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Valvular Heart Disease: An Update in Management

Valvular Heart Disease: An Update in Management. Bruce W. Andrus MD DHMC Cardiology Symposium December 2002. Learning Objectives . Locate and review ACC/AHA guidelines Review timing of surgery in VHD Consider role of medicine in VHD Discuss impact of VHD on operative risk

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Valvular Heart Disease: An Update in Management

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  1. Valvular Heart Disease:An Update in Management Bruce W. Andrus MD DHMC Cardiology Symposium December 2002

  2. Learning Objectives • Locate and review ACC/AHA guidelines • Review timing of surgery in VHD • Consider role of medicine in VHD • Discuss impact of VHD on operative risk • Revisit endocarditis prophylaxis

  3. Outline • Case Presentations (with audience participation) • Specific Valve Lesions • Physiologic principles/natural history • Images • Guidelines • Cases Revisited

  4. Audience Response Test What did you have for breakfast? A) cereal or bagel B) donuts or danish C) eggs, bacon, and/or sausage D) a foil wrapped energy bar E) none of the above

  5. Case 1 • JB, a 45 yo contractor, presents with a cc of increasing dyspnea over the past 6 months. Able to climb stairs, but very tired climbing scaffolding. Occ pounding in chest/neck. • Denies cp, syncope. • PMH significant only for htn. No rheumatic fever, anorexigen use, IE.

  6. Case 1 • On Exam: • Brawny, mildly overweight, no distress. • HR 80 regular, BP 160/50. • Rapidly collapsing pulse, subtle head nodding • Apical impulse hyperdynamic, diffuse and laterally displaced. Diastolic thrill at base. • Soft S1, soft S2, ejection sound at base (diaphragm), +S3 at apex (bell), descrescendo murmur leaning forward in expiration.

  7. Case 1 • CXR: • enlarged LV, widened mediastinum. • Echo: • dilated LV (ESD 57 mm, EDD 80 mm), EF 50%. • bicuspid aortic valve, 4+ AR, mildly dilated Asc Ao.

  8. Case 1 As the next step in management, would you A) start beta blocker for htn and repeat echo in 6 mos B) start long acting nifedipine C) refer for surgery now D) start diuretic and see in 1 month

  9. Case 2 • MB, a 50 yo woman, native of India, now working as a medical technologist in your hospital. • Makes appt to discuss frequent episodes of “bronchitis”, declining exercise tolerance and occasional episodes of hemoptysis. • PMH neg. for htn, tobacco use, dm, dyslipidemia, obesity.

  10. Case 2 • On exam: • Thin, pleasant woman. Comfortable looking. • HR 96 irreg, irreg. BP 146/88. • JVP 7 cm H20. Bibasilar insp crackles. • Apical impulse not displaced. • S1 varies in intensity, nl S2. Opening snap and diastolic rumble shortly following S2.

  11. Case 2 • Echo: • Thickened and immobile mitral valve. No calcification. Minimal fusion of subvalvular apparatus. • Moderately enlarged LA. • Doppler evidence of stenosis with estimated pressure gradient of 8 m Hg and MVA of 1.7 cm2.

  12. Case 2 Which of the following would you do next? A) begin asa for stroke prophylaxis B) begin warfarin C) start metoprolol D) B and C E) begin Coenzyme Q10

  13. Case 2 Which of the following would you next pursue? A) closely observe, repeat echo in 6 mos B) refer for mitral valve replacement C) refer for percutaneous balloon vavuloplasty D) schedule for exercise echocardiography

  14. Case 3 • EA, an 84 yo widow and retired english teacher, sees you for vague chest discomfort and a near syncopal episode while climbing stairs with groceries. • Longstanding “benign” murmur. • PMH: htn, mild hyperlipidemia, OA, familial tremor. On HCTZ 12.5 mg qD and atenolol 25 mg BID.

