VHD GUIDELINES 2014
-
Upload
praveen-nagula -
Category
Education
-
view
5.994 -
download
4
description
Transcript of VHD GUIDELINES 2014
![Page 1: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/1.jpg)
ACC/AHA VALVULAR HEART DISEASE
GUIDELINES 2014
Dr.NagulaPraveen
![Page 2: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/2.jpg)
Rick A.Nishimura,M.D.,FACC
Catherine M.Otto,MD.,FACC
![Page 3: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/3.jpg)
![Page 4: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/4.jpg)
![Page 5: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/5.jpg)
Introduction
• Diagnosis and management of adults with valvular heart
disease.
• Original VHD guidelines in 1998 – revised in 2006 –
updated in 2008.
• Evidence based recommendations are made.
![Page 6: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/6.jpg)
STAGES OF PROGRESSION OF VHD
![Page 7: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/7.jpg)
Frequency of Echocardiogram in Asymptomatic pts with VHD
![Page 8: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/8.jpg)
Secondary Prevention of Rheumatic fever
![Page 9: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/9.jpg)
Duration of Secondary Prophylaxis for
Rheumatic Fever
![Page 10: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/10.jpg)
![Page 11: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/11.jpg)
STS PROM
• Accepted tool to predict the risk of a surgical operation.
• STS – Society of Thoracic Surgeons
• PROM – Predicted Rate Of Mortality
STS database 2000 -2010
• Frailty – ability to perform activites of daily living.
AORTIC VALVE OPERATIONS
PROM MEAN MORTALITY RATE
80% <4% 1.4%
14% 4%-8% 5.1%
6% >8% 11.1%
![Page 12: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/12.jpg)
SEVEN FRAILTY INDICES
Katz Activities of daily living• Independence in feeding• Bathing• Dressing• Transferring• Toileting• Urinary continence
Independence in ambulation• No walking aid or
Assist required or
Walk 5 meter < 6 sec.
PROCEDURE SPECIFIC IMPEDIMENT Tracheostomy ,Heavily calcified ascending aorta,Chest deformity,arterial coronary graft adherent to chest wall,Radiation damage
![Page 13: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/13.jpg)
MAJOR ORGAN SYSTEM COMPROMISE
• Cardiac-• Severe LV systolic
dysfunction• Severe LV diastolic
dysfunction• RV dysfunction• Fixed pulmonary HTN
• CKD stage 3 or more• Pulmonary dysfunction with
FEV1 <50%,DLCO2 <50% of predicted value
• CNS dysfunction • Dementia• Alzhemiers disease• Parkinson’s disease• CVA with persistent physical
limitation
• GI dysfunction• Crohn’s disease• UC • Serum albumin <3.0 gm/dl
• Cancer –active malignancy• Liver –cirrhosis,variceal bleed• Elevated INR
![Page 14: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/14.jpg)
Does all patients need intervention?
• http://riskcalc.sts.org/de.aspx
NO• Life expectancy less than 1 yr.• Chance of survival with benefit <25% at 2yrs.• Improvement of NYHA by one class
![Page 15: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/15.jpg)
- Stages of Valvular Heart DiseaseDiagnosis and follow up
Diagnostic testing – initial diagnosisDiagnostic testing – changing signs or symptomsDiagnostic testing – routine follow up Diagnostic testing – cardiac catheterisationDiagnostic testing – exercise testing
Medical therapy Timing of interventionChoice of intervention
![Page 16: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/16.jpg)
Aortic StenosisAortic RegurgitationBicuspid Aortic valve and AortopathyMitral StenosisMitral RegurgitationTricuspid valve diseasePulmonic valve diseaseMixed valve diseaseProsthetic valves Infective EndocarditisPregnancy and VHDSurgical considerationsNon cardiac surgery in patients with VHDEvidence gaps and future directions
![Page 17: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/17.jpg)
AORTIC STENOSIS
![Page 18: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/18.jpg)
Stages of Valvular AS
Each of these stages is defined by
• Valve anatomy,
• Valve hemodynamics,
• The consequences of valve obstruction on left ventricle
and vasculature,
• Patient symptoms.
![Page 19: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/19.jpg)
Hemodynamic severity is
best characterized
by the transaortic maximum velocity
or
Mean Pressure Gradient
when the transaortic volume flow rate is normal.
![Page 20: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/20.jpg)
STAGES of VALVULAR AORTIC STENOSIS
![Page 21: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/21.jpg)
Stages C1 and C2
![Page 22: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/22.jpg)
Special Sub groups
• Some patients with AS have a low transaortic volume flow rate due
to either LV systolic dysfunction with a low LV ejection fraction
(LVEF) or due to a small hypertrophied left ventricle with a low
stroke volume.
• Diagnostic and management challenge.
Designated as
• D2 (with a low LV EF)
• D3 ( with a normal LVEF).
![Page 23: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/23.jpg)
![Page 24: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/24.jpg)
INDICATION CLASS RECOMMENDATION
ECHO I B Signs or symptoms of AS /bicuspid AV for ∆ ,cause, severity, LVsize ,function, systolicfunction, prognosis,timing of intervention.
IIa B Low dose DBS – D2AS calcified,EF<50%,1.0cm2area ,velocity <4m/sec, MPG - 40 mmHg.
Exercise testing
IIaB Asymptomatic pts >4m/sec , MPG >40 mmHg.
III B Symptomatic pts with >4m /sec , MPG>40 mmHg
Medical therapy
I B HTN in pts at risk, asymptomatic ,according to GDMT, low dose to start with
IIb C Vasodilator therapy in acute RX of decompensated severe AS with NYHA class IV HF symptoms
III A Statin therapy is not indicated for hemodynamic progression of AS in pts with mild to moderate AS calcific.
![Page 25: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/25.jpg)
Dobutamine Stress Echocardiography
• To be done in patients with severe AS(due to small valve area) and concurrent LV systolic dysfunction.(usually have MPG <40 mmHg).
• 1.Severe AS with LV systolic dysfunction due to afterload mismatch.
• 2.Primary myocardial dysfunction with only moderate AS and reduced leaflet opening due to low flow rate.
SEVERE /MODERATE AS
CONTRACTILE RESERVE PRESENT/ABSENT. • 5 mcg/kg/min – increments of 5 ug/kg/min(max 20 ug/kg/min)• AJV,MPG,LVEF,valve area
![Page 26: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/26.jpg)
• Pts who donot have true anatomically severe AS - increase in valve
area with only a modest increase in transaortic velocity or gradient as
transaortic stroke volume increases.
• Patients with severe AS – relatively fixed area even with an increase
in LV contractility and flow rate.
• EAE/ASE – Severe AS - >4m/sec, valve area <1.0cm2 at any point
during test protocol.
• Fail to increase in SV >20% with dobutamine – lack of Contractile
Reserve.
