Valvular Heart Disease: An Update in Management

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Valvular Heart DiseaseAn Update in Management

• Bruce W. Andrus MD
• DHMC Cardiology Symposium
• December 2002

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Learning Objectives

• Locate and review ACC/AHA guidelines
• Review timing of surgery in VHD
• Consider role of medicine in VHD
• Discuss impact of VHD on operative risk
• Revisit endocarditis prophylaxis

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Outline

• Case Presentations (with audience participation)
• Specific Valve Lesions
• Physiologic principles/natural history
• Images
• Guidelines
• Cases Revisited

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Case 1

• JB, a 45 yo contractor, presents with a cc of
  increasing dyspnea over the past 6 months. Able
  to climb stairs, but very tired climbing
  scaffolding. Occ pounding in chest/neck.
• Denies cp, syncope.
• PMH significant only for htn. No rheumatic
  fever, anorexigen use, IE.

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Case 1

• On Exam
• Brawny, mildly overweight, no distress.
• HR 80 regular, BP 160/50.
• Rapidly collapsing pulse, subtle head nodding
• Apical impulse hyperdynamic, diffuse and
  laterally displaced. Diastolic thrill at base.
• Soft S1, soft S2, ejection sound at base
  (diaphragm), S3 at apex (bell), descrescendo
  murmur leaning forward in expiration.

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Case 1

• CXR
• enlarged LV, widened mediastinum.
• Echo
• dilated LV (ESD 57 mm, EDD 80 mm), EF 50.
• bicuspid aortic valve, 4 AR, mildly dilated Asc
  Ao.

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Case 1

• As the next step in management, would you
• A) start beta blocker for htn and repeat echo in
  6 mos
• B) start long acting nifedipine
• C) refer for surgery now
• D) start diuretic and see in 1 month

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Case 2

• MB, a 50 yo woman, native of India, now working
  as a medical technologist in your hospital.
• Makes appt to discuss frequent episodes of
  bronchitis, declining exercise tolerance and
  occasional episodes of hemoptysis.
• PMH neg. for htn, tobacco use, dm, dyslipidemia,
  obesity.

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Case 2

• On exam
• Thin, pleasant woman. Comfortable looking.
• HR 96 irreg, irreg. BP 146/88.
• JVP 7 cm H20. Bibasilar insp crackles.
• Apical impulse not displaced.
• S1 varies in intensity, nl S2. Opening snap
• and diastolic rumble shortly following S2.

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Case 2

• Echo
• Thickened and immobile mitral valve. No
  calcification. Minimal fusion of subvalvular
  apparatus.
• Moderately enlarged LA.
• Doppler evidence of stenosis with estimated
  pressure gradient of 8 m Hg and MVA of 1.7 cm2.

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Case 2

• Which of the following would you do next?
• A) begin asa for stroke prophylaxis
• B) begin warfarin
• C) start metoprolol
• D) B and C
• E) begin Coenzyme Q10

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Case 2

• Which of the following would you next pursue?
• A) closely observe, repeat echo in 6 mos
• B) refer for mitral valve replacement
• C) refer for percutaneous balloon vavuloplasty
• D) schedule for exercise echocardiography

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Case 3

• EA, an 84 yo widow and retired english teacher,
  sees you for vague chest discomfort and a near
  syncopal episode while climbing stairs with
  groceries.
• Longstanding benign murmur.
• PMH htn, mild hyperlipidemia, OA, familial
  tremor. On HCTZ 12.5 mg qD and atenolol 25 mg BID.

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Case 3

• On exam
• thin, elderly woman neatly dressed.
• HR 60. BP 155/76 both arms. BMI 19.
• JVP 11 cm H2O. Carotid upstrokes brisk.
• Fine bibasilar crackles.
• Apical impulse sustained. Thrill at RUSB. Nl S1
  and harsh late peaking sys murmur at RUSB
  obscuring S2. Musical sounding sys murmur at
  apex. Valsalva strain and standing diminish
  murmur. Handgrip increases murmur.

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Case 3

• ECG
• LAD, LA abn, mild IVCD (QRS 110 ms), asymmetric T
  wave inversion in V5 and V6
• Echo
• dilated LA, normal LV chamber size, moderate LVH
• normal LV systolic function
• calcified Ao valve, estimated valve area 0.6 cm2

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Case 3

• How would you manage her?
• A) refer for EP study and possible ICD
• B) begin atorvastatin 80 mg qD
• C) refer for consideration of valvuloplasty
• D) refer for coronary arteriography in
  anticipation of AVR
• E) initiate Hospice referral, palliative care

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Case 4

• RD, a 73 yo retired insurance salesman, sees you
  because a urologist evaluating him for erectile
  dysfunction heard a murmur.
• Denies SOB, chest pain or syncope but is very
  sedentary. Has notice some fatigue and dependent
  edema.
• Diagnosed with MVP 25 yrs ago.

