Some Essentials of Valvular Heart Disease CCU lecture series.
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Transcript of Some Essentials of Valvular Heart Disease CCU lecture series.
Some Essentials of Some Essentials of Valvular Heart Valvular Heart
DiseaseDisease
CCU lecture seriesCCU lecture series
Case 1Case 1
• 56 YO M presents for DOE 6 months56 YO M presents for DOE 6 months• Denies CP, syncope, palpitationsDenies CP, syncope, palpitations• PMH significant for PMH significant for
hypercholesterolemiahypercholesterolemia• Had “murmur since I was a child”Had “murmur since I was a child”• Mother died of heart failure in 60sMother died of heart failure in 60s• Non-smokerNon-smoker
Case 1Case 1
• HR 66 BP 120/85 HR 66 BP 120/85 • Neck: No bruitsNeck: No bruits• Chest: CTAChest: CTA• CVS: RRR, harsh 3/6 SEM radiating to CVS: RRR, harsh 3/6 SEM radiating to
carotidscarotids• Abdomen: Soft, NTAbdomen: Soft, NT• Ext: No c/c/eExt: No c/c/e
Aortic StenosisAortic Stenosis
• Obstruction most commonly located at Obstruction most commonly located at the level of the aortic valvethe level of the aortic valve
• May be congenital or acquired (most May be congenital or acquired (most common)common)
• Calcific AS is associated with Calcific AS is associated with traditional risk factors for traditional risk factors for atherosclerosis (smoking, high LDL, atherosclerosis (smoking, high LDL, HTN)HTN)
• Also seen in ESRD, Pagets, SLE, Also seen in ESRD, Pagets, SLE, alkaptonuriaalkaptonuria
PathophysiologyPathophysiology
• Aortic stenosis generally develops Aortic stenosis generally develops gradually, leading to LV hypertrophygradually, leading to LV hypertrophy
• As stenosis progresses, LVEDP As stenosis progresses, LVEDP begins to increase – LV function begins to increase – LV function usually remains normal until late in usually remains normal until late in disease processdisease process
• Diastolic dysfunction may also Diastolic dysfunction may also contribute to symptom onsetcontribute to symptom onset
Clinical FeaturesClinical Features
• 3 classic symptoms of severe AS3 classic symptoms of severe AS
1)1) DOEDOE
2)2) SyncopeSyncope
3)3) AnginaAngina
Physical ExamPhysical Exam
• PulsePulse• Heart sounds (second heart sound)Heart sounds (second heart sound)• Murmur Murmur • Other clinical manifestations Other clinical manifestations
(bleeding, embolic events, CAD)(bleeding, embolic events, CAD)
TestingTesting
• EKGEKG• CXRCXR• Echo Echo • Cardiac catheterizationCardiac catheterization• CT/MRI?CT/MRI?
Catheterization findingsCatheterization findings
Cardiac MRI and CTCardiac MRI and CT
Grading Severity of ASGrading Severity of AS
Low Gradient ASLow Gradient AS
Indications for SurgeryIndications for Surgery
Indications for SurgeryIndications for Surgery
TreatmentTreatment
• No effective medical therapy for No effective medical therapy for what is primarily a mechanical what is primarily a mechanical obstructionobstruction
• Aortic valve replacement is standard Aortic valve replacement is standard of careof care
• Mechanical vs. Bioprosthetic valvesMechanical vs. Bioprosthetic valves• The Ross procedureThe Ross procedure• Aortic root replacement?Aortic root replacement?
Balloon ValvuloplastyBalloon Valvuloplasty
• 31 patients >90 years old who 31 patients >90 years old who underwent balloon valvuloplasty underwent balloon valvuloplasty from 2003-2006from 2003-2006
• Patients all had severe symptomatic Patients all had severe symptomatic AS and were deemed high risk for AS and were deemed high risk for surgerysurgery
• Mean STS score was 18.5%Mean STS score was 18.5%
ResultsResults
• 25 patients underwent retrograde 25 patients underwent retrograde BAV, 6 anterograde BAV, 6 anterograde
• Mean AVA increased from 0.52 to Mean AVA increased from 0.52 to 0.92 cm0.92 cm²²
• Mean NYHA Class increased from 3.4 Mean NYHA Class increased from 3.4 to 1.8to 1.8
• 30 day mortality was 9.7%30 day mortality was 9.7%
CoreValveCoreValve
• 86 patients with symptomatic severe 86 patients with symptomatic severe AS, >80 years old and high risk for AS, >80 years old and high risk for cardiac surgery enrolledcardiac surgery enrolled
• Percutaneous AV replacement Percutaneous AV replacement attempted with 18 and 21 French attempted with 18 and 21 French systemssystems
ResultsResults
• Acute device success was 88%Acute device success was 88%• Successful implantation led to a Successful implantation led to a
significant reduction in gradientsignificant reduction in gradient• Aortic regurgitation remained Aortic regurgitation remained
unchangedunchanged• Procedural mortality was 6%Procedural mortality was 6%• 30 day mortality was 12%30 day mortality was 12%
The SALTIRE StudyThe SALTIRE Study
• 155 patients with moderate to severe 155 patients with moderate to severe AS enrolled – randomized to 80 mg AS enrolled – randomized to 80 mg atorvastatin or placeboatorvastatin or placebo
• AV stenosis and calcification AV stenosis and calcification assessed by echocardiography and assessed by echocardiography and cardiac CTcardiac CT
• Primary endpoints changes in aortic Primary endpoints changes in aortic jet velocity and AV calcium scorejet velocity and AV calcium score
SALTIRESALTIRE
• LDL decreased to 62 mg/dl in the LDL decreased to 62 mg/dl in the atorvastatin group, 131 in placeboatorvastatin group, 131 in placebo
• No significant change in endpointsNo significant change in endpoints
The Critically Ill AS patientThe Critically Ill AS patient
Remember…Remember…
1)1) Atrial fibrillation is bad!Atrial fibrillation is bad!
