1. Adult Cardiac Valve Disease Marvin D. Peyton, M.D. Thoracic and Cardiovascular Surgery University of Oklahoma Health Sciences Center

2. Volume Stress vs Pressure Stress Valvular insufficiency = volume stress Valvular insufficiency = volume stress Valvular stenosis = pressure stress Valvular stenosis = pressure stress Chronic stress better tolerated than acute stress Chronic stress better tolerated than acute stress Pressure stress = chronic stress Pressure stress = chronic stress Volume stress = chronic stress (occasionally acute stress) Volume stress = chronic stress (occasionally acute stress) Acute stress very poorly tolerated Acute stress very poorly tolerated

3. Valve Disease

4. Tricuspid Valve Adult tricuspid stenosis very rare excluding rheumatic fever Adult tricuspid stenosis very rare excluding rheumatic fever Tricuspid valve insufficiency most commonly associated with left heart failure Tricuspid valve insufficiency most commonly associated with left heart failure Primary tricuspid valve insufficiency most often with endocarditis Primary tricuspid valve insufficiency most often with endocarditis Tricuspid valve insufficiency worsened with pulmonary hypertension Tricuspid valve insufficiency worsened with pulmonary hypertension Tricuspid valve endocarditis may warrant valvectomy Tricuspid valve endocarditis may warrant valvectomy Valvectomy tolerated over long period of time with normal pulmonary vascular resistance Valvectomy tolerated over long period of time with normal pulmonary vascular resistance Valve repair and preservation preferable to valve replacement Valve repair and preservation preferable to valve replacement Valve replacement for destroyed leaflet integrity Valve replacement for destroyed leaflet integrity Valve replacement – options mechanical vs bioprosthesis Valve replacement – options mechanical vs bioprosthesis

5. Pulmonary Valve Adult pulmonary valve disease rare Adult pulmonary valve disease rare Endocarditis Endocarditis Carcinoid disease Carcinoid disease Dietary medications Dietary medications Pulmonary valve insufficiency well tolerated with normal pulmonary vascular resistance Pulmonary valve insufficiency well tolerated with normal pulmonary vascular resistance

6. Mitral Valve Stenosis (Chronic) Much less common with eradication of rheumatic valve disease Much less common with eradication of rheumatic valve disease Carcinoid syndrome Carcinoid syndrome Dietary medications Dietary medications Atrial fibrillation Atrial fibrillation Stroke Stroke Congestive pulmonary disease Congestive pulmonary disease

7. Mitral Valve Insufficiency Most common from ischemic left ventricular failure Most common from ischemic left ventricular failure Endocarditis Endocarditis Innate valve disease (Barlow syndrome) Innate valve disease (Barlow syndrome)

8. Mitral Valve Insufficiency Ischemic Ischemic Endocarditis Endocarditis Degenerative Degenerative

9. Valve Repair Preferable to Valve Replacement Leaflet and chordae reconstruction Leaflet and chordae reconstruction Annular ring Annular ring Ischemic –revascularization Ischemic –revascularization

10. Valve Replacement Mechanical prosthesis Mechanical prosthesis Bioprosthesis Bioprosthesis Lifestyle, age and comorbidity Lifestyle, age and comorbidity

11. Mitral Insufficiency Well Tolerated on Chronic Basis as Flow Stress Phenomenon Repair or replacement with symptoms or dilating chambers Repair or replacement with symptoms or dilating chambers Earlier surgery may allow repair over replacement Earlier surgery may allow repair over replacement

12. Aortic Valve Disease Stenosis – pressure stress Stenosis – pressure stress Insufficiency – volume stress Insufficiency – volume stress Chronic volume stress well tolerated Chronic volume stress well tolerated Repair rare Repair rare Replacement Replacement Mechanical prosthesis Mechanical prosthesis Bioprosthesis Bioprosthesis Surgical indications dilating ventricle Surgical indications dilating ventricle Symptoms Symptoms

13. Aortic Stenosis Chronic process Chronic process Intervene before symptoms Intervene before symptoms Objectivity for surgery Objectivity for surgery Pressure gradient Pressure gradient Valve area Valve area Flow velocity Flow velocity Associated coronary disease a compounding risk factor Associated coronary disease a compounding risk factor

14. Choice of prosthesis Age Age Lifestyle Lifestyle Comorbidity Comorbidity

15. Acute Valvular Insufficiency Endocarditis Endocarditis Dissection Dissection

16. Summary of Valve Concerns Closely follow clinical signs, symptoms and objective measurements Closely follow clinical signs, symptoms and objective measurements