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Case 4

• On exam
• obese, loquacious man with petite wife
• HR 86. BP 170/94. BMI 45.
• JVP 12 cm H2O. Nl carotid upstrokes
• diminished bs, no crackles
• apical impulse not palpable
• Neither S1 or S2 are well heard, obscured by a
  holosystolic blowing murmur at apex and left
  parasternal border

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Case 4

• ECG
• SR, RAD, LA abn, RgtS in V1, NSSTT abn
• CXR
• LA and LV enlargement
• Echo
• severe LA enlargement, mild LV dilatation (ESD
  45mm), nl LVEF (60), pulmonary hypertensio (est
  PASP 55 mmHg)

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Case 4

• How would you manage this gentleman?
• A) begin ACE inhibitor
• B) begin digoxin for inotropic support
• C) refer for exercise echo
• D) refer for consideration of MV repair
• E) A and D

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Case 4

• Does this man need endocarditis prophylaxis for a
  dental extraction?
• A) yes
• B) only if the tooth is infected
• C) only if local anaesthetic will be used
• D) no

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Aortic StenosisPhysiologic Principles-Natural
History

• Normal aortic valve area is 3.0 - 4.0 cm2
• Circulation affected when valve area is reduced
  by 75 (i.e. 0.75 - 1.0 cm2)
• valve area (cm sq) mean gradient (mm Hg)
• Mild gt 1.5 lt 25
• Moderate 1.0 - 1.5 25 - 50
• Severe lt 0.75 gt 50

assumes normal cardiac output
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Aortic StenosisPhysiologic Principles-Natural
History

• Primary adaptation is concentric hypertrophy
• Latent phase usually lasts decades
• Risk of sudden death is very low during this
  phase
• Rate of progression ranges from 0-0.3 cm2/yr.
  (average rate is 0.12 cm2/yr)
• 50 of patients with severe AS do not progress
• Cannot predict who will progress

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Aortic StenosisPhysiologic Principles-Natural
History
Bonow et al. Valvular Guidelines. Circ
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Aortic StenosisPhysiologic Principles-Natural
History

• Once symptoms develop, average survival is 2-3
  yrs
• With LV systolic dysfunction, there may be
  increased risk of sudden death and permanent LV
  dysfunction

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Ross J Jr, Braunwald E Aortic stenosis.
Circulation 38Suppl V61, 1968
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Aortic StenosisManagement Guidelines

• Initial Diagnostic Testing
• Lipids, renal fxn, Ca, P---all patients
• CXR, ECG, Echocardiography---all patients
• Cardiac catheterization with angiography
• If clinical and echo data are discordant
• To assess coronary circulation prior to surgery

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Aortic StenosisManagement Guidelines

• Initial Diagnostic Testing (cont.)
• Treadmill stress testing
• Dangerous in symptomatic pts
• Not useful for dx of CAD
• May be used to assess functional significance of
  severe AS in pts who deny symptoms (e.g. bp
  response)

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Aortic StenosisManagement Guidelines

• Scheduled Follow-up
• office interval echo interval
• Mild AS 12 mos 5 yrs
• Moderate AS 6 mos 2 yrs
• Severe AS 6 mos 1 yr

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Aortic StenosisManagement Guidelines

• Low Gradient AS
• Special case
• Minimal valve mobility and low cardiac output
• Calculated valve area is small but pressure
  gradient is also small
• Functional vs. fixed AS?
• Consider dobutamine stress test (DSE) to clarify

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ACC Classification of Recommendations

• Class I
• Conditions for which there is evidence and/or
  general agreement that a given procedure or
  treatment is useful and effective.
• Class II
• Conditions for which there is conflicting
  evidence and/or a divergence of opinion about the
  usefulness/efficacy of a procedure or treatment.
• IIa. Weight of evidence/opinion is in favor
  of usefulness/efficacy
• IIb. Usefulness/efficacy is less well
  established by evidence/opinion.
• Class III
• Conditions for which there is evidence and/or
  general agreement that the procedure/treatment is
  not useful/effective, and in some cases may be
  harmful.

