Download timing of surgery in valvular heart disease

VALVULAR HEART DISEASE
Evaluation
• CLINICAL
• symptoms
• physical findings
• rhythm
• cardiac size
• ventricular hypertrophy
• PAH
• RHF
• complications
• ECG / CXR
• Echo – TTE / TEE / 3D
• Stress tests
• CAG / CT / MRI / Angio
Assessment of the risks for intervention
VALVULAR HEART DISEASE
Surgical risk assessment
4 parameters
STS PROM … institution related
< 4 % ; 4 – 8 % ; > 8 % ; Iyr mortality + morbidity > 50%
Frailty
7 indices – feeding, bathing, dressing, transferring, toileting,
continence
ambulation – no walking aid / assist required /
5 m walk in less than 6 s
Major organ dysfunction
Procedure specific impediment
none / possible / severe
STAGES OF HEART DISEASES
A
At risk
Patients with risk factors for development of VHD
B
Progressive
Patients with progressive VHD (mild-to-moderate severity and
asymptomatic)
C Asymptomatic severe
Asymptomatic patients who have the criteria for severe VHD:
C1: Asymptomatic patients with severe VHD in whom
the left or right ventricle remains compensated
C2: Asymptomatic patients with severe VHD, with
decompensation of the left or right ventricle
D Symptomatic severe
For AS
D1 .. High gradient AS
D2 .. Low flow low gradient AS
D3 .. Paradoxical low flow
MITRAL STENOSIS
MITRAL STENOSIS
Severe
MVA
< 1.5 cm 2
< 1.5 cm - very severe
PHT
> 150 ms ( > 220 - ,, )
PASP
> 30 mm Hg
Dilated left atrium
MITRAL STENOSIS
MITRAL STENOSIS
Indications for intervention
PTMC ( favourable valve morphology , no LA clots , no / mild MR)
Class I
Severe symptomatic MS (D)
Class II a
Very severe ; asymptomatic MS
Class II b
Severe MS ; NYHA III / IV ; unfavourable anatomy;
High surgical risk
Moderate MS ; symptomatic ; PAWP > 25 mm Hg on exercise
MVR
symptomatic severe MS not suitable for PTMC
MR – vena contracta
MITRAL REGURGITATION
Severe MR
• central jet MR > 40 % of LA
• holosystolic eccentric MR
• VC > 7 mm
• RV > 60 ml ; RF > 50 % ; ERO > 0.4 cm2
• Angio grade 3 /4
• LV dilatation - ESD > 40 mm
• PAH … PASP > 50 mm Hg
• moderate to severe LA enlargement
EF < 60 % -- LV dysfunction
MITRAL REGURGITATION
Indications for intervention
Class I
stage D ; EF > 30 %
stage C2 ; EF 30 – 60 %
stage C1 + other cardiac surgery
Class II a
MV repair
C1
success rate > 95 % ; op. mortality < 1 %
+ new onset AF / SPAP > 50 mm Hg
+ other cardiac surgery
AORTIC REGURGITATION
Severe
• jet width > 65 % of LVOT
• vencontracta > 6 mm
• RV > 60 ml ; RF > 50 % ; RO > 0.3 cm2
• Holodiastolic reversal in abd. aorta
• LV dilatation ( ESD > 50 mm or > 25 mm / m2 ; EDD > 65 mm )
• Angio grade – 3 / 4
AORTIC REGURGITATION
Indications for surgery
Class I
stage D
stage C2
stage C1 + other cardiac surgery
Class II a
stage C1 + LV dilatation
stage B + other cardiac surgery
AORTIC STENOSIS
AORTIC STENOSIS
Valve area (cm2)
• normal
-
3.0 – 4.0 ( 2 cm2 / m2 )
• mild AS
-
1.5 – 2.0
• moderate AS
-
1.0 – 1.5
• severe AS
-
< 1.0
( < 0.6 cm2 / m2 )
• critical AS
-
< 0.75
( < 0.5 cm2 / m2 )
AORTIC STENOSIS
3D TEE
