Download bwValvular Heart Disease[1].pptx

9/28/15 OBJECTIVES
VALVULAR HEART
DISEASE
Aaron R. Rossett, R.N., MSN
F N P - C , AC N P - C
C ardiot h o rac ic S urg e r y
UT HS CSA
OBJECTIVES CONTINUED
¡  Review common clinical finding of VHD.
¡  Review common diagnostic studies and explanation of results.
¡  Discuss medical and surgical treatment options.
¡  Discuss the perceived incidence of Valvular Heart Disease
(VHD).
¡  Review key concepts regarding the definition of valvular heart
disease.
¡  Focus on Aortic Stenosis and Mitral Regurgitation.
¡  Review 2014 ACC/AHA Guidelines of care for Aortic Stenosis
(AS) and Mitral Regurgitation (MR).
INCIDENCE OF VHD ?
¡  It is estimated that 5 million Americans have VHD*.
¡  It is estimated that 1.5 million Americans suffer from Aortic
Stenosis (AS)**.
¡  It is estimated that 500,000 have AS and 250,000 are
symptomatic from AS**.
¡  Highlight patient education.
*Nkomo V, Gardin M, Sktelton T, et al. Burden of valvular heart diseases: a population based study (part2). Lancet 2006: 1005-11
**Bach D, Radeva J, Bimbaum H, et al. Prevalence, Referral Patterns, Testing and Surgery in Aortic Disease: Leaving Women and Elderly
Patients Behind. J Heart Valve Disease. 2007:362-9.
FREQUENCY OF VHD
VHD INCIDENCE CONTINUED
¡  Aortic Regurgitation (AR) was mild 13% of Framingham Study
participant and 29% of Helsinki Aging Study patients.
¡  Mitral stenosis is a leading concerning in developing countries
due to Rheumatic Fever.
¡  Mitral Regurgitation (MR) was at least mild in 19% of
Framingham subjects who underwent echocardiography.
¡  However in the U.S. mitral annular calcification causing
stenosis are seen.
1 9/28/15 VHD INCREASE BY AGE
COPIED FROM THE LANCET, VOL. 368, NKOMO, V. T. ET AL.,
BURDEN OF VALVULAR HEART DISEASES:
A POPULATION-BASED STUDY, PAGES 1005–1011, ©
(2006)
T YPE OF VHD BY AGE
WHAT MAKES VHD A CONCERN?
¡  Prevalence is loosely understood.
¡  There are questions of underestimation.
¡  VHD risk increases with age.
¡  The US Census Bureau estimates an increasing population size
from 45 million to 80 million by 2050.
COPIED FROM EPIDEMIOLOGY OF VALVULAR HEART
DISEASE IN THE ADULT. BERNARD IUNG & ALEC
VAHANIAN
NATURE REVIEWS CARDIOLOGY 8, 162-172 (MARCH
2011)
POPULATION AGED 65 AND OVER FOR
THE UNITED STATES: 2012 TO 2050
PERCENT OF TOTAL POPULATION
U.S. Census Bureau, 2012 Population Estimates and 2012 National Projections.
2 9/28/15 HEART VALVES
¡  Aortic Valve – gateway from the left ventricle to the aorta
¡  Mitral Valve – trapdoor from the left atrium to the left
ventricle
¡  Pulmonic Valve – gateway from right ventricle to the
pulmonary vasculature.
¡  Tricuspid Valve- trapdoor from the right atrium to the right
ventricle
http://sundar.me/2011/03/22/the-heart-and-ekg-i-anatomy-of-the-heart-1/heart-valves-from-above/
AUSCULTATION ZONES
DIAGNOSTIC STUDIES
¡  EKG- rhythm, chamber enlargement, acute ST changes,
evidence of infarction
¡  Chest x ray - cardiac size, presence of effusion(s), cardiac
border, pulmonary congestion
https://www.ole.bris.ac.uk/bbcswebdav/institution/Faculty
%20of%20Medicine%20and%20Dentistry/MB%20ChB/
Hippocrates%20Year%203%20Medicine%20and%20Surgery/
Cardiology%20%20Valvular%20heart%20disease/page_07.htm
DIAGNOSTIC STUDIES
¡  Transthoracic echocardiogram (TTE)- hallmark study to assess
for function and anatomy. Class I, level C
¡  Transesophageal echocardiogram (TEE)- can provide further
detail on valve anatomy, vascular anatomy, chamber sizes.
