Valvular Heart Disease

7 Question to answer for any valvular heart disease:  Is the valvular heart disease severe? Does the patient have symptoms? Are the symptoms related to valvular disease? Life expectancy of patient, and Expected quality of life? Does the expected benefit of intervention outweigh its risk? What are patient wishes? Local Expertise? ESC Guidelines on the management of valvular heart disease (version 2012) How to assess the severity of a valvular heart disease? Qualitative Regurgitant volume >60 mL Valve morphology Color flow regurgitant jet  CW signal of regurgitant jet Semi-quantitative Vena contracta  > 0.7 cm Narrowest portion of MR jet at or just downstream from the regurgitant orifice Upstream vein flow Inflow Quantitative Regurgitant volume >60 mL ERO (Effective Regurgitant Orifice Area) >0.4 cm2 = Q (2pir2v)/Vmax MR jet Enlargement of cardiac chambers / vessels  ESC Guidelines on the management of valvular heart disease (version 2012) Aortic Valve area is 3-4 cm 2 Cause Primary Valvular Cause Unicuspid Bicuspid Non-valvular Cause Sub-aortic stenosis Supravalvular AS HCOM Degenerative AS Clinical Presentation Angina Syncope abnormal baroreceptor Bezold Jarish Reflex Heart Failure  Fatigue Aortic and LV peak pressure variation is a hallmark  Pressure Gradient Bernoulli equation Valve area; Torricelli equation 3.2. Aortic Stenosis : AHA/ACC 2014 Stages of Valvular AS: A: At risk B: Progressive C: Asymptomatic Severe AS With LV Dysfunction D: Symptomatic High-gradient AS Low-gradient / low flow  AS with low EF Low Gradient with normal EF or paradoxical low flow AS  AHA/ACC 2014 Treatment: Medical: Surgery: AHA/ACC 2014 Chronic AR  Clinical Stage : A, B, C, D  Valve Anatomy Valve Hemodynamics (Mild, Mod, Severe) - Reg Vol, Reg Fraction, Effective Reg Orifice, Jet Width Hemodynamics Consequences: LV Systolic Function (EF), LV Size or dilatation (LVESD) Symptoms (Nature of Symptoms if Stage D AHA/ACC 2014 Treatment:   AHA/ACC 2014 Chronic MR   AHA/ACC 2014  AHA/ACC 2014 2D Echo is very useful in identifying the mechanism of MR. Mechanism of MR is a major focus of 2014 guideline.  Mechanism of MR is the key (has implication in treatment) : Primary vs Secondary. This effects treatment option and clinical outcomes.  Primary or  Myxomatous Degeneration  Non-ventricular, non-inflammatory, chronic or acute-on-chronic. Prolapse (excessive valvular motion) Reparable, and no need of replacement Perforation (normal valvular motion) Rheumatic Changes  (restricted valvular motion). Also, seen post radiation, and in SLE  Replacement better than repair on this group  Reference: Mitral Regurgitation Due to Degenerative Mitral-Valve Disease NEJM 2010 Secondary or Functional (apical tethering) (Repairable, but high risk as the problem is not in valve)  due to LV dilatation  Ischemia   due to A fib / atrial dilatation  Clinical Stage (Symptomatic Severe MR (Stage D) or Asymptomatic Severe MR (Stage C) or Progressive MR (Stage B) Valve Anatomy Valve Hemodynamics (For both Primary or Secondary; Severe MR criteria in parenthesis) Rather than focusing on one  factor, weighted average of the following based on quality of those factors should be considered Regurgitant volume >60 mL Regurgitant fraction  > 50 % ERO (Effective Regurgitant Orifice Area) >0.4 cm2 = Q (2pir2v)/Vmax MR jet In addition we can assess the following for Primary MR Central jet MR or holosystolic eccentric jet MR  Vena contracta  > 0.7 cm Narrowest portion of MR jet at or just downstream from the regurgitant orifice Angiographic grade   Hemodynamic Consequences Symptoms (Nature of Symptoms if Stage D) Treatment: 5 factors that suggests the need of surgery are Symptoms LV size LV function A Fib Pulmonary HTN  Mechanism defines the treatment option (as noted above in mechanism) Primary MR  Secondary MR  Preferably medical management Even though reparebilty is possible, peri-operative mortality is high compared to primary MR (note: Mayo, Cleveland group has comparatively lower preoperative mortality)  Such surgery is for symptoms control, long term mortality is still high.  If other indications for surgery exists, then surgery can be considered.  When not to operate LVEDD > 7-8 cm low output state despite optimal medical therapy Severe RV dysfunction Type of surgery Mitral Repair Mitral annuloplasty Suturing in the middle MitraClip - COAPT Trial Mitral Valve Replacement Preferably should be done by the surgeon who has better experience of these surgery   AHA/ACC 2014 Food for thoughts: Valvular severity and the volume regurgitation severity may be different issues. Additional references  MVARC 2015   TR (Page 95 - 104): Cause (Primary or Functional) 2/2 Etiology for Primary or Functional Clinical Stage (Table 19, Page 97) (Stage A, B, C, D) Valve Anatomy Valve Hemodynamics (Mild, Mod or Severe for both Primary or Functional) Central jet area Vena contracta width  CW jet density and contour: dense, triangular with early peak Hepatic vein flow Hemodynamic Consequences RV Enlargement Interventricular Septal Flattening + or - RV Systolic Function RA Enlargement RA Pressure IVC Enlargement Symptoms  Indications for Surgery for TR AHA / ACC 2014 Valvular Heart Disease  Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction NEJM 2014   What is SAM (Systolic Anterior Motion) of the posterior Mitral Valve? Causes ventricular outlet obstruction MS Pathophysiology Heart rate dependent reduction of diastolic filling of ventricle Causes Reduced cardiac output - fatigue  High LA pressure causing Pulmonary Artery HTN - RV failure - A rib - Embolic Process  Signs Loud S1 with opening snap  Severity Moderate 1.6-2 cm2 Severe < 1.5 cm2 Very Severe <1.0 cm2 Stage At risk Progressive  (Mild to moderate MS) Asymptomatic Severe Symptomatic Severe  Treatment Limited role of medical treatment  Intervention for symptomatic patients  Balloon Valvuloplasty  Open commisurotomy Mitral valv replament  If anatomy is unfavorable, severe MR  Mechanical  Bioprosthesis  Rate control Anti-caogulaiton with A Fib Pulmonary Valve Disease  PR (most common) Can be difficult to diagnose  PS Severe > 64 mmHg Carcinoid Valve Ds Mix of PS and severe PR  Also, will have involvement of the TV  Falied ROss Procedure Papillary fibro Tricuspid Valve Disease  Anatomy Anterior leaflet is the largest Septal leaflet is the smallest Posterior Leaflet is most difficult to visualize Parasternal RV View Anterior and Septal leaflet Parasternal Short Axis vew Posterior leaflet  Apical 4 chamber view Much more variable anatomy than MV  Annular ANatomy (6-7 cm2) More apically displaced than MV Functional TR is due to medial-lateral dilation Etiology Primary COngential  Endocarditis Iagtogenic Traumatic Prolapse Secondary RV dilation LV disease P HTN  RV disease Infarction Severe TR It is difficult to estimate Pulmonary Pressure based on RA pressure  Views of doing an 2D ECHO  Epstein anamoly