AORTIC STENOSIS
Dimensionless valve index (velocity ratio)
Very simple method
Variable of area is taken away from the continuity equation
LVOT velocity
Aortic valve velocity
Value < 0.25 .. Severe AS
SEVERE AS
Peak gradient = 120 mm Hg ( Vmax 5.4 m / s
Dimensionless index = 0.5 / 5.5 = 0.1
V1 = 1. 5 m /sec
V 2 = 4 m / sec
DI = 1.5 / 4 = 0.375
AORTIC STENOSIS
Global LV hemodynamic load
Valvuloarterial impedance ( Z va )
Valvular resistance + vascular resistance
Mean gradient
Zva =
SBP + mean gradient
Stroke volume index
> 4.5 … severe AS
SBP
AORTIC STENOSIS
Severity
Parameters
sclerosis
mild AS
moderate
severe
Vmax..m/sec
< 2.5
2.6 – 2.9
3.0 – 3.9
≥ 4.0
MPG mm Hg
--
< 20
20 – 39
≥ 40
AVA cm2
--
> 1.5
1.0 – 1.5
< 1.0
AVAI cm2 / m2
--
> 0.85
0.6 – 0.85
< 0.6
Dimensionless
index
--
> 0.5
0.25 – 0.5
< 0.25
Zva
> 4.5
Very severe AS … V max > 5 m /s ; mean gr > 60 mm Hg
AORTIC STENOSIS
Terminologies
Low flow low gradient severe AS
Paradoxical low flow AS
Pseudosevere AS
AORTIC STENOSIS
DSE
Valve area
(cm2)
mean gr.
(mm Hg)
SVI change
( %)
assessment
< 1.0
> 40
> 20
severe AS
myocardium OK
< 1.0
< 40
< 20
myocardial failure
↑ by > 0.3
no change
> 20
pseudo severe AS
AORTIC STENOSIS
Low flow low gradient AS
Valve area
< 1.0 cm2
Mean gr.
< 40 mm Hg
SVI
< 35 ml / m2
EF < 50 %
• severe AS with reversible LV dysfunction
• with dobutamine – increase in gradient & SVI
AORTIC STENOSIS
Paradoxical low flow severe AS
( Hachicha et al 2007)
1/3 rd of cases ; poor surgical outcome
Severe true AS … area < 1.0 cm2
Low flow … SVI < 35 ml / m2
Preserved EF .. > 50 %
1. Impaired LVEDV
• severe LVH
• AF , tachycardia
• MS , MR, PAH, TR
2. Impaired LV longitudinal strain
AORTIC STENOSIS
Indications for intervention
Class I
stage D 1 , C2
stage C1 + other cardiac surgery
Class II a
very severe AS + low surgical risk
low flow low gradient severe AS
paradoxical low flow low gradient AS
stage C1 + stress test > poor effort tolerance / fall in SBP
stage B + other cardiac surgery
TRICUSPID REGURGITATION
TV -- anatomy
Complex apparatus
Largest valve orifice area
TR JET
Normotensive TR
Hypertensive TR
HEPATIC VEIN FLOW
Normal
Normal
severe TR
severe TR
TRICUSPID REGURGITATION
Mild
Moderate
Severe
Jet area (cm2)
<5
5 -10
> 10
Vena contr.
Not defined
not defined
(but < 7 mm
> 7 mm
PISA dia (cm)
< 0.5
0.5 – 0.9
. 0.9
CW jet
soft / parabolic
dense /
variable shape
dense
triangular
early peak
Hepatic
Vein flow
normal
systolic blunting
systolic reversal
< 15 mm
normal
15 -20 mm
normal
mild blunting
> 20 mm
absent
IVC
size
respirophasic
TRICUSPID REGURGITATIOM
RV function
• RV fractional area change
RV area(d) – RVarea (s)
RV area (d)
Normal .. 35 – 65 %
• TAPSE … 15 – 30 mm
• TDI … annular velocity … 6 -14 cm / s
• MPI (PWD) .. 0.15 – 0.40
• RVEF .. 45 – 70 %
Indications for TV surgery
VALVULAR HEART DISEASE
Specific situations
Pregnancy
Stenotic lesions are poorly tolerated
Critical evaluation before pregnancy is important
Balloon mitral / aortic valvuloplasty can be considered
a little liberally