  15. Case 3 • On exam: • thin, elderly woman neatly dressed. • HR 60. BP 155/76 both arms. BMI 19. • JVP ~11 cm H2O. Carotid upstrokes brisk. • Fine bibasilar crackles. • Apical impulse sustained. Thrill at RUSB. Nl S1 and harsh late peaking sys murmur at RUSB obscuring S2. Musical sounding sys murmur at apex. Valsalva strain and standing diminish murmur. Handgrip increases murmur.

  16. Case 3 • ECG: • LAD, LA abn, mild IVCD (QRS 110 ms), asymmetric T wave inversion in V5 and V6 • Echo: • dilated LA, normal LV chamber size, moderate LVH • normal LV systolic function • calcified Ao valve, estimated valve area 0.6 cm2

  17. Case 3 How would you manage her? A) refer for EP study and possible ICD B) begin atorvastatin 80 mg qD C) refer for consideration of valvuloplasty D) refer for coronary arteriography in anticipation of AVR E) initiate Hospice referral, palliative care

  18. Case 4 • RD, a 73 yo retired insurance salesman, sees you because a urologist evaluating him for erectile dysfunction heard a murmur. • Denies SOB, chest pain or syncope but is very sedentary. Has notice some fatigue and dependent edema. • Diagnosed with MVP 25 yrs ago.

  19. Case 4 • On exam: • obese, loquacious man with petite wife • HR 86. BP 170/94. BMI 45. • JVP 12 cm H2O. Nl carotid upstrokes • diminished bs, no crackles • apical impulse not palpable • Neither S1 or S2 are well heard, obscured by a holosystolic blowing murmur at apex and left parasternal border

  20. Case 4 • ECG: • SR, RAD, LA abn, R>S in V1, NSSTT abn • CXR: • LA and LV enlargement • Echo: • severe LA enlargement, mild LV dilatation (ESD 45mm), nl LVEF (60%), pulmonary hypertensio (est PASP 55 mmHg)

  21. Case 4 How would you manage this gentleman? A) begin ACE inhibitor B) begin digoxin for inotropic support C) refer for exercise echo D) refer for consideration of MV repair E) A and D

  22. Case 4 Does this man need endocarditis prophylaxis for a dental extraction? A) yes B) only if the tooth is infected C) only if local anaesthetic will be used D) no

  23. Aortic StenosisPhysiologic Principles-Natural History • Normal aortic valve area is 3.0 - 4.0 cm2 • Circulation affected when valve area is reduced by ~ 75% (i.e. 0.75 - 1.0 cm2) valve area (cmsq)mean gradient (mm Hg)* Mild > 1.5 < 25 Moderate 1.0 - 1.5 25 - 50 Severe < 0.75 > 50 * assumes normal cardiac output

  24. Aortic StenosisPhysiologic Principles-Natural History • Primary adaptation is concentric hypertrophy • Latent phase usually lasts decades • Risk of sudden death is very low during this phase • Rate of progression ranges from 0-0.3 cm2/yr. (average rate is 0.12 cm2/yr) • 50% of patients with severe AS do not progress • Cannot predict who will progress

  25. Aortic StenosisPhysiologic Principles-Natural History Bonow et al. Valvular Guidelines. Circ

  26. Aortic StenosisPhysiologic Principles-Natural History • Once symptoms develop, average survival is 2-3 yrs • With LV systolic dysfunction, there may be increased risk of sudden death and permanent LV dysfunction

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

  28. Aortic StenosisManagement Guidelines Initial Diagnostic Testing • Lipids, renal fxn, Ca, P---all patients • CXR, ECG, Echocardiography---all patients • Cardiac catheterization with angiography • If clinical and echo data are discordant • To assess coronary circulation prior to surgery

  29. Aortic StenosisManagement Guidelines Initial Diagnostic Testing (cont.) • Treadmill stress testing • Dangerous in symptomatic pts • Not useful for dx of CAD • May be used to assess functional significance of severe AS in pts who deny symptoms (e.g. bp response)

  30. Aortic StenosisManagement Guidelines Scheduled Follow-up office intervalecho interval Mild AS 12 mos 5 yrs Moderate AS 6 mos 2 yrs Severe AS 6 mos 1 yr

  31. Aortic StenosisManagement Guidelines Low Gradient AS • Special case • Minimal valve mobility and low cardiac output • Calculated valve area is small but pressure gradient is also small • Functional vs. fixed AS? • Consider dobutamine stress test (DSE) to clarify

  32. ACC Classification of Recommendations Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb. Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful.

