AS presentation more subtleIn earlier stages, AS presentation more subtle
– DyspneaDyspnea– Decreased exercise toleranceDecreased exercise tolerance
Rarely, AS diagnosed in the setting of GI bleedingRarely, AS diagnosed in the setting of GI bleeding– Heyde’s syndromeHeyde’s syndrome
Bleeding caused by AVMBleeding caused by AVM Concurrent AS occurs at prevalence rate of 15-25%Concurrent AS occurs at prevalence rate of 15-25% Associated with an acquired von Willebrand syndrome due Associated with an acquired von Willebrand syndrome due
to disruption of vW multimers through a diseased AVto disruption of vW multimers through a diseased AV
Management of Aortic StenosisManagement of Aortic Stenosis
Prognosis in asymptomatic disease excellent Prognosis in asymptomatic disease excellent Conservative approach with monitoring for Conservative approach with monitoring for
symptoms recommendedsymptoms recommended When severe stenosis present-When severe stenosis present-
– 38% of asymptomatic patients develop symptoms within 38% of asymptomatic patients develop symptoms within 2 years2 years
– 79% are symptomatic within 3 years79% are symptomatic within 3 years Once symptoms occur, AVR neededOnce symptoms occur, AVR needed LV dysfunction and severe AS have increased LV dysfunction and severe AS have increased
perioperative mortality with AVRperioperative mortality with AVR– But outcomes still favorable with surgeryBut outcomes still favorable with surgery
Nitroprusside may transiently improve cardiac Nitroprusside may transiently improve cardiac function as a bridge to valve replacement function as a bridge to valve replacement – Does not supplant AVR in symptomatic patientsDoes not supplant AVR in symptomatic patients
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Aortic Valve ReplacementAortic Valve Replacement
Prophylatic AVR in asymptomatic patients not Prophylatic AVR in asymptomatic patients not routinely performed due to surgical risksroutinely performed due to surgical risks– Thromboembolism, bleeding associated with Thromboembolism, bleeding associated with
anticoagulation, prosthetic valve dysfunction, and anticoagulation, prosthetic valve dysfunction, and endocarditis endocarditis
– Occurs at a rate of 2-3% annuallyOccurs at a rate of 2-3% annually– Only should be considered:Only should be considered:
If other cardiac surgery (such as CABG) plannedIf other cardiac surgery (such as CABG) planned Severe LVH or systolic dysfunctionSevere LVH or systolic dysfunction Women contemplating pregnancyWomen contemplating pregnancy Patients remote from health carePatients remote from health care
Surgical valve replacement with operative Surgical valve replacement with operative morbidity and mortality of 10%morbidity and mortality of 10%
Percutaneous balloon aortic valvotomy rarely usedPercutaneous balloon aortic valvotomy rarely used
Mitral StenosisMitral Stenosis
Usually associated with history of Usually associated with history of rheumatic feverrheumatic fever
>40% of cases of RHD result in >40% of cases of RHD result in mitral stenosismitral stenosis– Women affected more than men (2:1)Women affected more than men (2:1)
Presentation 20-40 years after the Presentation 20-40 years after the initial episode of rheumatic feverinitial episode of rheumatic fever– If infected at a young age, latent period If infected at a young age, latent period
is a few yearsis a few years
Clinical Presentation of Mitral Clinical Presentation of Mitral StenosisStenosis
Significant MS leads to Significant MS leads to ↑↑LA pressure and pulm HTNLA pressure and pulm HTN Symptoms include dyspnea with Symptoms include dyspnea with ↑↑ cardiac demand cardiac demand
– ExerciseExercise– PregnancyPregnancy
Survival excellent with asymptomatic or minimally Survival excellent with asymptomatic or minimally symptomatic patientssymptomatic patients– >80% survival at 10 years>80% survival at 10 years
Survival in symptomatic patients much worseSurvival in symptomatic patients much worse– 10 year survival drops to 15% or lower (if pulm HTN present)10 year survival drops to 15% or lower (if pulm HTN present)
Findings consistent with severe MS:Findings consistent with severe MS:– Transvalvular diastolic pressure gradient >10 mmHgTransvalvular diastolic pressure gradient >10 mmHg– MVA <1.0 cm2MVA <1.0 cm2– Severe pulmonary hypertension (>60 mmHg)Severe pulmonary hypertension (>60 mmHg)