• Very poor prognosis with either medical or surgical therapy.
![Page 27: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/27.jpg)
![Page 28: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/28.jpg)
What is the rate of progression of Aortic Stenosis?
AORTIC STENOSIS PROGRESSION/EVENT FREE SURVIVAL
Severe AS (asymptomatic –sympotmatic)
Event free survival 30-50% at 2yrs
Moderate AS (3.0-3.9m/sec) 0.3m/sec/yr,7mmhg/yr,0.1cm2/yr
Aortic sclerosis 10% in 2 yrs
Progression of AS more rapid in older patients and those with more leaflet calcification
![Page 29: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/29.jpg)
What are the symptoms in favour of AS in ExerciseTesting?
• 1.Exercise induced angina
• 2.Excessive dyspnea early in exercise
• 3.dizziness
• 4.syncope
• 5.abnormal BP response(<20 mm Hg increase)
• 6.ST-T abnormalities .
![Page 30: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/30.jpg)
Studies on Aortic Stenosis
TRIAL NAME DRUGS USED RESULT
1 SEAS SIMVASTATIN,EZETIMIBE NO BENEFIT
2 SALTIRE HIGH DOSE ATORVASTATIN NO BENEFIT
3 ASTRONOMER ROSUVASTATIN NO BENEFIT
4 SCOPE -AS ENALAPRIL BENEFIT
![Page 31: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/31.jpg)
SEAS study• SIMVASTATIN EZETIMIBE IN AORTIC STENOSIS• RCT ,Simvastatin 40 mg and Ezetimibe 10 mg did not reduce
aortic valve events (AVEs), while ischemic cardiovascular events (ICEs) were significantly reduced in the overall study population.
• the impact of baseline AS severity on treatment effect has not been reported.
• rates of AVEs and ICEs increased with increasing baseline severity of AS.
• Higher baseline peak aortic jet velocity predicted higher rates of AVEs and ICEs in all tertiles (all p values < 0.05) and in the total study population (p < 0.001).
![Page 32: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/32.jpg)
Simvastatin-ezetimibe treatment was not associated with a
statistically significant reduction in AVEs in any individual tertile.
A significant quantitative interaction between the severity of AS
and simvastatin-ezetimibe treatment effect was demonstrated for
ICEs (p < 0.05) but not for AVEs (p = 0.10).
In conclusion, the SEAS study results demonstrate a strong
relation between baseline the severity of AS and the rate of
cardiovascular events but no significant effect of lipid-lowering
treatment on AVEs, even in the group with the mildest AS.
![Page 33: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/33.jpg)
ASTRONOMER STUDY
AORTIC STENOSIS PROGRESSION OBSERVATION
MEASURING EFFECTS OF ROSUVASTATIN
(ASTRONOMER) STUDY.
• 168 patients (56 ± 13 years), AS severity was categorized based on peak velocity at baseline (Group I: 2.5-3.0 m/s; Group II: 3.1-3.5 m/s; Group III: 3.6-4.0 m/s).
• Baseline and follow-up hemodynamics, LV dimensions and diastolic functional parameters were evaluated in all three groups.
• There was increased diastolic dysfunction from baseline to follow-up in each of the placebo and rosuvastatin groups.
![Page 34: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/34.jpg)
Conclusions
• In patients with increasing severity of AS in Groups I and II,
the lateral E' was lower and the E/E' (as an estimate of
increased LVEDP) was higher at baseline (p < 0.05).
• However, treatment with rosuvastatin did not affect the
progression of diastolic dysfunction from baseline to 3.5 year
follow-up between patients in any of the three predefined
groups.
![Page 35: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/35.jpg)
I C
II b C
II b C
![Page 36: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/36.jpg)
N
N
N
II b C
![Page 37: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/37.jpg)
![Page 38: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/38.jpg)
Choice of Surgical or Transcatheter intervention
![Page 39: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/39.jpg)
TAVR• TAVI VIDEO• Dr Alain Cribier pioneered the first transcatheter aortic valve
implantation (TAVI) procedure in 2002
![Page 40: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/40.jpg)
![Page 41: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/41.jpg)
TAVRPARTNER trial.
FRANCE study.
Antegrade – Acute MR
Retrograde approaches
Transfemoral approach
Transapical approach
Transaortic surgical retrograde approach
Two types of stent-valve devices
Balloon-expandable valves (Edwards SAPIEN and SAPIEN XT, which have replaced the Cribier-Edwards valve)
Self-expanding valve (Medtronic CoreValve) thesubclavian/axillary artery , direct aortic access via either ministernotomy or right anterior thoracotomy.
![Page 42: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/42.jpg)
C/I for TAVR/TAVI• Bicuspid or unicuspid or noncalcified aortic valve• Severe AR (>3+)• Native aortic annulus size as measured by echo <18 mm or > the largest
annulus size for which a TAVR device is available (eg, 29 mm for the largest Medtronic CoreValve).
• HOCM. LVEF < 20 %.• Severe PAH and RV dysfunction.• Renal insufficiency (eg, creatinine >3.0 mg/dL) and/or ESRD• MRI confirmed CVA or TIA within six months (180 days) of the procedure.• Estimated life expectancy <12 months due to noncardiac comorbid
conditions.• Severe MR• Thoracic or abdominal aortic aneurysm (luminal diameter ≥5 cm), marked
tortuosity (hyperacute bend), Aortic arch atheroma (especially if >5 mm thick, protruding, or ulcerated) ,Narrowing (especially with calcification and surface irregularities) of the abdominal or thoracic aorta ,
![Page 43: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/43.jpg)
Case scenario 1
A 50 yr old male,hypertensive since 15 yrs ,came with complaints of SOB on exertion.class III NYHA.
• On examination his pulse – 68/min, normal volume,regular ,BP 160/100 mm Hg,CVS – apex in 5th ICS left side,heaving ,S1 ,S2 normal an ESM 4/6 at right 2nd ICS heard.
• ECG- LV strain• ECHO – aortic valve calcified, valve area 1.0 cm2,AJV – 3.6m/sec ,
mean gradient 38 mm Hg, LVEF – 45%,grade I LVDD,conc LVH.
• What is the diagnosis?• What would be the next investigation in management of patient?• Finally will he be posted for surgery or not ,how, why?
![Page 44: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/44.jpg)
• Severe Asymptomatic aortic stenosis with LV dysfunction(StageC2)
• Dobutamine stress echo• See for contractile reserve• Even if reserve absent ,Take him for surgery• Benefit is present.
![Page 45: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/45.jpg)
Case 2 A 38 yr old male,labourer by occupation,k/c/o RHD on regular
penicillin prophylaxis was evaluated by echo on routine follow up.
• His echo showed thickened mitral valve,no MS.• Aortic valve tricuspid,thickened,calcified• Aortic valve area 0.9cm2 • AJV – 4.5m/sec,MPG – 81mmHg.• LVEF - 50%,grade I LVDD.
