Valvular Heart Disease¶
Jonathan Napper, Marcus Threadcraft
Aortic stenosis¶
Jonathan Napper
Etiology¶
- Degenerative calcification of the aortic cusps
- Congenital bicuspid aortic valve
- Chronic deterioration (calcific)
- Prior rheumatic fever/inflammation
Presentation¶
- Angina, syncope, exertional dyspnea, heart failure (HF carries worse prognosis)
- Typically aged 70 – 80 y/o; if bicuspid aortic valve expect 10-20 yrs earlier
- Physical exam: Systolic crescendo-decrescendo murmur that radiates towards the carotids
- Late peaking murmur, faint or absent S2, or delayed carotid upstroke suggest severe AS
Evaluation¶
- TTE with doppler is test of choice
Severity | Valve Area (cm2) | Mean Gradient (mmHg) | Velocity (m/s) |
Indexed Valve Area (cm2/m2) |
---|---|---|---|---|
Mild | >1.5 | <20 | 2.0-2.9 | >0.85 |
Moderate | 1.0-1.5 | 20-39 | 3.0-3.9 | 0.60-0.85 |
Severe | <1.0 | >40 | >4.0 | <0.6 |
Critical | <0.5 | -- | -- | -- |
AS stages
- A: at risk of AS (those with bicuspid anatomy or calcification
- B: Asymptomatic non-severe AS
- C: asymptomatic AS
- C1: normal EF
- C2: abnormal EF
- This stage might benefit from exercise or stress testing to elicit symptoms
-
D: Symptomatic AS
-
Some with symptomatic AS might not have enough LV reserve to produce high velocities and gradients (ex EF of 10% w/ critical valve area) = low flow/low gradient AS; consider dobutamine to unmask AS
Management¶
- No proven effective medical therapy
- Definitive treatment is valve replacement for:
- Stage D
- Stage C with inducible symptoms on stress testing, low EF, or undergoing other cardiac procedure
- Rapid progression (increase in velocity >0.3m/sec per year)
- Consult cardiac surgery for determination of SAVR vs TAVR
- In general, high risk surgical patients benefit most from TAVR
- At VUMC: If determined to be intermediate to high operative risk by Cardiac Surgery, they will often recommend contacting the TAVR team for evaluation
- Avoid rapid hemodynamic shifts and aggressive changes in preload or afterload
- Aim for normotension
- Avoid preferential vasodilators such as hydralazine or nitroglycerin
- Significant vasodilation may ↓ coronary filling pressures -> myocardial ischemia
Monitoring¶
- Severe AS: TTE q 6-12 months
- Moderate AS: TTE q 1-2 years
- Mild AS: TTE q 3-5 years
Post AVR anticoagulation¶
- All patients will get 3-6 months of AC s/p AVR
- Continued duration based on type of AVR
- Bioprosthetic (TAVR and some SAVRs): antiplatelets alone after Initial AC
- Mechanical: lifelong AC with warfarin only
Aortic Regurgitation¶
Jonathan Napper
Etiology¶
- Primary valve disease (rheumatic disease, bicuspid aortic valve, infective endocarditis, syphilis)
- Primary aortic root disease (medial degeneration, aortic dissection, Marfan’s syndrome, bicuspid aortic valve, syphilis, non-syndromic familial)
Presentation¶
- Acute AR: LV cannot respond to increased volume to maintain stroke volume pulmonary edema and cardiogenic shock
- Chronic AR: indolent presentation, often patient will develop symptoms of heart failure including DoE, orthopnea, PND
- Physical exam: “Water-hammer” pulses, wide pulse pressure, laterally displaced PMI, high pitched “blowing” decrescendo murmur best heard at third intercostal space at left sternal border, S3
Management¶
- Acute severe AR
- Prompt surgical repair
- Vasodilators such as nitroprusside and diuretics can be used to stabilize patient
-
Chronic severe AR
- Medical management
- Early symptoms of exercise intolerance can be treated with diuretics
- Systolic BP should also be controlled with goal SBP \< 140 in chronic AR
-
Repeat imaging should be performed 3-6 month to assess for depressed LVEF or LV dilation
-
Stages of Chronic AR: Ranging from Stage (A): Asymptomatic but “At Risk” AR to Stage (D) Symptomatic Severe AR
- If symptoms are present, automatically Stage D, otherwise Progression through stages is determined by AR Jet Width
- Class I indications for Valve Repair:
- Stage D (Symptomatic) or Stage C (Asymptomatic Severe AR) with LVEF \< 55%, or are undergoing other cardiac surgery
- If LVEF > or equal 55%, patients should be considered for surgery if LV is dilated (LVESD > 50 mm (class IIa) or LVEDD > 65 mm (class IIb))
- Any patient with progressive AR, even if they do not meet criteria for severe AR, should consider valve replacement if undergoing cardiac surgery for other reasons
- Note: TAVI for isolated chronic AR is challenging 2/2 dilation of the aortic annulus and root
Mitral Regurgitation¶
Marcus Threadcraft
Etiology¶