Management of Mitral StenosisManagement of Mitral Stenosis
Atrial fibrillationAtrial fibrillation– Prevalence >30% in symptomatic patients and Prevalence >30% in symptomatic patients and
associated with poorer long term outcomeassociated with poorer long term outcome– Warfarin indicated:Warfarin indicated:
In patients with AF and MSIn patients with AF and MS Patients without history of AF but with MS and Patients without history of AF but with MS and
embolic CVAembolic CVA
– In patients with prior history of AF who have In patients with prior history of AF who have mitral valve surgery, decreased postoperative mitral valve surgery, decreased postoperative AF observed if MAZE performed concominantlyAF observed if MAZE performed concominantly
Mitral Valve RepairMitral Valve Repair Percutaneous valvotomyPercutaneous valvotomy
– Therapeutic intervention of choice if:Therapeutic intervention of choice if: LAA thrombus excludedLAA thrombus excluded MR less than moderateMR less than moderate Valvular characteristics favorableValvular characteristics favorable
– Pliable leaflets, minimal commisural fusion, minimal Pliable leaflets, minimal commisural fusion, minimal valvular or subvalvular calcificationvalvular or subvalvular calcification
– Pulmonary HTN not contraindication to valvotomyPulmonary HTN not contraindication to valvotomy– Major complications include: severe MR (1-8%), Major complications include: severe MR (1-8%),
systemic embolization (1-3%), and tamponade (1-systemic embolization (1-3%), and tamponade (1-2%)2%) Periprocedural mortality- 1%Periprocedural mortality- 1%
Surgical commissurotomy or MVR can be Surgical commissurotomy or MVR can be performed in unfavorable anatomyperformed in unfavorable anatomy
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Rheumatic Fever ProphylaxisRheumatic Fever Prophylaxis Primary prophylaxisPrimary prophylaxis
– If living in an endemic area, with pharyngitis and a If living in an endemic area, with pharyngitis and a +test for group A strep or positive throat culture+test for group A strep or positive throat culture
– Given once, may be repeated as needed:Given once, may be repeated as needed: PCN G 1.2 million U IM or PCN V 500 mg TID x 10dPCN G 1.2 million U IM or PCN V 500 mg TID x 10d Azithromycin 500 mg on day 1, 250 mg daily for 4dAzithromycin 500 mg on day 1, 250 mg daily for 4d
Secondary prophylaxisSecondary prophylaxis– PCN G 1.2 million units IM every 4 weeks or PCN V PCN G 1.2 million units IM every 4 weeks or PCN V
250 mg PO BID or erythromycin 250 mg BID250 mg PO BID or erythromycin 250 mg BID RHD without carditis-RHD without carditis- At least 5 years or until >21 y of At least 5 years or until >21 y of
ageage RHD with carditis, no valvular HD-RHD with carditis, no valvular HD- At least 10 y or well At least 10 y or well
into adulthoodinto adulthood RHD with carditis and valvular HD-RHD with carditis and valvular HD- At least 10 years At least 10 years
from last episode or until patient is older than 40 yearsfrom last episode or until patient is older than 40 years
Acute Aortic RegurgitationAcute Aortic Regurgitation Causes of acute aortic regurgitation:Causes of acute aortic regurgitation:
– Aortic dissectionAortic dissection– Valve distruction from endocarditisValve distruction from endocarditis– Traumatic ruptureTraumatic rupture
Classic physical exam findings may be absent in Classic physical exam findings may be absent in the acute presentationthe acute presentation– Diastolic murmur may not be present due to sudden Diastolic murmur may not be present due to sudden
increase of LVEDPincrease of LVEDP TTE, along with TEE, cath, CT or MRI may be used TTE, along with TEE, cath, CT or MRI may be used
for diagnosisfor diagnosis Surgical AV repair or replacement should be Surgical AV repair or replacement should be
performed emergentlyperformed emergently Afterload reducing medications and inotropes Afterload reducing medications and inotropes
may help to acutely stabilize the patientmay help to acutely stabilize the patient IABP contraindicatedIABP contraindicated
Acute Mitral RegurgitationAcute Mitral Regurgitation
Most often occurs in:Most often occurs in:– Chordae tendineae rupture due to Chordae tendineae rupture due to
myxomatous valve disease or endocarditismyxomatous valve disease or endocarditis– Myocardial infarction with papillary muscle Myocardial infarction with papillary muscle