• What is the stage of VHD?• Plan of management?
![Page 46: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/46.jpg)
• Asymptomatic severe AS (C1)• Exercise stress test• Look for symptoms,exercise tolerance• If present,decreased exercise tolerance • Take him for surgery.
![Page 47: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/47.jpg)
Case 3
A 65 yr old male,hypertensive, having prostatic carcinoma been referred to cardiologist for evaluation of cardiac status.
• On evaluation ,he had aortic valve calcified,valve area 0.8cm2,AJV – 5.4m/sec, MPG – 116 mm Hg.
• LVH present.• LVEF -40%• Grade II LVDD
• What would be the plan of management?• Should he be posted for surgery or VHD corrected ?• If so ,why?
![Page 48: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/48.jpg)
• He would have high surgical risk• He should be taken for TAVI.
![Page 49: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/49.jpg)
Case 4 A 60 yr old male,hypertensive,diabetic,with diabetic
neuropathy culminating in lower limb loss was referred to cardiologist for evaluation of cardiac function.
• h/o CVA rt hemiparesis in the past.• Mitral annular calcification present• Aortic valve calcified,• AJV – 4.2 m/sec, mean gradient – 48 mm Hg, AVA -0.8 cm2,
• What would be the plan of management?
![Page 50: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/50.jpg)
• He would not be benefited by surgery• Increased risk of mortality,morbidity as there are other
organ system compromise• Medical management
![Page 51: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/51.jpg)
AORTIC REGURGITATION
![Page 52: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/52.jpg)
![Page 53: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/53.jpg)
Stage D AR
![Page 54: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/54.jpg)
INDICATION CLASS RECOMMENDATION
ECHO I B Pts with symptoms of AR ,cause,severity,LV size , function, intervention timing.
I B In pts with dilated aortic sinuses,asc aorta for presence, severity of AR.
I B CMR - moderate to severe AR.
Medical therapy I B HTN (SBP > 140 mmHg) in pts with chronic AR ---- CCB,ACEI./ARBS
II a B Medical therapy with ACEI/ARBs ,BB in pts with LVD when surgery not performed.
![Page 55: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/55.jpg)
Vasodilator therapy in AR• Effective in reducing SBP in patients with chronic AR.• Improve hemodynamic abnormalities,forward flow.
Donot alter the natural h/o of asymptomatic pts with chronic severe AR and normal LV function..
DRUG REFERENCE
Nifedipine Fioretti et al.,Am J Cardiol;1982:49:1728-32
Felodipine Sondergard L et al .,Am Heart Journal 2000;139:667-74
Enalapril vs Hydralazine J Am Coll Cardiol.1994:24:1046-53
Hydralazine Circulation.1980:62:48-55
Nifedipine JACC,1984;4;902-7.
Nifedipine vs Captopril JACC 1993
![Page 56: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/56.jpg)
VASODILATOR THERAPY
REGURGITANT LESIONS
CHRONIC
AORTIC REGURGITATION
Treatment of hypertension (SBP>140
mmHg ) for chronic stage (Band C)with
CCBs /ACEI/ARBs
CLASS I B
Medical therapy with ACEI/ARBs in pts with severe AR and
LV dysfunction when surgery is not
performed because of comorbidities
CLASS II a B
MITRAL
Vasodilator therapy is useful to improve
hemodynamic compensation in Acute
MR
Vasodilator therapy in symptomatic pts with chronic primary MR
LVEF< 60%,in whom surgery is not preferred
Class II aB
C/ I in
asymptomatic
patients
STENOTIC LESIONS
AORTIC STENOSIS
Reasonable if used with hemodynamic monittoring in acute management of pts with severe decompensated
AS (Stage D)NYHA CLASS IV symtpoms
II b C
![Page 57: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/57.jpg)
![Page 58: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/58.jpg)
![Page 59: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/59.jpg)
BICUSPID AORTIC VALVE
![Page 60: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/60.jpg)
INDICATION CLASS RECOMMENDATION
ECHO I B Pts with bicuspid AV ,to know severity of AS/AR,shape , diameter of aortic sinuses, ascending aorta.
MRI/CT angio I B MRI,CT angio when the above cannot be assessed by echocardiography.
I B Serial evaluation is needed in BAV, aortic diameter >4.0 cm ,frequency determined by progression of dilation(annually if >4.5 cm).
Medical therapy
No proven therapies.(previously B Blockers,ARBs)
Intervention I B If diameter of aortic sinuses or Asc aorta >5.5 cm.
II a B If diameter of aortic sinuses or asc. Aorta >5.0 cm,risk for dissection present (family h/o)rate being 0.5cm/year.
IIa B Replacement of Asc aorta if pts having severe AS/AR when Asc aorta >4.5 cm
N
![Page 61: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/61.jpg)
• Incidence of aortic dilation is higher in patients with fusion of
right or left and the non coronary cusps than the more common
phenotype of fusion of the right and left non coronary cusps.
(68% vs 40% ).
• Report of a patient with BAV – aortic measurements at the aortic
annulus,sinuses,sinotubular junction and mid –ascending aorta.
• Aortic diameters by MRI/CT typically are 1 mm to 2mm larger
than by 2d echo – inclusion of aortic wall in measurement.
• 20-30% of pts with BAV ,other family members also have
bicuspid aortic valve /aortopathy –specific gene not been
identified, patterns of inheritance variable.
![Page 62: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/62.jpg)
• Mean rate of diameter progression was 0.5 mm/yr at the sinuses of
valsalva,0.5 mm/yr at the sinotubular junction,0.9 mm/yr at the
proximal ascending aorta.
• Previous guidelines recommended surgery when diameter >5.0cm at
any level.
• Surgery is recommended presently if diameter is 5.1-5.5 cm only if
there is a family h/o aortic dissection or rapid progression of
dilation(>0.5cm/yr). (in all others >5.5 cm).
• Does not recommend the application of formulas to adjust diameter
to body size.
• Replacement of sinuses of valsalva when considering asc aorta
replacement, is not necessary in all cases (pts with BAV and AS/AR).
![Page 63: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/63.jpg)
Bicuspid Aortic Valve M Mode Echo
NORMAL – 1.0 -1.5BAV – 1.5-5.6
![Page 64: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/64.jpg)
MITRAL STENOSIS
![Page 65: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/65.jpg)
![Page 66: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/66.jpg)
INDICATION CLASS RECOMMENDATION
ECHO I B Diagnosis, quantify hemodynamic severity , assess concomitant valvular lesions, and demonstrate valve morphology.
I B Assess the presence or absence of left atrial thrombus and to further evaluate the severity of MR.
I C Evaluate the response of the mean mitral gradient and pulmonary artery pressure in patients with MS when there is a discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs.
