Overview of Valvular Heart Disease January 28, 2006 David R. Richards, DO, FACC, FASE MidOhio Cardiology and Vascular Consultants Director, Heart Disease Management Program Riverside Hospital

Valve Disease: general concepts Etiology and natural history Physical findings Therapy –types of surgical therapy –indications for surgery –indications for anticoagulation –antibiotic prophylaxis

Etiology of valve disease “Secondary” valve disease “Primary” valve disease

Etiology of valve disease “Secondary” valve disease –Hypertension –CAD –Cardiomyopathy “Primary” valve disease

Etiology of valve disease “Secondary” valve disease “Primary” valve disease –Calcific aortic stenosis –Rheumatic valve disease –Mitral prolapse / myxomatous mitral disease –Primary aortic regurgitation –Infective endocarditis

Diseases primary degenerative rheumatic endocarditis myxomatous congenital secondary CAD / cardiomyopathy Mechanisms Aortic stenosis Mitral stenosis Mitral regurg. Aortic regurg. Tricuspid regurg

Mechanisms of Valve Disease

Valvular Emergencies Acute Endocarditis Papillary Muscle Rupture Flail Mitral Leaflet Prosthetic Valve Thrombosis / Dehiscence

65 y.o. female with MVR and acute CHF

S/P thrombolytic therapy

S/P bioprosthetic valve replacement

Valve disease: Diagnosis Physical exam suggests diagnosis Transthoracic Echo (TTE) confirms mechanism and severity of lesion Transesophageal Echo (TEE) usually reserved to: plan surgery confirm borderline diagnosis/severity

2 D Echocardiography

Transesophageal Echo (TEE)

S1S1 S2S2 systole diastole MV closure AV closure

S1S1 S2S2 Mild AS Severe ASMitral regurgMVP

S1S1 S2S2 Mitral Stenosis Severe AR Mild AR

Valve disease: Management Medical therapy ineffective –except: vasodilators for AR Surgical therapy curative Surgery for symptoms or LV dysfunction Surgical trends: –minimally invasive surgery –valve repair –homograft use

Mechanical Prostheses

2D Echo: normal mechanical MV

Heterografts: Porcine

Aortic Homograft

TEE: aortic homograft

Mitral Annuloplasty Ring

Prosthetic Valves: selection Bioprosthetic Mechanical Homograft No Coumadin needed Less thromboembolic complications Lifelong cure No Coumadin needed Potential lifelong integrity Lifespan yrs. Lifelong Coumadin 1% annual comp. Rate Limited availability ? Late failure Technically challenging ProsCons

Prosthetic Valves: selection Bioprosthetic Mechanical Homograft Elderly pts.(lifespan < 15 yrs. Contraindication to Coumadin Elderly who already need Coumadin All other patients Young patients with Aortic Valve disease

Prosthetic Valves: types of dysfunction Stenosis –degenerative –thrombosis Regurgitation –Paravalvular –Transvalvular Endocarditis Mechanical Failure

Prosthetic Valve Endocarditis

Valve disease: Management Endocarditis prophylaxis High-risk patient High-risk procedure + = prophylaxis

Endocarditis prophylaxis High-risk patient High-risk procedure + *Congenital disease *Prior endocarditis *Prosthetic valves Acquired valve disease MVP with MR Dental GU GI Resp

Antibiotic Regimens Oral, Dental, Upper Resp Procedures: Amoxicillin 2.0 gm p.o. Alternative: –Clindamycin 600 mg p.o. –Cephalexin, Azithromycin GU, GI Procedures: Ampicillin and Gentamycin Alternative: Vancomycin

Case 1 36 year old male presents with palpitations. No past history. No meds. Sibling has heart murmur. Exam: normal S1, S2. No murmur. Soft mid-systolic click. EKG: normal except for PACs.

Case 1 Initial management should include: A.antibiotic prophylaxis B.2D echo C. beta-blockade D.EP study

Case 1: 2D echo Findings:Posterior Leaflet Prolapse Mild (1+) Regurgitation

Case 1 Further management should include: A.antibiotic prophylaxis B.yearly 2D echo to follow MR C. Holter monitor D.empiric beta-blockade

Case 1 Further management should include: A.antibiotic prophylaxis B.yearly 2D echo to follow MR C. Holter monitor D.empiric beta-blockade

Mitral Valve Prolapse A form of myxomatous valve disease symptoms may be from: –mitral regurgitation –hyperadrenergic state May progress to “surgical” MR Often familial Overdiagnosed clinically

Severe Posterior Leaflet Prolapse

Case 2 56 year old male with known heart murmur and MVP for 20 years. 3 days prior to admission, he had acute onset dyspnea and orthopnea. Exam: pulse /6 holosystolic murmur at apex. Bilateral crackles. Labs: Troponin negative EKG: sinus tachy CXR: pulmonary edema

Case 2 Potential Causes of CHF include all except: A.Endocarditis on pre-existing myxomatous mitral valve B.Flail mitral leaflet due to ruptured chordae tendinae C. Papillary muscle rupture from acute MI D.LV dysfunction from chronic MR