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Aortic StenosisManagement Guidelines

• Recommendations for AVR
• Class I
• Severe AS and symptoms
• Severe AS (with or without sxs) and need for
  CABG, other valve replacement or aortic surgery
• Class IIa
• Moderate AS and need for other cardiac surgery
• Asymptomatic severe AS and diminished LVEF or
  hypotensive response to exercise

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Aortic StenosisManagement Guidelines

• Recommendations for AVR (cont.)
• Class IIb
• Asymptomatic AS and VT, severe LVH (gt15mm)
• or valve area lt0.6 cm2
• Class III
• Asymptomatic AS with none of the above

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Aortic Regurgitation Physiologic
Principles-Natural History

• LV faces combined pressure and volume load
• Primary adaptation is dilatation (eccentric
  hypertrophy)
• Since this adaptation takes time, AR classified
  as acute or chronic
• Acute AR results in sudden increase in LVEDP gtgtgt
  pulmonary edema and cardiogenic shock

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Aortic Regurgitation Physiologic
Principles-Natural History

• Latent phase of AR, like AS, may last decades
• Decompensation when
• LV systolic function begins to fail
• Progressive LV dilatation occurs
• Spherical geometry develops
• Initially this is reversible
• LV systolic function and ESD are the most
  important predictors of postop survival and LV
  function

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Aortic Regurgitation Physiologic
Principles-Natural History

• In asymptomatic pts with severe AS and nl LV
  systolic function, progression is slow
• 4.3/yr develop symptoms of LV systolic
  dysfunction
• 1.3/yr progress to LV dysfunction without
  symptoms

pooled data from 7 series. 490 pts with mean
follow-up of 6.4 yrs
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Aortic Regurgitation Management Guidelines

• Initial Evaluation
• ECG
• CXR
• Echo
• ETT (if pt asymptomatic but sedentary or if
  symptoms are equivocal)

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Aortic Regurgitation Management Guidelines

• Scheduled Follow-up (office and echo)
• Severe AR without symptoms
• q 4-12 month depending on pace of change and
  current LV ESD/EDD
• Moderate AR without symptoms
• 1st follow-up in 2-3 months to establish pace,
  then q 12 months

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Aortic RegurgitationManagement Guidelines

• Vasodilator Therapy
• Expected to ? afterload, ? stroke volume and
• ? regurgitant volume
• Hemodynamic benefit shown with hydralazine and
  nifedipine, less consistent results with ACEi
• Improvement in clinical outcomes in trial of LA
  nifedipine vs. digoxin (need for AVR in 143 pts
  followed for 6 yrs--- 15 vs 34)
• Dose titrated to achieve ? in SBP, not
  normalization

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Aortic RegurgitationManagement Guidelines

• Vasodilator Therapy Indications
• Class I
• Severe AR with symptoms or severe LV dilatation
  but contraindications to surgery
• Severe AR without symptoms but LV dilatation and
  elevated SBP
• Any degree of AR with hypertension
• Persistent LV systolic dysfunction s/p AVR (ACEi)
• Short term therapy prior to AVR

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Aortic RegurgitationManagement Guidelines

• Vasodilator Therapy Indications
• Class III
• Mild to mod AR without sxs and nl LV function
• In lieu of AVR in pts without contraindications

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Aortic RegurgitationManagement Guidelines

• Recommendations for AVR (chronic severe AR)
• Class I
• NYHA functional class III or IV sxs
• NYHA functional class II sxs and progressive LV
  dilatation or declining LVEF on serial studies
• CCS class II angina
• Mild or moderate reduction in EF (25-50)
• Need for CABG or surgery on other valves

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Aortic RegurgitationManagement Guidelines

• Class IIa
• NYHA class II sxs with nl LVEF (gt50) with stable
  EF, LV size and exercise tolerance
• Asymptomatic pts with nl LVEF but severe LV
  dilatation (ESD gt 55 mm or EDD gt 75 mm)
• Class IIb
• LVEF lt 25
• Asymptomatic pts with nl LVEF and progressive LV
  dilatation with ESD 50-55 mm or ESD 70-75 mm

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Mitral StenosisPhysiology/Natural History

• Normal MVA 4 -5 cm2
• Symptoms not apparent until area lt 2.5 cm2
• valve area (cm sq) mean gradient (mmHg)
• Mild gt 1.5 lt 5
• Moderate 1.0 - 1.5 5 -10
• Severe lt 1.0 gt 10

assumes normal cardiac output
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Mitral StenosisPhysiology/Natural History

• Akin to severe diastolic dysfunction
• V IR (electrical)
• P QR (hydraulic)
• Q P/Rvalve

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Mitral StenosisPhysiology/Natural History

• ?LA pressure ? ?PV pressure ? ?interstitial edema
  ? alveolar flooding
• Adaptations
• -pulmonary vascular constriction, intimal
  hyperplasia, medial hypertrophy ? reversible
  pulmonary hypertension ? fixed pulm htn
• -downregulation of neuroreceptors, ?lymphatic
  drainage

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Mitral StenosisPhysiology/Natural History

