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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 ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ 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. Braverman, A.C. Management of adults with bicuspid aortic valve disease. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015). Cunningham, R., Corretti, M., Henrich, W.L. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015). Foster, E. Transesophageal echocardiography in the evaluation of mitral valve disease. In:UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015) Gaasch, W.H. Overview of the Management of chronic mitral regurgitation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015). Iung, B.& Vahanian, A. (2014). Epidemiology of acquired valve heart diease. Canadian Journal of Cardiology, Sept. 30(9), 962-970. Mohty, D., Enriquez-Sarano, M., Pislaru, S. Valvular heart disease in elderly adults. In:UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May, 17, 2015) Nkomo, V.T., Gardin, J.M., Skelton, T.N., Gottdiener, J.S., Scott, C.G., Enriquez-Sarano, M. (2006). Burden of valvular heart disease: a population based study. The Lancet, 368(9540), 1005-1011. Ortman, J.M., Velkoff, V.A., Hogan, H. U.S. Census Bureau. May (2014). An Aging Nation: The older population in the United States- population estimates and projections: Retrieved May 1, 2015, from https://www.census.gov/prod/2014pubs/p25-1140.pdf 8