Download Valve Disease – From Bench to Bedside

Southeast Regional
Heart and Vascular Symposium
Heart Valves
for Primary Care Providers
Valvular Heart Disease
2014 AHA/ACC Guideline for the
Management of Patients With
Valvular Heart Disease
William Oellerich, MD, Ph.D, FACC
• Dysfunction results from stenosis or
incompetency (regurgitation)
• Stenosis leads to pressure overload in
the upstream chamber compensated
for by hypertrophy
• Incompetency leads to volume overload
compensated for by chamber dilatation
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Causes
• Congenital: pulmonic, bicuspid aortic
• Infectious: endocarditis, rheumatic fever
• Acquired: Fen fen, carcinoid, methysurgide
• Connective tissue disease
• Radiation
• Structural: annular enlargement, MI
• Degenerative- Age related
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Guideline Based
Recommendations
Clinical Evaluation
• History
• Class I
– Valve problem, murmur
– Asymptomatic
– Dyspnea or fatigue
– should be performed
• Class IIa
– is reasonable
• PE
• Class IIb
– Heart murmur
– Neck veins
– Carotid arteries
– may be considered
• Class III
– recommended against, may be harmful
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Timing of Echocardiography
Valvular Heart Disease
Class I
Testing
• ECG
• CXR
• Echocardiogram
1. TTE is recommended in the initial evaluation of
patients with known or suspected VHD
2. TTE in patients with known VHD with any change in
symptoms or physical examination findings.
3. Periodic monitoring with TTE in asymptomatic
patients with known VHD at intervals depending on
valve lesion, severity, ventricular size, and
ventricular function.
Follow up
• Annual H&P in most stable patients
• Frequency of repeat Echo variable
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F/U Echocardiography
Considerations for Referral
• Moderate-to-severe or severe valve Dz
• Patients with symptoms thought to be
related to valvular disease
• Consider earlier referral for patients
with unexplained dyspnea and/or
fatigue, LV dysfunction, LV or RV
chamber enlargement
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1
1
Mitral Regurgitation
Medical Management
• Mitral valve
• Treat hypertension ( Ca++,
ACE/ARB for chronic AI)
• Endocarditis prophylaxis?
• Diuretics?
– Complex structure
• Primary pathology
– collagen vascular
disease
– Rheumatic heart disease
– Endocarditis
– LV dysfunction (Annular
enlargement, papillary
muscle displacement)
• Mild MR in 20%
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0
Mitral Valve Prolapse
Indications to Intervene: MR
Class I
• Mitral valve surgery is recommended for asymptomatic
patients with chronic severe primary MR and LV dysfunction
(LVEF 30% to 60% and/or LVESD ≥40 mm,)
Class IIa
• MV repair reasonable in asymptomatic patients with chronic
severe primary MR with preserved LV function in whom the
likelihood of a successful and durable repair is present
• Connective tissue
disease
• Only about 2.5% of
population
• Over diagnosed in the
past
• Regurgitation can
worsen rapidly
1.
2.
3.
at a Heart Valve Center of Excellence OR
with new onset of AF OR
with resting pulmonary hypertension (pulmonary artery systolic
arterial pressure >50 mm Hg)
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Aortic Stenosis
Pathophysiology of MR
• Congenital Bicuspid
valve
• Pure Volume Overload
• Progressive left atrial dilation and right
ventricular dysfunction due to pulmonary
hypertension.
• Progressive left ventricular volume
overload leads to dilation and progressive
heart failure
– Aortopathy
• Age related(senile)
degenerative
– 25% >65yr sclerosis
– 3.4% >65yr Severe AS
• Normal AVA 3-4cm2
– Severe AS ¼ th nl size
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Bicuspid Aortic Valve
•
•
•
•
1-2 % of population
Some genetic component
AS or AI
Associated with coarctation and ascending
aortic aneurysms
– Serial testing for aorta > 4 cm
– Annual testing for aorta >4.5 cm
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Endocarditis Prophylaxis
Aortic Stenosis - Presentation
Only indicated for High risk Cardiac Conditions:
1. Prosthetic heart valves
2. History of Infective Endocarditis
3. Congenital heart disease (CHD)
• Murmur
• Progressive ~0.1cm2 decline in AVA/year
• Symptoms:
–
o Angina
o Dyspnea, CHF
o Syncope
Complex Disease
4. Heart Transplant patients with valvular heart
disease
• Death if untreated
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Anticoagulant Rx: Prosthetic Valves
Take Home Points
Class I
1.
2.
3.
VKA and (INR) monitoring for mechanical valve
INR of 2.5 for mechanical AVR, uncomplicated
INR of 3.0 with a mechanical AVR and additional risk factors for
thromboembolic events (AF, previous thromboembolism, LV dysfunction,
or hypercoagulable conditions) or an older-generation mechanical AVR
INR of 3.0 in patients with a mechanical MVR
Aspirin 75 mg to 100 mg daily with VKA in patients with a mechanical
valve
4.
5.
• If there is a question about heart valve
problems, get an echo.
• Repeat echo as indicated.
• Refer earlier rather than later,
symptoms not needed.
• Call if there is a question.
Class IIa
1.
Aspirin 75 mg to 100 mg per day is reasonable in all patients with a
bioprosthetic aortic or mitral valve
Anticoagulation with a VKA is reasonable for the first 3 months after
bioprosthetic MVR or repair to achieve an INR of 2.5
2.
Class III
1.
NOAC
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Bridging Rx for Mechanical Valves
References
Class I
1.
2.
3.
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2014 AHA/ACC Guideline for the Management
of Patients With Valvular Heart Disease
Executive Summary: A Report of the American
College of Cardiology/American Heart
Association Task Force on Practice Guidelines
Continue VKA in patients with mechanical heart valves
undergoing minor procedures (such as dental extractions or
cataract removal) where bleeding is easily controlled.
Temporary interruption of VKA, without bridging while INR is
subtherapeutic, with a mechanical AVR and no other risk
factors for thrombosis.
Bridging anticoagulation with either iv unfractionated heparin
or subcutaneous low-molecular-weight heparin when the INR
is subtherapeutic preoperatively in patients with a
I.
mechanical AVR and any thromboembolic risk
factor,
II.
older-generation mechanical AVR, or
III.
mechanical MVR
http://circ.ahajournals.org/content/early/201
4/02/27/CIR.0000000000000029.citation
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Thank you!
William Oellerich, MD, Ph.D, FACC
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