dysfunction or rupturedysfunction or rupture Symptoms almost always occurSymptoms almost always occur
– Dyspnea and pulmonary edemaDyspnea and pulmonary edema Systolic function may occur normal or Systolic function may occur normal or
hyperdynamichyperdynamic IABP or afterload reducing drugs to IABP or afterload reducing drugs to
temporize temporize Surgical intervention for treatmentSurgical intervention for treatment
Chronic Valvular RegurgitationChronic Valvular Regurgitation
Cardiac chamber size and function have time to Cardiac chamber size and function have time to compensate for dysfunctioncompensate for dysfunction– May allow patients to remain asymptomatic for a long May allow patients to remain asymptomatic for a long
timetime Both preload and afterload increasesBoth preload and afterload increases Once increase in cardiac output insufficientOnce increase in cardiac output insufficient→ →
systolic function declines systolic function declines →→ pulmonary HTN may pulmonary HTN may develop and symptoms developdevelop and symptoms develop
LV enlargement and progressive systolic LV enlargement and progressive systolic dysfunction are associated with significant dysfunction are associated with significant morbidity and mortalitymorbidity and mortality
Serial echocardiography and evaluation by a Serial echocardiography and evaluation by a cardiologist is indicated cardiologist is indicated
Chronic Aortic RegurgitationChronic Aortic Regurgitation Occurs most often in bicuspid AVOccurs most often in bicuspid AV Other causes include ascending aortic aneurysm and Other causes include ascending aortic aneurysm and
Marfan’s DiseaseMarfan’s Disease Risk factors for poorer outcome:Risk factors for poorer outcome:
– AgeAge– Cardiac symptomsCardiac symptoms– Atrial fibrillationAtrial fibrillation– LV enlargementLV enlargement– Lower LVEFLower LVEF
Asymptomatic patients with normal LV size and function do Asymptomatic patients with normal LV size and function do not require prophylatic surgerynot require prophylatic surgery
Surgery should be considered if:Surgery should be considered if:– LVESD LVESD >> 55 mm 55 mm– Ejection fraction <60%Ejection fraction <60%– Symptoms developSymptoms develop
Oral afterload reduction (nifedipine or ACE-I) may slow rate of Oral afterload reduction (nifedipine or ACE-I) may slow rate of LV dilationLV dilation
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Chronic Mitral RegurgitationChronic Mitral Regurgitation
Often caused by myxomatous disease or MVPOften caused by myxomatous disease or MVP– Myxomatous mitral valve disease with progressive Myxomatous mitral valve disease with progressive
MR associated with poor long term outcomeMR associated with poor long term outcome Higher risk of arrhythmias and sudden cardiac deathHigher risk of arrhythmias and sudden cardiac death
– Mitral valve prolapse occurs in ~2% of the general Mitral valve prolapse occurs in ~2% of the general populationpopulation Consists of the buckling of the mid portion of the valve Consists of the buckling of the mid portion of the valve
leaflets into the LAleaflets into the LA Usually asymptomatic, but may be associated with Usually asymptomatic, but may be associated with
palpitations or chest discomfortpalpitations or chest discomfort Prognosis usually benignPrognosis usually benign Antibiotic prophylaxis now not indicatedAntibiotic prophylaxis now not indicated
Chronic Mitral RegurgitationChronic Mitral Regurgitation
Other causes include secondary or Other causes include secondary or acquired leaflet dysfunctionacquired leaflet dysfunction– EndocarditisEndocarditis– Rheumatic heart diseaseRheumatic heart disease– Annular tethering from LV dilationAnnular tethering from LV dilation– Tethering of the chordal apparatus from Tethering of the chordal apparatus from
ischemic heart diseaseischemic heart disease– Rare cause: Fenfluramine and phentermine, Rare cause: Fenfluramine and phentermine,
also associated with AIalso associated with AI Compensatory increase in LV chamber size Compensatory increase in LV chamber size
initially allows for increase in total stroke initially allows for increase in total stroke volume and restoration or total forward volume and restoration or total forward cardiac outputcardiac output
Treatment of Chronic Mitral Treatment of Chronic Mitral RegurgitationRegurgitation
