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Surgical Management of Valvular Heart Disease. Current Treatment and Future Trends. Anthony J. Palazzo, M.D.F.A.C.S. Objectives. Brief discussion of most common pathologic valvular disease involving aortic and mitral valves Focus on aortic stenosis and mitral regurgitation
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Surgical Management of Valvular Heart Disease Current Treatment and Future Trends Anthony J. Palazzo, M.D.F.A.C.S.
Objectives • Brief discussion of most common pathologic valvular disease involving aortic and mitral valves • Focus on aortic stenosis and mitral regurgitation • Indications for surgical intervention • Best choice of prosthetic device • Current and future trends
Aortic Stenosis • Etiology • Degenerative (Calcification) • Bicuspid • Rheumatic
Aortic Stenosis - Classification Normal Aortic Valve Area 2-4 cm²
Aortic Stenosis-Pathophysiology • Increased transvalvular gradient • Increased left ventricular afterload • Leads to development of LVH
Aortic Stenosis-Natural History • Multiple echocardiographic studies have demonstrated that the average rate of decrease in aortic valve area is approximately 0.12 cm² per year • Ross and Braunwald study (1968)- landmark paper revealing natural history as it relates to symptoms • average survival with angina/syncope 3 yrs • average survival with dyspnea 2 yrs • average survival with CHF 1.5 yrs
Aortic Stenosis-Natural History • Loma Lima study • Retrospective review of 453 patients with documented severe aortic stenosis on ECHO • Treated non-surgically • Survival at 1, 5, and 10 years was 62%, 32% and 18% • Demonstrated grave prognosis of patients with severe aortic stenosis • AnnThorSurg, 2006
Aortic Stenosis-Indications for Surgery • Patients with symptoms • Asymptomatic patients with evidence of diminished left ventricular function (EF < 50%) • Asymptomatic patients with normal ventricular function should be followed closely with serial echocardiography every 6 months due to known history of progression of 0.1-0.12 cm² and risk of death of 1-3% per year
Aortic Stenosis-Salient Points • Once diagnosis is suspected echocardiogram is single best non-invasive diagnostic test to determine aortic valve morphology, gradient and jet velocity • Symptomatic patients should be referred for surgical evaluation • Asymptomatic patients need to be followed closely for natural progression of disease • Asymptomatic patients with diminished left ventricular function should be referred for surgery
Aortic Regurgitation-Etiology • Calcific degeneration (mixed lesion with stenosis) • Bicuspid aortic valve • Connective tissue disease (Marfan’s) • Aortic aneursym • Aortic dissection • Endocarditis
Aortic Regurgitation-Pathophysiology • Increased left ventricular overload • Left ventricular dilatation • Diminishing left ventricular function
Aortic Regurgitation-Indications for Surgery • Symptomatic patients with severe aortic regurgitation patients with angina have >10% mortality/year >20% mortality/year with CHF • Endocarditis with hemodynamic decompensation • Asymptomatic patients •surgery for patients with EF <50% •surgery for patients with evidence of left ventricular distension (end-diastolic dimension > 75 mm and end-systolic dimension > 55 m)
Mitral Stenosis • Normal mitral valve area 4-6 cm² • Rheumatic heart disease most common cause • prevalence decreased significantly • Thickening and calcification of leaflets • Thickening of subvalvular structures (chords) • May have mixed lesions-MS/MR • Stenosis tends to progress slowly
Mitral Stenosis-Classification Normal mitral valve area = 4-6 cm²
Mitral Stenosis-Indications for Surgery • Patients with severe mitral stenosis with class NYHA class III and IV symptoms who are not candidates for percutaneous balloon mitral valvulotomy (patients with mixed lesions or heavy calcification) • Asymptomatic patients with severe MS and severe pulmonary hypertension (PAP > 60 mm Hg) • No therapy recommended in asymptomatic patients without evidence of severe pulmonary hypertension
Mitral Regurgitation-Etiology • Degenerative “myxomatous” isolated leaflet prolapse Barlow’s disease • Ischemic acute- ruptured papillary muscle/chord 2° AMI chronic- chronic myocardial ischemia • Endocarditis
Mitral Regurgitation-Etiology • Isolated “P-2” segmental prolapse
Mitral Regurgitation-Etiology Barlow’s disease
Ischemic Mitral Regurgitation Chronic ischemic mitral regurgitation annular dilatation papillary muscle retraction
Mitral Regurgitation-Diagnosis • ECHO most informative non-invasive diagnostic test • Assess leaflet morphology • Chordal rupture • Leaflet prolapse • Regurgitant jets • Ejection fraction
Mitral Regurgitation-Indications for Surgery (Class I indications) • Symptomatic acute mitral regurgitation ruptured chord ruptured papillary muscle • Symptomatic patients with chronic severe MR as long as EF > 30% • Acute endocarditis with hemodynamic compromise, persistent sepsis, annular abscess, recurrent emboli • Asymptomatic patients with severe MR and EF 30-60%
Mitral Regurgitation-Class IIa and IIb Indications • Patients with severe MR with class III-IV symptoms and EF < 30% and/or end-systolic dimension > 55 mm and if a repair is highly likely • There are 2 class IIb indications with asymptomatic patients with severe MR with EF > 60% who develop new onset atrial fibrillation and/or pulmonary hypertension (PAP > 50 mm Hg)
Mitral Regurgitation-Asymptomatic • Asymptomatic patients with severe MR should be followed closely with ECHO every 6 months • If there is evidence of left ventricular dysfunction with a decreased EF < 60 %, patients should be referred for surgery • Preoperative EF important predictor of long term survival after mitral valve surgery
Effect of preoperative EF • Long term postoperative prognosis is related to preoperative EF Circulation, 1995
Mitral Regurgitation-Salient Points • In asymptomatic patients with severe mitral regurgitation ventricular function should be followed closely • If EF decreases to < 60% or left ventricular end systolic diameter dimension exceeds 40 mm patient should be referred for surgery • Mitral valve repair is the ideal procedure
Prosthetic Valves • No “perfect” prosthetic valve • Bioprosthetic valves versus mechanical
Prosthetic Valves porcine bovine pericardial mechanical
Prosthetic Valves-Selection • Generally, if patient is > 65 a tissue valve is recommended • Due improvements in the manufacturing process tissue valves have increased durability demineralization to prevent calcification “zero pressure” tissue fixation • General trend to place tissue valves in younger patients • Ultimate decision is patient’s
Prosthetic Valve Selection • Some tissue valves have demonstrated 85% 15 year structural free deterioration • Some evidence to suggest antiplatelet therapy may be sufficient anticoagulation in select patients with mechanical AVR (not a guideline) select cohort normal LV function normal sinus rhythym bileaflet mechanical valve ongoing clinical trails to determine efficiacy
Early Anticoagulation in bioprosthetic valves • Historically “early” anticoagulation recommended in immediate postoperative period for tissue valves is warfarin for 3 months (AHA/ACC guidelines) • Expanding clinical evidence to support use of antiplatelet therapy alone after aortic tissue valve placement in early postoperative period unless there is some other indication for warfarin¹΄² JTCS,2005 JTCS,2010
Percutaneous Therapy • TAVI (transcatheter aortic valve implantation) • Reserved for patients with severe aortic stenosis who are not surgical candidates for open procedure • Recently FDA approved • Likely will be regulated • Should involve societal (STS) oversights and database • Should be collaborative, multidisciplinary approach
Percutaneous Aortic Valve • ? Long term durability • Aortic insufficiency • equivalent 1 year survival¹ • compared to open surgery • in some studies 1. NEJM, 2010