• Latent (subclinical) phase in RHD 20-40 yrs
• 10 yrs of symptoms before disabling
• With physically limiting symptoms
• 10 yr survival 0-15
• 10-20 systemic embolism
• 30-40 develop AF
• With onset of severe pulm hypertension
• Mean survival lt 3 yrs

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Mitral StenosisManagement Guidelines

• Initial Evaluation
• History
• Physical
• ECG
• CXR
• Echocardiogram
• Exercise echocardiogram

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Mitral StenosisManagement Guidelines

• Medical Therapy
• Rheumatic fever prophylaxis
• Infective endocarditis prophylaxis
• Limitation of strenuous physical activities
• Control of HR (negative chronotropes)
• Na restriction, intermittent diuretic use
• Prompt management of AF

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Mitral StenosisManagement Guidelines

• Interventional and Surgical Options
• Percutaneous mitral balloon valvotomy (PMBV)
• Closed commissurotomy (obselete)
• Open commissurotomy
• Mitral valve replacement

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Mitral StenosisManagement Guidelines

• Indications for PMBV (class I and IIa)
• Suitable anatomy, no LA clot, mild MR
• Symptomatic pts (NYHA class II-IV) with MVA lt1.5
  cm2
• Asymptomatic pts with MVA lt1.5 cm2 and PASP 50
  mmHg at rest, 60 with exercise

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Mitral StenosisManagement Guidelines

• Indications for MVR (class I and IIa)
• Symptomatic pts (NYHA class III and IV) with MVA
  lt 1.5 cm2 unsuitable for PMBV
• NYHA class I and II pts with MVA lt 1.0 cm2 and
  PASP gt60 at rest unsuitable for PMBV

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Acute Mitral RegurgitationPhysiology and Natural
History

• Abrupt volume load---no time for adaptation
• Sudden ? in forward stroke volume
• Sudden ? in LA volume/pressure ? ? PV pressure
• Rapidly fatal

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Acute Mitral RegurgitationManagement Guidelines

• Medical Stabilization (while gathering OR team)
• If normotensive nitroprusside
• If hypotensive nitroprusside dobutamine
• or
• intra-aortic balloon pump (IABP)

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Chronic Mitral RegurgitationPhysiology and
Natural History

• Gradual development allows adaptation
• LA dilatation and increase in compliance
• LV dilatation and ? EF (via ? preload and ?
  afterload) ? maintenance of forward SV
• Compensation often adequate for vigorous exercise
• May last many years

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Chronic Mitral RegurgitationPhysiology and
Natural History

• Eventually, volume overload ? LV decompensation
• Preop LVEF (gt60) and LVESD (lt45 mm) are primary
  predictors of postop survival

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Wisenbaugh T, et al Prediction of outcome after
valve replacement for rheumatic mitral
regurgitation in the era of chordal preservation.
Circulation 89191, 1994.
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Chronic Mitral RegurgitationManagement Guidelines

• Initial evaluation
• History
• Physical Exam
• ECG
• CXR
• Echo
• Exercise echo

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Chronic Mitral RegurgitationManagement Guidelines

• Scheduled Follow-up
• Instruct all pts to report any cv symptoms
• office interval echo interval
• Mild MR 12 mos if sxs
• Moderate MR 12 mos 1-2 yrs
• Severe MR 6-12 mos 6-12 mos

assumes no symptoms and no sequellae consider
exercise echo
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Chronic Mitral RegurgitationManagement Guidelines

• Medical Therapy
• No generally accepted rx in asymptomatic pts
• No long term studies suggesting benefit of
  afterload reduction in absence of hypertension
• ACEi if hypertensive
• AF requires rate control, anticoagulation and 1
  attempt at restoration of SR

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Chronic Mitral RegurgitationManagement Guidelines

• Surgical Options
• Mitral valve repair
• Mitral valve replacement with preservation of
  subvalvular apparatus
• Mitral valve replacement with excision of
  subvalvular apparatus
• MVR with CABG (in ischemic MR)

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Rozich JD et al Mitral valve replacement with
and without chordal preservation in patients with
chronic mitral regurgitation mechanisms for
differences in postoperative ejection
performance. Circulation 861718, 1992.
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Chronic Mitral RegurgitationManagement Guidelines

• Indications for Surgery (class I and IIa)
• Symptomatic pts with severe MR and an LV
  appearing less than hopeless (EF gt 30, ESD lt 55
  mm)
• Asymptomatic pts with moderate or severe MR and
  any of the following EF 30-60, ESD gt 45 mm, AF,
  PASP gt 50 at rest, PASP gt 60 with exercise

consider if chordal preservation appears very
likely
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