Mitral valve repair preferred over mitral Mitral valve repair preferred over mitral valve replacementvalve replacement– Avoids risk of anticoagulationAvoids risk of anticoagulation– Preservation of subvalvular apparatusPreservation of subvalvular apparatus
Better postoperative LV function and long term survivalBetter postoperative LV function and long term survival When MR occurs in volume overloaded When MR occurs in volume overloaded
states, afterload reduction can be beneficialstates, afterload reduction can be beneficial– Dilated CM Dilated CM – CADCAD
Revascularization may improve dysfunction Revascularization may improve dysfunction of the papillary muscleof the papillary muscle
Biventricular pacing may improve LV Biventricular pacing may improve LV geometrygeometry
Timing of Intervention for Left-Sided Valvular Timing of Intervention for Left-Sided Valvular ConditionsConditions
Aortic StenosisAortic Stenosis Mitral StenosisMitral Stenosis Chronic Severe ARChronic Severe AR Chronic Severe Chronic Severe MRMR
Intervention:Intervention:
AVRAVRIntervention:Intervention:
Percutaneous Percutaneous valvotomy if anatomy valvotomy if anatomy amenable and amenable and <moderate MR, and no <moderate MR, and no LAA clot. Otherwise, LAA clot. Otherwise, open commissurotomy open commissurotomy or MVRor MVR
Intervention:Intervention:
Surgical AVR with aortic Surgical AVR with aortic root replacement if root replacement if neededneeded
Intervention:Intervention:
Surgical mitral valve Surgical mitral valve repair if anatomy repair if anatomy amenable. Otherwise, amenable. Otherwise, MVRMVR
IF:IF:
Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater, angina due to greater, angina due to AS, or syncope)AS, or syncope)
OROR
Patient has Patient has symptomatic severe AS symptomatic severe AS and needs other and needs other cardiothoracic surgery cardiothoracic surgery (i.e. CABG)(i.e. CABG)
IF:IF:
Patient has moderate or Patient has moderate or more severe MS (MVA < more severe MS (MVA < 1.5 cm1.5 cm22))
OROR
Pulmonary Pulmonary hypertrension at rest hypertrension at rest (PAP > 60 mmHg)(PAP > 60 mmHg)
OROR
Abnormal hemodynamic Abnormal hemodynamic response to exercise:response to exercise:
PAP > 60 mmHgPAP > 60 mmHg
Mean gradient > 15 Mean gradient > 15 mmHgmmHg
IF:IF:
Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater)greater)
OROR
EF <60%EF <60%
OR OR
ESD > 55 mmESD > 55 mm
OR OR
Abnormal hemodynamic Abnormal hemodynamic response to exerciseresponse to exercise
PAP increase by 25 PAP increase by 25 mmHgmmHg
IF:IF:
Patient is symptomatic Patient is symptomatic (NYHA class II or (NYHA class II or greater)greater)
OROR
EF <60%EF <60%
OR OR
ESD > 45 mmESD > 45 mm
OR OR
Pulmonary hypertension Pulmonary hypertension or atrial fibrillationor atrial fibrillation
OTHERWISEOTHERWISE
Depending on the Depending on the severity of AS, at least severity of AS, at least annual clinical annual clinical evaluation with TTE to evaluation with TTE to monitor for symptom monitor for symptom onsetonset
OTHERWISEOTHERWISE
Clinical evaluation at Clinical evaluation at least annually, least annually, depending on the depending on the severity of the mitral severity of the mitral stenosisstenosis
OTHERWISEOTHERWISE
Repeat TTE at least Repeat TTE at least yearly, repeat clinical yearly, repeat clinical evaluation at least evaluation at least biannually depending biannually depending on the severity of the on the severity of the LV dilitiationLV dilitiation
OTHERWISEOTHERWISE
Repeat TTE yearly, Repeat TTE yearly, repeat clinical repeat clinical evaluation biannuallyevaluation biannually
Tricuspid Valve DiseaseTricuspid Valve Disease
Tricuspid stenosis is rareTricuspid stenosis is rare– Associated with rheumatic heart diseaseAssociated with rheumatic heart disease
TR usually occurs secondary to:TR usually occurs secondary to:– Pulmonary hypertensionPulmonary hypertension– RV chamber enlargement with annular dilatationRV chamber enlargement with annular dilatation– Endocarditis (associated with IV drug use)Endocarditis (associated with IV drug use)– Injury following pacer lead placementInjury following pacer lead placement
Other secondary causes: carcinoid, radiation Other secondary causes: carcinoid, radiation therapy, anorectic drug use, and traumatherapy, anorectic drug use, and trauma
Primary causes: Marfan’s syndrome and Primary causes: Marfan’s syndrome and congenital disorders such as Ebstein’s anomaly congenital disorders such as Ebstein’s anomaly and AV canal malformationand AV canal malformation