Case 2 Potential Causes of CHF include all except: A.Endocarditis on pre-existing myxomatous mitral valve B.Flail mitral leaflet due to ruptured chordae tendinae C. Papillary muscle rupture from acute MI D.LV dysfunction from chronic MR

Case 2: TEE Findings:Severe MV prolapse Flail Posterior Leaflet Severe (4+) MR

Case 2 Flail Mitral Leaflet: A.is a rare but potentially life- threatening cause of severe MR B.is most commonly a result of endocarditis C. is often amenable to valve repair D.is best initially managed with medical therapy

Case 2 Flail Mitral Leaflet: A.is a rare but potentially life- threatening cause of severe MR B.is most commonly a result of endocarditis C. is often amenable to valve repair D.is best initially managed with medical therapy

Flail Mitral Valve Leaflet A complication of myxomatous valve disease: rupture of chordae tendinae Rarely from endocarditis, rheumatic, etc Presents as severe MR with CHF Accurately diagnosed with TEE High untreated mortality Accounts for 30 to 50 % of MV surgery Highly amenable to valve repair

Mitral Regurgitation Etiology: Chronic _ Myxomatous valve disease (MVP) –LV dysfunction, prior MI –Endocarditis, rheumatic disease Etiology: Acute –Papillary muscle rupture s/p AMI –Chordal rupture (flail leaflet) –Acute endocarditis Accurately diagnosed with TEE (mechanism, severity, reparability) Surgery indicated for symptoms or LV dilatation/dysfunction No role for med therapy

Case 3 53 y.o. female with chronic dyspnea. Atrial fib for 12 years. Exam: –4/6 blowing systolic murmur at apex with harsh component at LSB –harsh diastolic rumbling murmur –reduced S2, loud opening snap –prominent JVD

Case 3: 2D echo Findings:Rheumatic changes of MV Severe MS, Moderate AS Moderate MR

Case 3 Potential complications expected in this patient include all except: A.Endocarditis B.Chronic Atrial Fibrillation C. CVA D.CHF due to LV dysfunction E.Pulmonary Hypertension

Case 3 Potential complications expected in this patient include all except: A.Endocarditis B.Chronic Atrial Fibrillation C. CVA D.CHF due to LV dysfunction E.Pulmonary Hypertension

Mitral Valve Stenosis A complication of acute rheumatic fever Valve disease occurs 20 yrs after initial acute illness Presents as exertional dyspnea and murmur Complications: A.Fib., emboli, refractory pulmonary hypertension Therapy: Commisurotomy or valve replacement

Case 3b 72 y.o. female with dyspnea. Exam: –2/4 systolic murmur –Normal S1 and S2

Case 3b

Normal Aortic Valve Calcific Aortic Stenosis

Aortic Stenosis Most common etiology is degenerative calcific disease (age < 50, bicuspid AV or rheumatic ) Classic Triad: Chest Pain, Dyspnea, Syncope Reduced exercise capacity may be earliest symptom (use exercise test) Surgery indicated for –any symptoms –LV dilation or dysfunction (EF 50mm) –NOT for specific valve area

Case 4 35 y.o. male found to have heart murmur. No symptoms. Exam: –ejection click –2/4 diastolic murmur

Case 4: 2D Echo Findings: Moderate AR Bicuspid AV Normal LV size and function

Case 4 Echo: moderate AR, bicuspid AV, normal LV Exercise EKG: normal exercise capacity All are appropriate except: A.p.o. nifedipine B.yearly 2D echo C.surgery, if echo shows mild LV cavity dilation D.surgery, if mild symptoms develop E.endocarditis prophylaxis

Case 4 Echo: moderate AR, bicuspid AV, normal LV Exercise EKG: normal exercise capacity All are appropriate except: A.p.o. nifedipine B.yearly 2D echo C.surgery, if echo shows mild LV cavity dilation D.surgery, if mild symptoms develop E.endocarditis prophylaxis

Aortic Regurgitation Most common etiology is degenerative (age < 50, bicuspid AV or rheumatic ) Reduced exercise capacity may be earliest symptom (use exercise test) Surgery indicated for –any symptoms –LV dilation or dysfunction (EF 50mm)

Case 5 10 years later, patient develops acute fever, weakness. Patent reports severe dyspnea at rest. Exam: BP 80/50, HR 110, bilateral crackles, soft diastolic murmur, S4 gallop

Case 5: 2D Echo

Case 4 Echo: bicuspid AV with vegetation, severe AR, dilated LV with EF 30% antibiotics, diuretics, & pressors are initiated. The patient initially stabilizes, but within 24 hours develops recurrent hypotension and respiratory failure.

Case 4 Which strategy is appropriate: A.continue antibiotics, no surgery B.antibiotics, with surgery after completed course, when blood sterile C.antibiotics, with surgery in several days D.antibiotics, with surgery within 24 hours

Case 4 Which strategy is appropriate: A.continue antibiotics, no surgery B.antibiotics, with surgery after completed course, when blood sterile C.antibiotics, with surgery in several days D.antibiotics, with surgery within 24 hours

25 y.o woman with fatigue Findings: MV mass ? Myxoma

Overview of Valvular Heart Disease August 10, 2005