Some Essentials of Valvular Heart Disease

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Some Essentials of Valvular Heart Disease

• CCU lecture series

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Case 1

• 56 YO M presents for DOE 6 months
• Denies CP, syncope, palpitations
• PMH significant for hypercholesterolemia
• Had murmur since I was a child
• Mother died of heart failure in 60s
• Non-smoker

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Case 1

• HR 66 BP 120/85
• Neck No bruits
• Chest CTA
• CVS RRR, harsh 3/6 SEM radiating to carotids
• Abdomen Soft, NT
• Ext No c/c/e

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Aortic Stenosis

• Obstruction most commonly located at the level of
  the aortic valve
• May be congenital or acquired (most common)
• Calcific AS is associated with traditional risk
  factors for atherosclerosis (smoking, high LDL,
  HTN)
• Also seen in ESRD, Pagets, SLE, alkaptonuria

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Pathophysiology

• Aortic stenosis generally develops gradually,
  leading to LV hypertrophy
• As stenosis progresses, LVEDP begins to increase
  LV function usually remains normal until late
  in disease process
• Diastolic dysfunction may also contribute to
  symptom onset

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Clinical Features

• 3 classic symptoms of severe AS
• DOE
• Syncope
• Angina

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Physical Exam

• Pulse
• Heart sounds (second heart sound)
• Murmur
• Other clinical manifestations (bleeding, embolic
  events, CAD)

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Testing

• EKG
• CXR
• Echo
• Cardiac catheterization
• CT/MRI?

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Catheterization findings
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Cardiac MRI and CT
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Grading Severity of AS
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Low Gradient AS
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Indications for Surgery
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Indications for Surgery
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Treatment

• No effective medical therapy for what is
  primarily a mechanical obstruction
• Aortic valve replacement is standard of care
• Mechanical vs. Bioprosthetic valves
• The Ross procedure
• Aortic root replacement?

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Balloon Valvuloplasty

• 31 patients gt90 years old who underwent balloon
  valvuloplasty from 2003-2006
• Patients all had severe symptomatic AS and were
  deemed high risk for surgery
• Mean STS score was 18.5

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Results

• 25 patients underwent retrograde BAV, 6
  anterograde
• Mean AVA increased from 0.52 to 0.92 cm²
• Mean NYHA Class increased from 3.4 to 1.8
• 30 day mortality was 9.7

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CoreValve

• 86 patients with symptomatic severe AS, gt80 years
  old and high risk for cardiac surgery enrolled
• Percutaneous AV replacement attempted with 18 and
  21 French systems

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Results

• Acute device success was 88
• Successful implantation led to a significant
  reduction in gradient
• Aortic regurgitation remained unchanged
• Procedural mortality was 6
• 30 day mortality was 12

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The SALTIRE Study

• 155 patients with moderate to severe AS enrolled
  randomized to 80 mg atorvastatin or placebo
• AV stenosis and calcification assessed by
  echocardiography and cardiac CT
• Primary endpoints changes in aortic jet velocity
  and AV calcium score

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SALTIRE

• LDL decreased to 62 mg/dl in the atorvastatin
  group, 131 in placebo
• No significant change in endpoints

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The Critically Ill AS patient

• Remember
• Atrial fibrillation is bad!
• Vasopressor agents are preferable to inotropes
  for blood pressure support
• Think IABP early
• Always auscultate before you give NTG for chest
  pain!

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Management Recommendations
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Case Number 2

• 72 YO M in the emergency department has had CP x
  5 days
• Finally decides to come to the ED
• Hypoxic on room air, rales 1/2 way up
• Heart sounds difficult to appreciate
• Troponin is 44

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EKG
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Stat Echo performed
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Acute Mitral Regurgitation

• Three main mechanisms
• Flail leaflet due to mitral valve prolapse
• Chordae tendinae rupture due to trauma, infective
  endocarditis or rheumatic fever
• Papillary muscle dysfunction due to
  ischemia/infarction (what kind of infarction will
  more often present with acute MR?)

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Mitral Valve Anatomy
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Pathophysiology

• Hemodynamic changes much more pronounced than in
  chronic MR due to lack of time for adaptation
• The abrupt increase in left atrial pressure is
  transmitted to the pulmonary circulation
• Cardiac output falls and systemic vascular
  resistance increases

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Clinical Manifestations

• Often present in cardiogenic shock and acute
  pulmonary edema
• Physical exam may reveal a hyperdynamic
  precordium (will the apex be displaced?)
• The murmur
• Up to 50 of patients will not have an audible
  murmur at the time of evaluation

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Testing

• Echocardiography mainstay of diagnosis
• Cardiac catheterization may be required for
  determination of the extent and severity of
  concomitant CAD
• Hemodynamics are characteristic

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Mitral Regurgitation
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Treatment

• Definitive treatment is surgical
• Supportive measures include nitroprusside (what
  is the mechanism?) and possibly dobutamine for
  low cardiac output
• IABP

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Class I Indications for MV Surgery in Severe MR

• Acute symptomatic MR
• Chronic severe MR with NYHA class II, III or IV
  in absence of severe LV dysfunction and/or
  LVESDgt55 mm.
• Symptomatic or asymptomatic patients with
  mild/mod LV dysfunction (EF 30-60) and
  end-systolic dimension gt40 mm
• MV repair recommended over replacement for
  majority of pts pts should be referred to
  experienced surgical center.

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Surgery

• Surgical mortality can be as high as 50 -
  however mortality is uniformly worse without
  surgical intervention
• Valve repair is always preferable to replacement,
  if possible
• The success rates depend on the etiology of the
  valvular dysfunction