- Primary MR – caused by direct involvement of the valve apparatus (leaflets or chordae tendineae)
- Degenerative/myxomatous mitral valve disease (mitral valve prolapse with flail leaflet, mitral annular calcification, chordal rupture)
- Rheumatic fever
- Infective endocarditis
- Papillary muscle rupture following acute (inferior) MI
- Secondary MR- caused by changes of the LV that lead to valvular incompetence
- Dilated Cardiomyopathy
- HOCM with systolic anterior motion
- Coronary Artery Disease or prior MI leading to papillary muscle tethering
Presentation¶
- Acute MR- sudden onset reduction in forward cardiac flow and left atrial/pulmonary vein volume overload
- Dyspnea with flash pulmonary edema
- Left-sided heart failure
- Chronic MR- progressive symptoms d/t cardiac remodeling to compensate for mitral flow reversal
- Progressively worsening heart failure: dyspnea, orthopnea, PND
- LV dilation from volume overload
- LA remodeling/dilation leading to afib
Auscultation¶
- Holosystolic Murmur
- Best heard at Apex
- Radiation to the Axilla
- Frequently associated with S3
- Murmur may be absent in acute MR due to large regurgitant orifice/low velocity regurgitant jet
- Increases w/ increased preload or afterload
- Pulmonary Rales
Evaluation¶
- CXR: assess for pulmonary edema, r/o other causes of acute dyspnea
- ECG: often non-specific, LVH
- Echocardiography: assess valve apparatus, size, and function of LA/LV, grade severity of MR
Chronic MR stages¶
- A: No symptoms
- B: >mild MR w/o hemodynamic changes or symptoms
- C: Severe MR w/o symptoms
- C1: preserved EF and normal LV size
- C2: reduced EF (\<60%), dilated LV (LVESD > 40mm)
- D: Severe/symptomatic
Management¶
Acute hemodynamically significant MR
- Urgent surgical repair or replacement
- Medical stabilization as a bridge to surgery
- Afterload reduction is key to promote forward flow
- Vasodilators (nitroprusside, nitroglycerin) reduce afterload
- Diuresis to reduce preload and improve pulmonary edema
- IABP placement can be used as mechanical afterload reduction
Chronic severe primary MR
- Surgical repair favored over valve replacement
- Class I:
- Asymptomatic patients w/ LVEF 30-59% or LVESD > or equal 40mm
- Symptomatic patients w/ EF > 30%
- Class II:
- A: asymptomatic patients with progressive EF decline or LV dilation on serial monitoring; or very severe MR
- B: new onset AF
- Secondary MR can consider MV repair with persistent class III-IV symptoms while on guideline directed medical therapy
- In HFrEF, consider MitraClip after volume optimization (see Heart Failure section)
Mitral Stenosis¶
Marcus Threadcraft
Etiology¶
Characterized by thickened mitral valve leaflets and fused leaflet tips.
- Rheumatic Fever (leading cause worldwide)
- Calcification of the mitral valve annulus (common in high income countries)
- Autoimmune Diseases: SLE, Rheumatoid arthritis
Presentation¶
- Progressive symptoms: Asymptomatic Heart Failure
- Orthopnea
- PND
- Hoarseness/Dysphagia (compression of recurrent laryngeal nerve/esophagus by enlarged left atrium from pressure overload)
- Symptoms of Right Heart Failure
- Acute Symptoms may present in settings of increased cardiac output (pregnancy, sepsis, or exercise) or tachyarrhythmias
- Dyspnea
- Fatigue
- Palpitations
Physical exam¶
- Low-pitched rumbling, diastolic Murmur, best heard at apex,
low-pitched, rum
- Loud S1, opening snap after S2
- Prominent P2 if pulmonary HTN develops
- Pulmonary Rales
Evaluation¶
- CXR: LA enlargement, increased pulmonary vasculature
- Echocardiography: thickening of mitral valve leaflets, decreased area of valve leaflets, left atrial enlargement
Management¶
- Varies between rheumatic MS and calcific MS (in general, intervention of calcific MS is very challenging and high risk)
- Severe, symptomatic rheumatic MS:
- Percutaneous mitral balloon commissurotomy (PMBC)
- Surgical repair/replacement if patient failed PMBC or undergoing other cardiac surgery
-
Calcific MS has a poor prognosis with 5-year survival \<50%, Intervention is higher risk and should be reserved for severely symptomatic patients
-
No role for commissurotomy with calcific MS
- Surgical valve replacement may be considered for severely symptomatic patients (technically challenging)
Anti-Coagulation¶
- Anti-coagulation is indicated if:
- Mechanical prosthetic mitral valve
- Warfarin, goal INR 3-4 lifelong
- Bioprosthetic mitral valve replacement
- Warfarin, goal INR 2-3 for first 3-6 months
- Atrial Fibrillation regardless of CHADS2VASC score
- Mechanical prosthetic mitral valve