Medical therapy
I B Anticoagulation MS with AF,MS with prior embolic event .,MS and left atrial thrombus
II a C Heart rate control can be beneficial in patients with MS and AF and fast ventricular response.
II b B Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise
![Page 67: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/67.jpg)
• Definition of severe MS is based on the severity at which
symptoms occur as well as the severity at which intervention will
improve symptoms.(MVA <1.5cm2 is considered severe).
• Transmitral gradient of >5-10 mm Hg at normal heart rate.
• DPHT is dependent not only on mitral obstruction,also on
compliance of LA,LV.
• Doppler hemodynamics (apical 4 C view)- peak and mean TVG
–averaged from 3-5 beats in SR,5-10 in AF.
• Heart rate should always to be included in the report.
• RVSP >60-70mm Hg on exercise.
![Page 68: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/68.jpg)
• 30-40% pts with MS will develop AF.
• A reduction in the diastolic interval from 604 milliseconds to
219 msec as heart rate increased from 60-120 bpm,indicating a
63% reduction in total diastolic time.for maintaining same
cardiac output a 38% increase in mean flow rate during
diastole ,which by bernoulli equation ,requires an increase in
mean mitral gradient by 90%.
• Moderate to severe MS – 0.09cm2/yr.
•
![Page 69: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/69.jpg)
Congenital MS
• Usually takes the form of a parachute mitral valve(mitral chordae are attached to a single or dominant papillary muscle
Form a component of shone complex
Includes• Supramitral rings• Valvular or subvalvular AS• Aortic coarctation
![Page 70: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/70.jpg)
![Page 71: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/71.jpg)
![Page 72: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/72.jpg)
![Page 73: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/73.jpg)
MITRAL REGURGITATION
![Page 74: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/74.jpg)
MITRAL REGURGITATION
PRIMARY
ACUTE CHRONIC
SECONDARY
CHRONIC
![Page 75: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/75.jpg)
Why does murmur of acute MR not holosystolic
• The rapid systolic rise in LA pressure with a concomitant fall in LV systolic pressure limits the pressure gradient driving MR to early systole. – short and unimpressive MR.
• Torrential MR – no murmur – rapid equalisation of LA and LV pressures.
• Vasodilator therapy • IABP –by lowering systolic aortic pressure,decreases LV
afterload,increases forward output• Increases diastolic mean aortic pressure –systemic circulation• Chordae tendinae –repair
![Page 76: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/76.jpg)
![Page 77: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/77.jpg)
![Page 78: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/78.jpg)
TTE I B LV size and function, RV function and left atrial size,PAP, severity of primary MR (stages A to D)
CMR I B Assess LV and RV volumes, function, or MR severity when not satisfactorily addressed by TTE
TEE I B Establish the anatomic basis for chronic primary MR (stages Cand D) and to guide repair
I C When noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of LV function.
EST II a B
Exercise hemodynamics reasonable in symptomatic patients with chronic primary MR ,in discrepancy between symptoms and the severity of MR at rest
II a C
Exercise treadmill testing can be useful in patients with chronic primary MR to establish symptom status and exercise tolerance
RX II a B
Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR (stage D) and LVEF less than 60% in whom surgery is not contemplated.
III B Vasodilator therapy is not indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function
![Page 79: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/79.jpg)
![Page 80: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/80.jpg)
![Page 81: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/81.jpg)
![Page 82: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/82.jpg)
![Page 83: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/83.jpg)
![Page 84: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/84.jpg)
![Page 85: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/85.jpg)
Mitra clip
MITRACLIP VIDEO
Described by Alfieri Originally for MR with MVPEVEREST II trial
![Page 86: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/86.jpg)
![Page 87: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/87.jpg)
![Page 88: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/88.jpg)
TRICUSPID VALVE DISEASE
![Page 89: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/89.jpg)
![Page 90: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/90.jpg)
![Page 91: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/91.jpg)
![Page 92: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/92.jpg)
![Page 93: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/93.jpg)
![Page 94: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/94.jpg)
TTE I C
PAP ,PVR invasive I C
CMR ,3D echo IIb C
Exercise testing IIb C
diuretics IIa C
Reduce PAP (functional TR) IIb C
![Page 95: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/95.jpg)
![Page 96: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/96.jpg)
![Page 97: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/97.jpg)
CLASS RECOMMENDATION
TTE I C Assess the anatomy,evaluate severity,associated regurgitation,left sided valve disease
Invasive hemodynamics
II b C Symptoms and noninvasive data are discordant
Medical therapy Loop diruetics
Intervention I C Severe TS at the time of operation for left sided valve disease
I C Isolated symptomatic severeTS
II b C PBTV in absence of TR
![Page 98: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/98.jpg)
PULMONIC VALVE DISEASE
![Page 99: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/99.jpg)
![Page 100: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/100.jpg)
![Page 101: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/101.jpg)
• ..\Documents\Transcutaneous Pulmonary Valve implantation.mp4
![Page 102: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/102.jpg)
PROSTHETIC VALVE DISEASE
![Page 103: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/103.jpg)
![Page 104: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/104.jpg)
CLASS RECOMMENDATIONS
TTE I B Evaluation of valve hemodynamics after implantation(6 weeks to 3 months)
Repeat TTE I C change in symptoms
TEE I C Prosthetic valve dysfuncton(accurate for mitral valve dysfunction)
Annual TTE II a C Bioprosthetic valves after the first 10 years
![Page 105: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/105.jpg)
![Page 106: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/106.jpg)
PROSTHETIC VALVE DYSFUNCTION
BIOPROSTHETIC VALVE
DYSFUNCTION
INSIDIOUS ONSET
Exterional dyspnea,
Louder systolic murmur
New diastolic murmur
ABRUPT ONSET
Valve endocarditis
Degenerative rupture of a valve cusp
MECHANICAL VALVE
DYSFUNCTION
Present with HF symptoms
Systemic thromboembolism
Hemolysis
Often acute/subacute
Acute or chronic paravalvular
regurgitation –IE,suture
dehiscence
![Page 107: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/107.jpg)
Earlier evaluation may be prudent in selected patients at risk of early bioprosthetic valve degeneration –
• Renal impairement• Diabetes mellitus• Abnormal calcium metabolism• Systemic inflammatory disease• Patients <60 yrs of age.
• Patients are usually asymptomatic until valve dysfunction is severe.
Rahimtoola et al,J Am Coll Cardiol.2010;55:2413-26
Kappetein et al,J Thorac Cardiovasc Surg,2009;137:881-5
![Page 108: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/108.jpg)
IIa C
65 yrs
![Page 109: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/109.jpg)
• Patient – prosthetic mismatch. • Aortic annular enlarging procedures.• Risk of need for reoperation with a bioprosthetic valve is
inversely related to the patient’s age at the time of implantation.