2)2) Vasopressor agents are preferable Vasopressor agents are preferable to inotropes for blood pressure to inotropes for blood pressure supportsupport
3)3) Think IABP early Think IABP early
4)4) Always auscultate before you give Always auscultate before you give NTG for chest pain!NTG for chest pain!
Management Management RecommendationsRecommendations
Case Number 2Case Number 2
• 72 YO M in the emergency 72 YO M in the emergency department has had CP x 5 daysdepartment has had CP x 5 days
• Finally decides to come to the EDFinally decides to come to the ED• Hypoxic on room air, rales 1/2 way Hypoxic on room air, rales 1/2 way
upup• Heart sounds difficult to appreciateHeart sounds difficult to appreciate• Troponin is 44Troponin is 44
EKGEKG
Stat Echo performed…Stat Echo performed…
Acute Mitral RegurgitationAcute Mitral Regurgitation
Three main mechanismsThree main mechanisms• Flail leaflet due to mitral valve prolapseFlail leaflet due to mitral valve prolapse• Chordae tendinae rupture due to Chordae tendinae rupture due to
trauma, infective endocarditis or trauma, infective endocarditis or rheumatic feverrheumatic fever
• Papillary muscle dysfunction due to Papillary muscle dysfunction due to ischemia/infarction (what kind of ischemia/infarction (what kind of infarction will more often present with infarction will more often present with acute MR?)acute MR?)
Mitral Valve AnatomyMitral Valve Anatomy
PathophysiologyPathophysiology
• Hemodynamic changes much more Hemodynamic changes much more pronounced than in chronic MR due pronounced than in chronic MR due to lack of time for adaptationto lack of time for adaptation
• The abrupt increase in left atrial The abrupt increase in left atrial pressure is transmitted to the pressure is transmitted to the pulmonary circulationpulmonary circulation
• Cardiac output falls and systemic Cardiac output falls and systemic vascular resistance increasesvascular resistance increases
Clinical ManifestationsClinical Manifestations
• Often present in cardiogenic shock Often present in cardiogenic shock and acute pulmonary edemaand acute pulmonary edema
• Physical exam may reveal a Physical exam may reveal a hyperdynamic precordium (will the hyperdynamic precordium (will the apex be displaced?)apex be displaced?)
• The murmurThe murmur• Up to 50% of patients will not have an Up to 50% of patients will not have an
audible murmur at the time of audible murmur at the time of evaluationevaluation
TestingTesting
• Echocardiography mainstay of Echocardiography mainstay of diagnosisdiagnosis
• Cardiac catheterization may be Cardiac catheterization may be required for determination of the required for determination of the extent and severity of concomitant extent and severity of concomitant CADCAD
• Hemodynamics are characteristicHemodynamics are characteristic
Mitral RegurgitationMitral Regurgitation
TreatmentTreatment
• Definitive treatment is surgicalDefinitive treatment is surgical• Supportive measures include Supportive measures include
nitroprusside (what is the nitroprusside (what is the mechanism?) and possibly mechanism?) and possibly dobutamine for low cardiac outputdobutamine for low cardiac output
• IABP IABP
Class I Indications for Class I Indications for MV Surgery in Severe MRMV Surgery in Severe MR
• Acute symptomatic MRAcute symptomatic MR• Chronic severe MR with NYHA class II, III or Chronic severe MR with NYHA class II, III or
IV in absence of severe LV dysfunction IV in absence of severe LV dysfunction and/or LVESD>55 mm.and/or LVESD>55 mm.
• Symptomatic or asymptomatic patients Symptomatic or asymptomatic patients with mild/mod LV dysfunction (EF 30-60%) with mild/mod LV dysfunction (EF 30-60%) and end-systolic dimension >and end-systolic dimension >40 mm40 mm
• MV repair recommended over replacement MV repair recommended over replacement for majority of pts; pts should be referred for majority of pts; pts should be referred to experienced surgical center. to experienced surgical center.
SurgerySurgery
• Surgical mortality can be as high as Surgical mortality can be as high as 50% - however mortality is uniformly 50% - however mortality is uniformly worse without surgical interventionworse without surgical intervention
• Valve repair is always preferable to Valve repair is always preferable to replacement, if possiblereplacement, if possible
• The success rates depend on the The success rates depend on the etiology of the valvular dysfunctionetiology of the valvular dysfunction