Echo is diagnostic in most casesEcho is diagnostic in most cases
Tricuspid RegurgitationTricuspid Regurgitation
Severe tricuspid regurgitation is difficult to Severe tricuspid regurgitation is difficult to treat and carries a poor overall clinical treat and carries a poor overall clinical outcomeoutcome
Symptoms are manifestations of systemic Symptoms are manifestations of systemic venous congestionvenous congestion– AscitesAscites– Pedal edemaPedal edema
Surgical intervention usually considered if Surgical intervention usually considered if other cardiac surgery plannedother cardiac surgery planned
Surgical options include valvular Surgical options include valvular annuloplasty or replacementannuloplasty or replacement– If replacement planned, bioprosthetic valve If replacement planned, bioprosthetic valve
preferredpreferred
Prosthetic Valves- MechanicalProsthetic Valves- Mechanical
Three types:Three types:– Ball-cage valveBall-cage valve– Single tilting disk valveSingle tilting disk valve– Bileaflet valveBileaflet valve
Durable but require life long anticoagulationDurable but require life long anticoagulation For operative procedures, warfarin typically For operative procedures, warfarin typically
is discontinued for 48-72 hours and is discontinued for 48-72 hours and restarted postop as soon as possible, restarted postop as soon as possible, except for:except for:– Mechanical mitral prosthesisMechanical mitral prosthesis– Atrial fibrillationAtrial fibrillation– Prior thromboembolic eventsPrior thromboembolic events
Ball-cage valve
Single tilting disk valve
Bileaflet valve
Prosthetic Valves- BiologicalProsthetic Valves- Biological Biological ValvesBiological Valves
– Composed of autologous or xenograft Composed of autologous or xenograft biological material mounted on stents and a biological material mounted on stents and a sewing ringsewing ring
– Warfarin therapy not required due to lower Warfarin therapy not required due to lower thromboembolic potentialthromboembolic potential
– Valve durability less when compared to Valve durability less when compared to mechanical valvesmechanical valves
– Newer stentless valves with increased Newer stentless valves with increased longevitylongevity
Anticoagulation Guidelines for Anticoagulation Guidelines for Mechanical ValvesMechanical Valves
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Prosthetic Valve ComplicationsProsthetic Valve Complications Common complications include:Common complications include:
– Structural valve deteriorationStructural valve deterioration– Valve thrombosisValve thrombosis– EmbolismEmbolism– BleedingBleeding– EndocarditisEndocarditis
Endocarditis prophylaxis required for patients with all types Endocarditis prophylaxis required for patients with all types of prosthetic valvesof prosthetic valves
Suspect valve dehiscence or dysfunction in:Suspect valve dehiscence or dysfunction in:– Acute CHF in the immediate postop periodAcute CHF in the immediate postop period– New cardiac symptomsNew cardiac symptoms– Embolic phenomenaEmbolic phenomena– Hemolytic anemiaHemolytic anemia– New murmursNew murmurs
TEE is the diagnostic procedure of choiceTEE is the diagnostic procedure of choice Postop TTE should be done 2-3 months after surgeryPostop TTE should be done 2-3 months after surgery
Valve ThrombosisValve Thrombosis
Incidence with mechanical prosthesis of 2-4 % per Incidence with mechanical prosthesis of 2-4 % per yearyear
Suspect in patients with new murmur, change in Suspect in patients with new murmur, change in cardiopulmonary symptoms, or an embolic eventcardiopulmonary symptoms, or an embolic event
Diagnosis based on clinical presentation, TTE/TEE, Diagnosis based on clinical presentation, TTE/TEE, and fluroscopyand fluroscopy
In small thrombus, treatment with heparin may be In small thrombus, treatment with heparin may be adequateadequate
Optimal treatment for left sided thrombosis is Optimal treatment for left sided thrombosis is emergency surgeryemergency surgery
Consider thrombolytic therapy for right sided Consider thrombolytic therapy for right sided thrombosis or if surgery cannot be performed with thrombosis or if surgery cannot be performed with left sided diseaseleft sided disease
Endocarditis ProphylaxisEndocarditis Prophylaxis
2007 AHA Prevention of Infective Endocarditis Guidelines