20 yrs of age at the time of implantation
70 yrs of age at time of implantation
90%
10%
Rate of structural deterioration 15-20 yrs after implantation
Pibarot et al,Circulation 2009;119:1034-48Pibarot et al,Circulation2006;92:1022-29
![Page 110: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/110.jpg)
Bioprosthetic valve vs Mechanical valve
• Prospective randomized study , 1977 and 1982• 575 pts • Older generation mechanical vs bioprosthetic valve
replacement (Bjork-Shiley spherical disc mechanical prosthesis or a Hancock porcine bioprosthetic valve).
• Overall survival was similar at 15 yrs in both groups.PRIMARY
VALVE FAILURE
BIOPROSTHETIC VALVE
MECHANICAL VALVE
P VALUE
AGE <65 yrs
AVR 26% 0% 0.0001
MVR 44% 4 %
VETERANS AFFAIRS randomized trial. J Am Coll Cardiol2000;36:1152-8.
![Page 111: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/111.jpg)
50 yrs40 yrs
30 yrs20 yrs
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
40%
55%
75%
90%
structural deterioration and reoperation
Age at the time of implantation and primary structural deterioration in
BIOPROSTHETIC VALVE IMPLANTATION
RahimtoolaSH et al ,J Am Coll Cardiol .2010;55:2413-26
![Page 112: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/112.jpg)
Edinburgh Heart Valve Study
• Outcomes are similar with implantation of either a bioprosthetic or mechanical valve for patients between 60 -70 yrs of age.
• 533 pts • Mean age 54.4 +/-10.4 yrs.• Bjork Shiley mechanical prosthesis or a porcine prosthesis• No difference in long term survival(p=0.39)
Wheatley DJ et al,Heart 2003;89:715-21
![Page 113: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/113.jpg)
Italian study
• 310 pts• 55-70 yrs of age • No difference in overall survival at 13 yrs • Thromboembolism,bleeding,IE,and major adverse prosthesis
related events were no different between the two valve types.
• Valve failures (p= 0.0001) ,reoperations were more frequent in the bioprosthetic group (p=0.0003)
Banbury MK,et al Long-term results of the Carpentier-Edwards pericardial aortic valvee: a 12 year follow-up. Ann Thorac Surg 1998;66Suppl:73– 6.
![Page 114: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/114.jpg)
Society for Cardiothoracic Surgery in the Great Britain and Ireland
National Database
• 2004-2009,Bioprosthesis at the time of valve replacement• 41,227 pts
60-65 yrs 65-70 yrs >70 yrs0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
37%
62%
87%
55%
78%
96%
initialfinal
Dunning et al,J Thorac Cardiovascular Surg 2011;142:776-82
![Page 115: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/115.jpg)
Ross procedure
Replacement of the aortic valve with a pulmonary autograft,
Replacing the pulmonary valve with a homograft.• Requires an experienced surgical team
Failure is most often due to regurgitation of the pulmonary autograft (the neoaortic valve ) in the second decade after the operation.
• Regurgitation is typically due to• leaflet prolapse ( if implanted in the subcoronary position )• Aortic sinus dilation (if implanted starting at the aortic sinuses)
• Placing the pulmonary valve within a dacron conduit.• Neoaortic valve in subcoronary position with a reinforced native
aorta.
![Page 116: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/116.jpg)
ANTITHROMBOTIC THERAPY FOR PROSTHETIC VALVES
![Page 117: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/117.jpg)
Anticoagulation with a VKA and INR monitoring is recommended in pts with a mechanical prosthetic valve
CLASS I A
Anticoagulation with VKA to achieve INR 2.5 is recommended in mechanical AVR ,no riskfactors for thromboembolism
CLASS I B
VKA ,INR -3.0 in pts with mechanical AVR ,additional risk factors for thromboembolism,older generation mechanical AVR
CLASS I B
VKA,INR -3.0 in mitral mechanical valve pts CLASS I B
Aspirin 75-100 mg in addition to VKA in mechanical prosthesis pts CLASS I A
Aspirin 75-100 mg in all pts with bioprosthetic aortic or mitral valve CLASS II a B
Anticoagulation with VKA – INR 2.5 reasonable in bioprosthetic MVR or repair ,first 3 months
CLASS II a C
Anticoagulation with VKA – INR 2.5 reasonable after bioprosthetic AVR
CLASS II b B
Clopidogrel 75 mg daily may be reasonable for first 6 months after TAVR in addition to life long aspirin 75-100mg daily
CLASS II b C
Anticoagulation with oral direct thrombin inhibitors or anti Xa agents should not be used in mechanical prosthesis patients
CLASS IIIHARMIII HARM
B
![Page 118: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/118.jpg)
Strive to attain the single INR value.
• It is preferable to specify a single INR target in each patient,
recognizing that the acceptable range is 0.5 INR units on each
side of this target, this is preferable because it avoids patients
having INR values consistently near the upper or lower edge of
the range.
• Fluctuations in INR are assosciated with increased incidence of
complications in pts with prosthetic valves.
![Page 119: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/119.jpg)
Mechanical valves
Thrombogenecity of prosthetic material
intravascularly
Zones of low flow
Platelet activation
Areas of high shear stress
Effects of mechanical valve
Valve thrombosisEmbolic events
![Page 120: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/120.jpg)
• Rate of thromboembolism in patients with bileaflet mechanical AVR on VKA and antiplatelet regimen in 0.53% per patient year over the INR range of 2.0 -4.5.
LOWERING –IT trial ,Am H J 2010;160:171-8
Adverse events increased if INR was >4.0.• New generation AVR ,without other risk factors for thromboembolism
, risk of thromboembolism was similar,
risk of hemorrhage is lower in group with an INR of 2.0 -3.0 vs INR 3.0- 4.5(p<0.01) Chest 2005;127:53-9.
• INR 1.5-2.5 vs INR 2.0 -3.0 – noninferior ,quality of evidence was low.
AREVA trial ,Circulation,1996;94:2107-12
• Preferred INR is 2.5 – bileaflet and single tilting disc in aortic position (low thromboembolic risk pts)
![Page 121: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/121.jpg)
Preferred target INR
CONDITION INR RANGE
AVR bileaflet ,current generation single tilting disc (Medtronic hall)
2.5 2.0 -3.0
Additional risk factors for thromboembolism (AF,LVD,prev.TE,hypercoagulability)
3.0 2.5-3.5
Ball in cage valve (Starr Edwards valve) 3.0 2.5-3.5
MVR All types of mechanical valves 3.0 2.5-3.5
![Page 122: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/122.jpg)
GELIA trial
G erman Experience with Low Intensity Anticoagulation • Mechanical mitral prosthesis (St Jude Medical valve)• Low INR (2.0 -3.5) was assosciated with lower survival rates
than a higher target INR range (2.5-4.5) in those with a mechanical valve.