2 014 A H A / AC C G UIDELINE FOR T H E MA NAG EMENT OF
PAT IEN T S W IT H VA LVULA R H E A R T D I S E A S E
¡  Stage
- A – At risk – those who have risk factors for developing VHD
-B – Progressive- Patients with progressive VHD (mild to moderate
severity by echo and asymptomatic)
¡  Heart catheterization- used to verify echocardiogram findings
when discrepancy occurs, most sensitive exam. Class I, level C
-C1- Asymptomatic patients with severe VHD with compensated
ventricle(s)
-C2- Asymptomatic patients with sever VHD with decompensated
ventricle(s)
¡  Exercise stress test- quantify symptoms. IIa, level B
-D- symptomatic, severe – patients who have developed symptoms
due to VHD (D1 , D2, D3)
3 9/28/15 LEVEL OF EVIDENCE
CLASSIFICATION OF RECOMMENDATION
¡  COR
I- Benefit >>> Risk (should be offerred)
II- Benefit >> Risk (reasonable to perform)
IIb-Benefit >/= Risk (may be considered)
III- risk of no benefit or harm
AORTIC STENOSIS (AS)
¡  Most common form of ventricular outflow obstruction
¡  It is the narrowing of the aortic valve orifice
-  Congenital etiology (bicuspid)
-  Calcified disease of a normal valve
-  Rheumatic reasons
COMMON SYMPTOMS
§ 
- 
- 
- 
LOE
A
multiple population evaluations, multiple random trials
B
single randomized trial or nonrandomized studies
C
limited population, consensus opinion, case studies
RISK FACTORS ASSOCIATED WITH AS
¡  Older age
¡  Male gender
¡  CKD
¡  DM
¡  Hypercholesterolemia / calcemia
¡  Metabolic syndrome
¡  Smoking / HTN
¡  Aortic jet velocity/ degree of calcification (echo)
PHYSICAL EXAM FINDINGS
Late symptoms:
¡  Angina
¡  Syncope
¡  Heart failure(JVD, orthopnea, edema, PND)
¡  Auscultation- reveals a mid to late systolic murmur,
Murmur grade generally III/VI or greater,
crescendo in nature, heard best in the 2 n d right intercostal
space. Associated with bruit to the carotids.
Early symptoms:
§  Dyspnea on Exertion
§  Decreased Exercise tolerance
§  Exertional angina/ dizziness/ lightheadedness
¡  Rate is generally regular unless associated with atrial
fibrillation
¡  Late AS can demonstrate a late pulse pressure, laterally
placed PMI, a delay or diminished carotid upstroke.
4 9/28/15 DIAGNOSTIC FINDINGS
¡  EKG- Left ventricular hypertrophy, ST segment depression, T
wave inversion, left atrial enlargement
¡  Echocardiogram- anatomy, hemodynamics, consequences
- generally an orifice less than 1.2 cm² (0.8 to 1)
-  Aortic V (max)- < 2m/s to > 4 m/s
-  Mean gradient between 20 to 40 Hg
-  Peak gradient value is generally given
-  Assessment of LV function
STAGES OF AS CONTINUED
¡  B- progressive
-valve anatomy mild to moderate leaflet calcification with
reduction of motion OR Rheumatic valve changes
-hemodynamics will mention “mild AS”, Aortic Vmax 2 to 2.9 ms
or Mean gradient < 20 mm Hg
“moderate AS”, Aortic Vmax 3 to 3.9 m/s or mean gradient 20
to 39 mm Hg
- Normal Ventricle, early diastolic dysfunction may be present,
no symptoms
STAGES OF AS CONTINUED
¡  Stage C- asymptomatic but severe
C2- same as C1
HOWEVER – LVEF <50%
No LV diastolic dysfunction
No mild LV hypertrophy (LVH)
Just as in C1, no clinical symptoms
STAGES OF AS
¡  A – at risk
-anatomy congenital problem or sclerosis
-hemodynamics Aortic V max < 2 m/s
-left ventricle will not demonstrate any abnormalities
-patient does not have symptoms
STAGES OF AS CONTINUED
¡  Stage C: Asymptomatic severe
C1- severe leaflet calcification or congenital stenosis.
-- Aortic Vmax > 4 m/s or mean gradient > 40 mm Hg
-- AVA - < 1.0cm² (or AVAi < 0.6 cm²/m²)
--Very severe Vmax > 5m/s or mean gradient > 60 mm Hg
¡  LV changes--diastolic dysfunction, mild hypertrophy, normal EF
¡  Symptoms—none, consider exercise testing
STAGES OF AS CONTINUED
¡  Stage D- severe AS
D1 – symptomatic severe high gradient
D2 -symptomatic severe low -flow/ low gradient with ↓LVEF
D3- symptomatic severe low gradient
Associated with LV diastolic dysfunction, LVH, +/- Pulmonary
artery hypertension, EF < 50%
Symptoms of DOE, angina, syncope, Heart failure.
