1. Valvular Heart Disease(VHD) in Primary Care Sayyadul (Sid) Siddiqui, MD Interventional Cardiologist CHI St. Vincent Heart Clinic Arkansas April 25, 2015

2. Outline Introduction of the valves: anatomy and murmurs Common VHD Infective endocarditis Dx and prophylaxis Pregnancy and VHD Anticoagulation in VHD Non-cardiac surgery in VHD

3. Introduction Mechanism of disease Degenerative Rheumatic Congenital Infective Ischemic Drugs Trauma Neoplastic Prosthetic + Prosthetic Valves

4. Introduction (contd) Net effect: Stenosis Regurgitation

5. Murmurs Common Murmurs: Aortic stenosis Aortic regurgitation Mitral stenosis Mitral regurgitation

6. Symptoms of VHD Dyspnea Chest pain Heart failure Arrhythmia Syncope

7. Treatment Options Medical: – Beta blocker – CCB – Diuretics – ACEI/ARB Surgical Catheter based

8. General guidelines for Intervention Decision to Rx: – Symptomatic – Preemptive – Adjunctive

9. Infective Endocarditis 15-20% in hospital mortality, one-year mortality approaching 40%! Complications: CVA(17%), Embolization( 23%), Heart failure (32%), intra-cardiac abscess (14%), need for surgical Rx (48%). Risk factors: – Prosthetic valve and intra-cardiac hardware. – IV drug use – Individuals with congenital or acquired VHD – Immunosuppression – Rheumatic heart disease – Prior history of infective endocarditis

10. Infective Endocarditis contd.. Table 24. Diagnosis of IE According to the Proposed Modified Duke Criteria Definite IE Pathological criteria " Microorganisms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or " Pathological lesions: vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis Clinical criteria " 2 major criteria; or " 1 major criterion and 3 minor criteria; or " 5 minor criteria Possible IE " 1 major criterion and 1 minor criterion; or " 3 minor criteria Rejected " Firm alternate diagnosis explaining evidence of IE; or " Resolution of IE syndrome with antibiotic therapy for <4 d; or " No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for <4 d; or " Does not meet criteria for possible IE as listed above

11. Infective Endocarditis contd.. Major Criteria 1. Blood culture positive for IE Typical microorganisms consistent with IE from 2 separate blood cultures: " Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), Staphylococcus aureus; or community-acquired enterococci, in the absence of a primary focus; or Microorganisms consistent with IE from persistently positive blood cultures, defined as follows: " At least 2 positive cultures of blood samples drawn 12 h apart; or " All of 3 or a majority of !4 separate cultures of blood (with first and last samples drawn at least 1 h apart) " Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800 2. Evidence of endocardial involvement " Echocardiogram positive for IE defined as follows: ' Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; ' Abscess; or ' New partial dehiscence of prosthetic valve " New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient) Minor Criteria 1. Predisposition, predisposing heart condition, or injection drug use 2. Fever, temperature >38' C (100.4' F) 3. Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions 4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor 5. Microbiological evidence: positive blood culture but does not meet a major criterion as noted above* or serological evidence of active infection with organism consistent with IE

12. Take home message – Identify individuals at risk for IE during fever evaluation – Blood culture x 2 PRIOR to starting Abx: – Echocardiographic evaluation – Consider transferring to a tertiary center. – Use Modified Duke Criteria to help diagnose IE

13. Prophylaxis Who needs prophylaxis? – Patients with prosthetic heart valves – Patients with previous infective endocarditis – Cardiac transplant recipients with valve regurgitation due to structurally abnormal valve – Patients with congenital heart disease with: Unrepaired cyanotic congenital heart disease Completely repaired congenital heart defects repaired with prosthetic material for 6 months Repaired congenital heart disease with residual defects near prosthetic patch/device. Who doesn’t need prophylaxis? – Normal folks if you can find one – VHD but non-dental procedure: (EGD, colonoscopy, cystoscopy) in absence of active infection.

14. Pregnancy and VHD VHD is poorly tolerated during pregnancy: HF + arrhythmia Critical to identify patients with VHD before pregnancy Identify aortopathy coexistent with VHD Counseling by cardiology must take place prior to pregnancy Refer to tertiary centers Asymptomatic with severe VHD will become symptomatic during pregnancy, so may need Rx before pregnancy – Choice of intervention: Balloon Vs. surgical Drugs needing attention: – Beta blockers are Ok: Metoprolol preferred over atenolol – Diuretics are also Ok – ACEI/ARB are a No No – Coumadin, Heparin and LMWH: lets talk about it

15. Pregnancy and Anticoagulation For mechanical valves

16. Anticoagulation for Prosthetic heart valves **No role for newer oral anticoagulants**

17. Surgical procedures & anticoagulation for prosthetic VHD Minor surgical procedure: continue VKA Mechanical bileaflet aortic valve and No other risk factors: may temporarily stop VKA Mechanical AOV + risk factors, or Older generation AOV or Mechanical MVR: bridge with LMWH

18. Non-cardiac Surgery and VHD Complication rate of 10-30% in undiagnosed severe AS or MS Left sided regurgitant valve lesions are better tolerated than stenotic valve lesions Avoid arrhythmias: use beta blocker if possible. Anesthesia: avoid hypotension Avoid excessive fluid input Intra-operative and post-operative cardiac monitoring