• Patient compliance is challenging with higher INR goals
INR WITHIN RANGE
2.0 -3.5 74.5%
3.0 -4.5 44.5%
CHEST ,2005:127:53-9.
![Page 123: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/123.jpg)
Role of Aspirin• Aspirin is recommended in all patients with prosthetic heart
valves (incl. mechanical valves with VKA therapy)• Risk of thromboembolism with VKA – 1 -2%/yr.
EVENTS VKA VKA plus aspirin p value
Major embolism/death
8.5% 1.9% < 0.001
Stroke rate 4.2% 1.3% <0.027
Overall mortality 7.4% 2.8% <0.01
Risk of minor bleeding (epistaxis,bruising)
increased
Major bleeding 6.6% 8.5% 0.43
LIWACAP study ,Clin Appl Thrombo hemostst 2007;13:241-8.
![Page 124: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/124.jpg)
The risk of GI irritation and hemorrhage with Aspirin
is
dose dependent over the range of 100mg-1,000 mg /day,
but the antiplatelet effects
are
independent of dose over this range.
LIWACAP study;Clin Appl Thromb Hemost.2007;13:241-8
![Page 125: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/125.jpg)
• Risk of clinical thromboembolism –average 0.7%/yr in pts with biological valves in sinus rhythm.
• Mitral > Aortic (2.4% vs 1.9%)
• St JUDE MEDICAL EPIC heart valve bioprosthesis(AVR)• Incidence of thromboembolic events,bleeding,death was
similar between those who received aspirin or warfarin.
• No studies examining the long term effects of antiplatelet agents in patients with bioprosthetic MVR or mitral valve repair.
WoA epic pilot trial.J Heart Valve Disease 2007;16:667-71
![Page 126: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/126.jpg)
Risk of stroke after all types of mitral valve surgery
30 days 180 days 5 years0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
2%
3%
8%
% stroke
Eur J Thoracic Surg1995;615-9
![Page 127: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/127.jpg)
Risk of ischemic strokeSurgery Within 30 days at 5 yrs P value
Mitral valve repair 1.5% 6.1% 0.9% <0.0001
Bioprosthetic 4.6% 8.0% 2.1%
Mechanical 1.3% 16.1%2.7% <0.001
Anticoagulation with a VKA in bioprosthetic AVR
Anticoagulation with an INR target of 2.5 may be reasonable for atleast 3 months and perhaps as long as 6 months after bioprosthetic AVR
Not treated with VKA Treated with VKA
Strokes per 100 person years
7.00 2.69
CV event rate at 6 months
6.50 2.08
![Page 128: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/128.jpg)
Antiplatelet therapy after TAVR
• Small prospective RCT• Single center study• 79 pts with self expanding TAVR
Clopidogrel +Aspirin
Aspirin P value
Events at 30 days 13% 15% 0.71
6 months 18% 15% 0.85
![Page 129: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/129.jpg)
RE ALIGN trial
• Randomized ,Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients after Heart Valve Replacement
• Stopped prematurely for excessive thrombotic complications in dabigatran arm.
• 252 pts
DABIGATRAN WARFARIN
Ischemic stroke 9 pts (5%) nil
Composite end point of stroke,TIA,systemic embolism,MI
15 pts (9%) 4 pts (5%)
Major bleeding episode 7 pts( 4%) 2 pts (2%)
Bleeding of any type 45 pts (27%) 10 pts (12%)
Am Heart J,2012;163:931-7.
![Page 130: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/130.jpg)
![Page 131: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/131.jpg)
![Page 132: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/132.jpg)
Bridging therapy for prosthetic valves Medical therapy
VKA anticoagulation with INR in range in pts with mechanical valves.
I C Minor procedures (dental extractions ,cataract surgery,surgeries on skin,dental caries)
Temporary interruption in VKA anticoagulation,INR being subtherapeutic,without bridging in bileaflet mechanical AVR
I C Invasive or surgical procedureINR <1.5 (stop warfarin 2-4 days before procedure)
Bridging anticoagulationMechanical AVR + thrombotic risk factor, older generation AVR, tricuspid valve,mechanical MVR
I C Invasive or surgical procedure
FFP or IV prothrombin complex
II a C Emergency noncardiac surgery
![Page 133: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/133.jpg)
BRIDGING THERAPY
• Usually UFH ,or SC LMWH used• Stop warfarin 2-4 days before surgery (INR<1.5),start 24
hrs after surgery.• Start IV UFH (48 hrs before surgery )and stopped 4-6 hrs
(IVUFH)or 12 hrs (for SC LMWH )before the procedure.
![Page 134: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/134.jpg)
• For procedures with a low bleeding risk,such as coronary
angiography from the radial approach,only slight
modification in VKA dosing is needed.
• With interventional procedures at higher risk,many prefer to
stop VKA anticoagulation and use bridging therapy as is
done for other surgical procedures.
ACCP ,Evidence based guidelines for thrombotic management,CHEST april 2012
![Page 135: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/135.jpg)
Excessive anticoagualtion and serious bleeding
• INR >5.0 –risk of hemorrhage.• Rapid decrease in INR below therapuetic range – risk of
thromboembolism.• High dose vitamin K not given routinely,creates a
hypercoagulable condition.• 5-10 INR ,withold VKA,serial INR• INR>10 ,not bleeding – 1-2.5 mg oral vitamin K1
(phytonadione) in addition to witholding VKA therapy.• Emergency conditions –FFP,prothrombin complex –
CLASS IIaB
![Page 136: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/136.jpg)
THROMBOEMBOLIC EVENTS
• Mechanical valve 1-2%• Bioprosthetic valve 0.7%• Embolic events do occur even when in therapeutic range.• AVR 2.5• AVR+RISK FACTORS
(AF,previous TE, hypercoagulable condition ,older gen ,LVSD,
>1 mechanical valve ) 3.0• MVR 3.0
• Time in therapuetic range is only 60-70%• Increase INR 2.53.0 in AVR,
3.0 4.0 in MVR
![Page 137: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/137.jpg)
Management
• Optimal anticoagulation
• Antiplatelet therapy.
• Improve patient compliance
• Surgical intervention is rarely needed.
• Replacement of prosthetic valve –
stenosed/regurgitation/degenerated.
![Page 138: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/138.jpg)
![Page 139: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/139.jpg)
PROSTHETIC VALVE THROMBOSIS
• Mechanical PVT – prevalence is 0.3% to 1.3% per pt yr in developed
countries.
• 6.1% per patient year in developing countries.
• TEE more sensitive for detection of valve thrombosis, mitral valve.
• Prior history of stroke,thrombosis area by TEE are independent
predictors of complications after thrombolysis.
• A thrombus area <0.8cm2 – lower risk of complications from
thrombolysis irrespective of NYHA classification.
• Fluoroscopy,CT imaging for prosthetic aortic valves.