5 9/28/15 S UMMAT ION OF REC OMMEN DAT ION S FROM A H A / AC C
CLINICAL TAKE HOME FOR AS
¡  Surgery is a Class I recommendation for:
-Severe AS demonstrated by Vmax > 4 m/s or mean gradient >
40 mm Hg, with symptoms.
- Asymptomatic, with LVEF >50%, with findings as above, who is
undergoing other cardiac surgery
- Asymptomatic, with LVEF >50%, and findings above.
AHA/ACC 2014 Valvular Heart Disease Guideline
WHICH PATIENTS CAN YOU MONITOR?
¡  Stage A (AS Vmax < 2m/s)- echo every 5 years or with
symptoms changes.
¡  Stage B mild AS (Vmax 2 to 2.9 m/s) or mean gradient < 20
mm Hg. –echo every 3 to 5 years.
¡  Stage B Moderate AS (Vmax 3 to 3.9 m/s) or mean gradient
20 to 39 mm Hg– echo every 1-2 years.
¡  Stage C only if EF >50%. – echo every 6 to 12 months.
MEDICATIONS CONTINUED
¡  Diuretics- use with caution, avoid if LV cavity is small. They
can cause sharp decrease in cardiac output
¡  “statin” therapy – no studies demonstrate prevention of
progression of AS
MEDICAL THERAPY OPTIONS
¡  ACE-I, beta blockers, class I, LOE B
-goal, control HTN, “fixed” valve obstruction generally occurs
late in process.
ACE-I may benefit LV remolding, retard LV fibrosis
Beta blockers- can assist in rate control, arrhythmia
management
¡  Vasodilators, class IIb, LEO C- only in class IV Heart Failure
with patients with invasive monitoring. These patients are
generally pending surgery. (nitroprusside, nicardipine)
MITRAL VALVE REGURGITATION (MR)
¡  Symptoms: fatigue, exertional dyspnea, orthopnea, right sided
heart failure, edmea.
¡  Physical exam: JVD, prominent a wave.
¡  Auscultation: 5 t h intercostal space, left midclavicular region
systolic murmur, at times a brisk impulse with radiation to the
left arm pit.
S1 may be difficult to hear.
Usually holosystolic.
6 9/28/15 ECHOCARDIOGRAM FINDINGS
¡  Flow across Mitral valve into the left atrium / pulmonary veins
¡  Assess valve morphology, rupture of chordae, flail leaflet,
evidence of vegetation.
¡  Assess EF and wall motion of the left ventricle
AHA/ACC 2014 Valvular Heart Disease Guideline
MR OVERVIEW
MR OVERVIEW
¡  Severe acute primary
-  Abrupt disruption of the mitral valve apparatus.
- Associate with Myocardial infarction or trauma
-  Can be associate with endocarditis or connective tissue
disorder.
-  Essentially an acute change that does not allow compensation
¡  Chronic primary - pathology of at least one component of the
MV, i.e. leaflets, chordae tendineae, papillary muscles,
annulus.
-  Can occur in Mitral valve prolapse (MVP)
-  severe myxomatous diseases.
-  fibroelastic diseases.
-  connective tissues disorders.
-  Less common, rheumatic heart disease, endocarditis,
radiation to the heart.
¡  If corrected early, you can save the integrity of the heart.
MR OVERVIEW
¡  Chronic secondary
-  The MV is usually normal.
-  LV dysfunction has caused distortion of the valvular structures
-  Seen in MI, ischemia, idiopathic myocardial diseases.
-  LV is generally dilated
-  Fixing / repairing the valve leaves the underlining problem
and may not be curative.
MEDICAL MANAGEMENT OF MR
¡  Vasodilator therapy can increase forward flow towards the
aorta.
-  Acutely consider IV nitrates
-  Diuretics with caution
-  ACE-I in chronic management
-  Betablockers in depressed EF / chronic management
7 9/28/15 SURGICAL OPTIONS
¡  AS- “gold standard” open chest aortic valve replacement via
sternotomy
-  Sub select individuals:
Transcatheter Aortic Valve Replacement (TAVR)
Balloon valvuloplasty
SURGICAL OPTIONS
¡  MR- “gold standard” open chest sternotomy.
-  Sub select individuals:
Right thoracotomy incision
Mitral valve clipping.
REFERENC ES
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American Heart Association. (2014, March 3). 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease . Retrieved August 8, 2015
from http://circ.ahajournals.org/content/129/23/e521.full#sec-67
Baumgartner, J., Hung, J., Bermejo, J., Chambers, J.B., Evangelista, A., Griffin, B.P., Iung, B., Otto, C.M., Pellikka, P.A., Quinones, M. (2009). Echocardiographic
assessment of Valve stenosis: EAE/ASE recommendations for clinical practice. European Journal of Echocardiography., 10, 1-25.
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