  33. Aortic StenosisManagement Guidelines Recommendations for AVR Class I • Severe AS and symptoms • Severe AS (with or without sxs) and need for CABG, other valve replacement or aortic surgery Class IIa • Moderate AS and need for other cardiac surgery • Asymptomatic severe AS and diminished LVEF or hypotensive response to exercise

  34. Aortic StenosisManagement Guidelines Recommendations for AVR (cont.) Class IIb • Asymptomatic AS and VT, severe LVH (>15mm) or valve area <0.6 cm2 Class III • Asymptomatic AS with none of the above

  35. Aortic RegurgitationPhysiologic Principles-Natural History • LV faces combined pressure and volume load • Primary adaptation is dilatation (eccentric hypertrophy) • Since this adaptation takes time, AR classified as acute or chronic • Acute AR results in sudden increase in LVEDP >>> pulmonary edema and cardiogenic shock

  36. Aortic RegurgitationPhysiologic Principles-Natural History • Latent phase of AR, like AS, may last decades • Decompensation when • LV systolic function begins to fail • Progressive LV dilatation occurs • Spherical geometry develops • Initially this is reversible • LV systolic function and ESD are the most important predictors of postop survival and LV function

  37. Aortic RegurgitationPhysiologic Principles-Natural History • In asymptomatic pts with severe AS and nl LV systolic function, progression is slow • 4.3%/yr develop symptoms of LV systolic dysfunction • 1.3%/yr progress to LV dysfunction without symptoms† † pooled data from 7 series. 490 pts with mean follow-up of 6.4 yrs

  38. Aortic RegurgitationManagement Guidelines Initial Evaluation • ECG • CXR • Echo • ETT (if pt asymptomatic but sedentary or if symptoms are equivocal)

  39. Aortic RegurgitationManagement Guidelines Scheduled Follow-up (office and echo) Severe AR without symptoms • q 4-12 month depending on pace of change and current LV ESD/EDD Moderate AR without symptoms • 1st follow-up in 2-3 months to establish pace, then ~ q 12 months

  40. Aortic RegurgitationManagement Guidelines Vasodilator Therapy • Expected to  afterload,  stroke volume and  regurgitant volume • Hemodynamic benefit shown with hydralazine and nifedipine, less consistent results with ACEi • Improvement in clinical outcomes in trial of LA nifedipine vs. digoxin (need for AVR in 143 pts followed for 6 yrs--- 15% vs 34%) • Dose titrated to achieve  in SBP, not normalization

  41. Aortic RegurgitationManagement Guidelines Vasodilator Therapy Indications Class I • Severe AR with symptoms or severe LV dilatation but contraindications to surgery • Severe AR without symptoms but LV dilatation and elevated SBP • Any degree of AR with hypertension • Persistent LV systolic dysfunction s/p AVR (ACEi) • Short term therapy prior to AVR

  42. Aortic RegurgitationManagement Guidelines Vasodilator Therapy Indications Class III • Mild to mod AR without sxs and nl LV function • In lieu of AVR in pts without contraindications

  43. Aortic RegurgitationManagement Guidelines Recommendations for AVR (chronic severe AR) Class I • NYHA functional class III or IV sxs • NYHA functional class II sxs and progressive LV dilatation or declining LVEF on serial studies • CCS class II angina • Mild or moderate reduction in EF (25-50%) • Need for CABG or surgery on other valves

  44. Aortic RegurgitationManagement Guidelines Class IIa • NYHA class II sxs with nl LVEF (>50%) with stable EF, LV size and exercise tolerance • Asymptomatic pts with nl LVEF but severe LV dilatation (ESD > 55 mm or EDD > 75 mm) Class IIb • LVEF < 25% • Asymptomatic pts with nl LVEF and progressive LV dilatation with ESD 50-55 mm or ESD 70-75 mm

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