![Page 140: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/140.jpg)
RECOMMENDATIONS
CLASS II a B Fibrinolytic therapy is reasonable for patients with a thrombosed left sided prosthetic heart valve ,recent onset (<14 days) of NYHA class I –II symptoms and a small thrombus <0.8cm2
CLASS II a B Fibrinolytic therapy is reasonable for right sided prosthetic heart valves
CLASS I B Emergency surgery is recommended in pts with a thrombosed left sided prosthetic heart valve with NYHA III-IV symptoms
CLASS IIa B Emergency surgery is reasonable for patients with a thrombosed left sided prosthetic heart valve with a mobile or large thrombus >0.8cm2
![Page 141: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/141.jpg)
Factors that predict adverse outcomes from fibrinolytic therapy
• Active internal bleeding• History of hemorrhagic stroke• Recent cranial trauma/neoplasm• Diabetic hemorrhagic retinopathy• Large thrombi• Mobile thrombi• Systemic hypertension (>200/120 mm Hg)• Hypotension/shock• NYHA III/IV
![Page 142: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/142.jpg)
• Fibrinolytic therapy of a left sided obstructed prosthetic valve is
assosciated with an overall rate of thromboembolism and
bleeding of 17.8%,the degree of risk is directly proportional
to thrombus size.
• A mobile thrombus or a length of >5 -10 mm – increased
embolic risk.
• >1.0 cm or 0.8cm2 area – 2.4 fold increase in embolism risk per
1.0cm2 increase in size.
![Page 143: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/143.jpg)
Fibrinolytic agent
rTPA 10 mg IV bolus – 90 mg infused IV over 2 hours.Heparin,GPIIb/IIIa held,aspirin continued
20 mg IV bolus – 10 mg per hour for 3 hours
STREPTOKINASE 5,00,000 IU in 20 minutes – 15,00,000 IU over 10 hours.i.e.,1,50,000 U/hr
UROKINASE Less effective
If fibrinolytic therapy is successful ,it is followed by IV UFH
until VKA achieves an INR of 3.0 -4.0 for aortic prosthetic
valves and 3.5-4.5 for mitral prosthetic valves
J Am Coll Cardiol 1997;30:1521-6
![Page 144: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/144.jpg)
Surgery vs fibrinolytic therapy in patients with left sided PHVT
• Success rate - 90% with surgery.
70%.-fibrinolytic therapy
No difference in mortality between two groups.
SURGERY FIBRINOLYTIC THERAPY
THROMBOEMBOLISM 1.6% 16%
MAJOR BLEEDING 1.4% 5%
RECURRENT PVT 7.1% 25.4%
RESTORING NORMAL VALVE FUNCTION
90% 70%
Karthikeyan et al,Eur Heart Journal,2013:34:1557-66
![Page 145: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/145.jpg)
• Mortality rate was 17.6% pts with NYHA class IV, 4.7% in pts with NYHA class I –III.
• Mortality was similar for removing the thrombus or replacing the entire prosthetic valve.
• In pts with recent hemorrhagic stroke,surgery is a better option.
Guidelines for management of left sided prosthetic valve thrombosis,JACC,1997;30:1521-6
![Page 146: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/146.jpg)
PROSTHETIC VALVE STENOSIS
• Mechanical valve - chronic thrombus or pannus• Bioprosthetic valve ----- leaflet fibrosis ,calcification• Patient –prosthesis mismatch – prosthesis functions normally.
Indexed effective orifice area <0.85cm2 for AV prosthesis.
Severe patient –prosthesis mismatch - <0.65cm2/m2
Detrimental in pts with low LVEF.
Can be avoided by adequate indexed orifice area (pts body size,annular dimension)
• No medical therapy for prevention• Valve in valve approach.(not fully validated)• For mechanical valve – consider bioprosthetic valve at reoperation,if
noncompliant is the cause
![Page 147: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/147.jpg)
![Page 148: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/148.jpg)
PROSTHETIC VALVE REGURGITATION
• TEE –clear images of the LA side of mitral prosthesis,delineation,severity of paravalvular MR.
• No medical therapies.• Intractable hemolysis or HF due to severe mechanical
Prosthetic/paraprosthetic valve regurgitation - surgery indicated (I B)
• Severe symptomatic or asymptomatic bioprosthetic regurgitation – (II a C)
• Catheter based approaches in high risk for surgery -II a B
Success -80-85%
Complications -9%
Procedural death <2%
![Page 149: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/149.jpg)
INFECTIVE ENDOCARDITIS
![Page 150: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/150.jpg)
• In hospital mortality rate - 15-20%
• 1 yr mortality rate - 40%
• Overall incidence of IE – 3-10/100,000 pt –yrs
• Higher prevalence in older patients.
• IE associated with prosthetic,intracardiac – 50 times more
compared to general population.
![Page 151: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/151.jpg)
![Page 152: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/152.jpg)
![Page 153: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/153.jpg)
![Page 154: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/154.jpg)
Class I C At least 2 sets of blood culture should be obtained in patients at risk of IE ,who have unexplained fever for more than 48 hours,pts with a new diagnosis of left sided valve regurgitation
Class I B Modified duke criteria for evaluation of pt with suspected IE.
Class I B Intraoperative TEE in pts undergoing valve surgery for IE
Class II a B TEE to diagnose IE in pts with Staph.aureus bacteremia without a known source.
Class II a B TEE in pts with prosthetic valve ,fever ,no murmur,no bacteremia
Class II a B Cardiac CT when echo not conclusive
Class II a B Temporarily discontinue anticoagulation in pts with IE who develop CNS compatible with embolism/stroke regardless of indications for anticoagulation
Class I B Early surgery in pts with HF
Class I B Early surgery n left sided IE by S.aureus,fungal
Class I B Early surgery if there is heart block,annular or aortic abscess
Class IB Early surgery if persistent fever >5-7 days despite antibiotics
![Page 155: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/155.jpg)
• In patients with chronic (subacute ) – 3 sets of blood culture.
• Blood cultures are positive 90% of pts with IE.• 10% - serology.• 3/4ths of pts with IE are diagnosed within 30 days of onset
of infection- classic features are absent.
![Page 156: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/156.jpg)
In hospital mortality 15-20%
1 yr mortality rate 40%
Stroke 16.9%
Embolization other than stroke 22.6%
HF 32.3%
Intracardiac abscess 14.4%
Need for surgical therapy 48.2%
Arch Internal Med2009;169:463-73.
NVE PVE
TTE sensitivity 50-90% 36-69%
specificity >90%
TEE sensitivity 90-100% lower
specificity
PPV 90% 90%
![Page 157: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/157.jpg)
TTE TEE
1.Anterior aspect of a prosthetic aortic valve
2.Aortic transvalvular gradient
3.Vegetations and perivalvular complications
4.Active and healed vegetations
5.Thickened valves or valvular nodules and vegetations
differentiation
Most vegetations 83.8% remain constant in size under therapy and this does not worsen prognosis
Right sided pacemaker leads IE – intracardiac echo
![Page 158: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/158.jpg)
![Page 159: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/159.jpg)
![Page 160: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/160.jpg)
S.Aureus
bacteremia
Neurological complications
30%
Paravalvular cardiac abscesses
30-40%
HF
20-50%Mortality 19%-65%
Systemic embolization
40%
![Page 161: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/161.jpg)
• PVE – less incidence of vegetations(mechanical) ,higher incidence of annular abscess and other paravalvular complications.
• 15-35% of all pts with IE develop clinically evident emboli.(CMR - >30%)
• MC cause of stroke in pts with IE – septic embolus resulting in ischemia –with hemorrhagic transformation later -11 days later also.
• Death may occur suddenly in pts with endocarditis induced HF ,if aortic valve is involved.
![Page 162: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/162.jpg)
ICE –PCS IE pts with HF Rx with surgery Medical Rx
inhospital mortality 21% 45%
1 yr mortality 29.1% 58.4%
In complicated left heart NVE -4 baseline featureshave been independently assosciated with 6 month mortalityAbnormal mental statusModerate –to severe HF Bacterial etiology other than viridansMedical therapy alone
Reinfection is more common in injectable drug users (5-10% pts)Repair better than replacement
![Page 163: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/163.jpg)
PVEEARLY <60 days of surgery Health care acquired
infection - S. aureus
INTERMEDIATE 60-365 days after surgery Health care +community acquired – coagulase
negative staphylococcus
2/3 cases of PVE
LATE >1 yr after surgery Resembles NVE
INJECTABLE DRUG USERS MORTALITY
Staphylococcus <5% *right sided 20-30%*left sided
Enterococcus 15-25%
Pseudomonas aeruginosa
Enterobacteriaciae >50%
![Page 164: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/164.jpg)
Embolism
• 20-40% pts with IE.
• Incidence decreases to 9-21% on antibiotic use
• New embolic event occurs if vegetation >10 mm,anterior mitral
leaflet vegetations.
• Risk of embolism is highest during the first days after initiation
of antibiotic treatment and decreases after 2 weeks.
• Surgical intervention is needed in case of staphylococcal PVE.
![Page 165: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/165.jpg)
PREGNANCY AND
VALVULAR HEART DISEASE
![Page 166: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/166.jpg)
NATIVE VALVE STENOSIS
Medical therapy I C MS WITH AF
II a C Bblockers for rate control in AF(metoprolol)
II b C Diuretics in MS and HF
III ACEI/ARBS not to be given in pts with valve stenosis
Intervention I C Before pregnancy ,Severe symptomatic AS
I C Before pregnancy ,Severe symptomatic MS
I C
IIa B
Before pregnancy ,PBMV in asymptomatic severe MS.
For pregnant pts ,with MS ,in HF despite medical therapy
II a C Before pregnancy ,Severe asymptomatic AS
III Valve operation in absence of HF symptoms
![Page 167: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/167.jpg)
AORTIC STENOSIS MITRAL STENOSIS
MATERNAL MORTALITY RATE
17% uncommon
FETAL,NEONATAL MORTALITY RATE
32% 30%
HF 10-44% 75%
Risk of arrhythmia 25% 75%
increased incidence of HTN emergencies
Valve operation 30-40% fetal mortalityMaternal -9%No ideal time
High pump flows and normothermic perfusion
![Page 168: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/168.jpg)
NATIVE VALVE REGURGITATION
• Symptomatic pts - High risk of HF during pregnancy• Valve repair is ideal.• Threshold to be higher
CLASS I C Valve repair or replacement before pregnancy for symptomatic women with severe valvular regurgitation
CLASS II a C Valve operation for pregnant with severe valvular regurgitation only if there are refractory NYHA class IV HF symptoms
CLASS IIb C Valve repair Before pregnancy may be considered in asymptomatic pts with severe MR
CLASS III Not to be performed in pregnancy in absence of HF symtpoms (NYHA CLASS III/IV)
![Page 169: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/169.jpg)
![Page 170: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/170.jpg)
• Risk of embryopathy is dose dependent • <3% - <5 mg/day• >8% - >5mg/day
![Page 171: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/171.jpg)
CONCOMITANT PROCEDURES
![Page 172: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/172.jpg)
![Page 173: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/173.jpg)
INTERVENTION FOR AF
Class II a C A concomitant MAZE procedure at time of MV repair/replacement for Rx of chronic persistent AF.
Class II a B A full biatrial MAZE procedure
Class II b C Concomitant maze or pulmonary vein isolation in patients with paroxsymal AF with h/o embolism on anticoagulation
Class II b C Concomitant maze or pulmonary vein isolation at time of other cardiac surgeries with paroxysmal AF
Class III Catheter ablation in pts with severe MR in place of combined maze procedure plus mitral repair.
![Page 174: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/174.jpg)
MAZE PROCEDURE
MAZE I - initial incisons deep into the atrial wall,open sternotomy,CP bypass
MAZE II -
MAZE III – cut and sew (1992)
MAZE IV – cryoablative /radiofrequency
"Maze" refers to the series of incisions arranged in a maze -like pattern in the atria. Today, various methods of minimally invasive maze procedures, collectively named mini maze procedures, are used.James Cox in 1987.Mini mazeWolf maze
![Page 175: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/175.jpg)
Non cardiac surgery in HVD• Rate of cardiac complications in undiagnosed severe AS
undergoing noncardiac surgery is 10-30%.• 30 day mortality high for pts with AS 2.1%• HIGH risk of post operative MI in AS pts.• Tachycardia to be avoided in AS. DC shock for conversiob in
acute setting.• CCB s for HTN• Phenylephrine is useful.• High dilution neuraxial local anaesthetic • MS – IV fluids cautious• Regional anaesthesia in AR/MR• Preload to be maintained• 48-72 hrs post op
![Page 176: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/176.jpg)
CLASS IIa B Moderate risk elective noncardiac surgery, asymptomatic severe AS.
CLASS II a C Moderate risk elective noncardiac surgery, asymptomatic severeMR
CLASS II a C Moderate risk elective non cardiac surgery asymtpomatic sevvere AR,normal LVEF
CLASS II b C Moderate risk in pts with asymptomatic severe MS ,not favourable for PBMV
![Page 177: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/177.jpg)
EVIDENCE GAPS AND FUTURE DIRECTIONS
• Vaccine development• At risk of calcific aortic stenosis – therapies to prevent
progression.• Values of measures of LV size,volumes,myocardial structure
immediately after intervention.• TAVI
![Page 178: VHD GUIDELINES 2014](https://reader038.fdocuments.in/reader038/viewer/2022102711/5549d65bb4c9051c778b50a2/html5/thumbnails/178.jpg)