VALVULARHEARTDISEASE InternalMedicineDidactics August 12, 2009 StevenR. BruhlMD,

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VALVULARHEARTDISEASE Internal. Medicine. Didactics August 12, 2009 Steven. R. Bruhl. MD, MS VALVULARHEARTDISEASE Internal. Medicine. Didactics August 12, 2009 Steven. R. Bruhl. MD, MS

Overview • Aortic. Stenosis • Mitral. Stenosis • Aortic. Regurgitation – Acuteand. Chronic • Mitral. RegurgitationOverview • Aortic. Stenosis • Mitral. Stenosis • Aortic. Regurgitation – Acuteand. Chronic • Mitral. Regurgitation – Acuteand. Chronic

 • Etiology • Pathophysiology • Physical. Exam • Natural. History • Testing • Treatment • Etiology • Pathophysiology • Physical. Exam • Natural. History • Testing • Treatment

Aortic. Stenosis Aortic. Stenosis

Aortic. Stenosis. Overview:  • Normal. Aortic. Valve. Area: 34 cm 2 • Symptoms: Occurwhenvalveareais 1/4Aortic. Stenosis. Overview: • Normal. Aortic. Valve. Area: 34 cm 2 • Symptoms: Occurwhenvalveareais 1/4 th ofnormalarea. • Types: – Supravalvular – Subvalvular – Valvular

Etiologyof. Aortic. Stenosis • Congenital • Rheumatic • Degenerative/Calcific Patientsunder 70: 50haveacongenital cause Patientsover 70: 50duetodegenerativeEtiologyof. Aortic. Stenosis • Congenital • Rheumatic • Degenerative/Calcific Patientsunder 70: >50%haveacongenital cause Patientsover 70: 50%duetodegenerative

Pathophysiologyof. Aortic. Stenosis • Apressuregradientdevelopsbetweenthe leftventricleandtheaorta. (increased afterload) • LVfunctioninitiallymaintainedby compensatorypressurehypertrophy • Whencompensatorymechanisms exhausted, LVfunctiondeclines. Pathophysiologyof. Aortic. Stenosis • Apressuregradientdevelopsbetweenthe leftventricleandtheaorta. (increased afterload) • LVfunctioninitiallymaintainedby compensatorypressurehypertrophy • Whencompensatorymechanisms exhausted, LVfunctiondeclines.

Presentationof. Aortic. Stenosis Syncope: (exertional) Angina: (increasedmyocardialoxygen demand; demand/supplymismatch) Dyspnea: onexertionduetoheartfailure (systolicanddiastolic) Suddendeath Presentationof. Aortic. Stenosis Syncope: (exertional) Angina: (increasedmyocardialoxygen demand; demand/supplymismatch) Dyspnea: onexertionduetoheartfailure (systolicanddiastolic) Suddendeath

Physical. Findingsin. Aortic. Stenosis • Slowrisingcarotidpulse( pulsustardus )& decreasedpulseamplitude( pulsusparvus ) • Heartsoundssoftandsplitsecondheart sound, S 4Physical. Findingsin. Aortic. Stenosis • Slowrisingcarotidpulse( pulsustardus )& decreasedpulseamplitude( pulsusparvus ) • Heartsoundssoftandsplitsecondheart sound, S 4 gallopdueto. LVH. • Systolicejectionmurmur cresendodecrescendocharacter. This peaks lateras the severity ofthestenosis increases. – Loudnessdoes. NOTtellyouanythingabout severity

Natural. History • Mild. ASto. Severe. AS: – 8in 10 years – 22in 22 years –Natural. History • Mild. ASto. Severe. AS: – 8%in 10 years – 22%in 22 years – 38%in 25 years • Theonsetofsymptomsisapoorprognostic indicator.

Evaluationof. AS • Echocardiographyisthemostvaluabletest fordiagnosis, quantificationandfollowup ofpatientswith. AS.  • Twomeasurementsobtainedare: a) Leftventricularsizeandfunction: LVH, Dilation, and.Evaluationof. AS • Echocardiographyisthemostvaluabletest fordiagnosis, quantificationandfollowup ofpatientswith. AS. • Twomeasurementsobtainedare: a) Leftventricularsizeandfunction: LVH, Dilation, and. EF b) Dopplerderivedgradientandvalvearea (AVA)

Evaluationof. AS Cardiaccatheterization: Shouldonlybedoneforadirect measurementifsymptomseverityandechoseveritydon’t match. ORpriortoreplacementwhenreplacementisplanned. Evaluationof. AS Cardiaccatheterization: Shouldonlybedoneforadirect measurementifsymptomseverityandechoseveritydon’t match. ORpriortoreplacementwhenreplacementisplanned.

Managementof. AS • General IEprophylaxisindentalprocedures withaprosthetic. AVorhistoryofendocarditis.  • Medical limitedrolesince. ASisamechanical problem. Vasodilatorsare relatively contraindicatedManagementof. AS • General IEprophylaxisindentalprocedures withaprosthetic. AVorhistoryofendocarditis. • Medical limitedrolesince. ASisamechanical problem. Vasodilatorsare relatively contraindicated insevere. AS • Aortic. Balloon. Valvotomy showslittle benefit. • Surgical. Replacement: Definitivetreatment

Echo. Surveillance • Mild: Every 5 years • Moderate: Every 2 years • Severe: Every 6Echo. Surveillance • Mild: Every 5 years • Moderate: Every 2 years • Severe: Every 6 monthsto 1 year

Simplified Indicationsfor. Surgery in. Aortic. Stenosis • Any. SYMPTOMATICpatientwithsevere AS(includessymptomswithexercise) • Anypatientwithdecreasing. EF • Anypatientundergoing. CABGwithSimplified Indicationsfor. Surgery in. Aortic. Stenosis • Any. SYMPTOMATICpatientwithsevere AS(includessymptomswithexercise) • Anypatientwithdecreasing. EF • Anypatientundergoing. CABGwith moderateorsevere. AS

Summary • Diseaseofaging • Lookforthesignsonphysicalexam • Echocardiogramtoassessseverity • Asymptomatic: Medicalmanagementand surveillance • Symptomatic: Ao. Vreplacement(evenin elderlyand.Summary • Diseaseofaging • Lookforthesignsonphysicalexam • Echocardiogramtoassessseverity • Asymptomatic: Medicalmanagementand surveillance • Symptomatic: Ao. Vreplacement(evenin elderlyand. CHF)

Mitral. Stenosis Mitral. Stenosis

Mitral. Stenosis. Overview • Definition: Obstructionof. LVinflowthat preventsproperfillingduringdiastole • Normal. MVArea: 46 cm 2 • TransmitralgradientsandsymptomsbeginMitral. Stenosis. Overview • Definition: Obstructionof. LVinflowthat preventsproperfillingduringdiastole • Normal. MVArea: 46 cm 2 • Transmitralgradientsandsymptomsbegin atareaslessthan 2 cm 2 • Rheumaticcarditisisthepredominantcause • Prevalenceandincidence: decreasingdue toareductionofrheumaticheartdisease.

Etiologyof. Mitral. Stenosis • Rheumaticheartdisease: 7799ofall cases • Infectiveendocarditis: 3. 3 • Mitralannularcalcification: 2. 7 Etiologyof. Mitral. Stenosis • Rheumaticheartdisease: 7799%ofall cases • Infectiveendocarditis: 3. 3% • Mitralannularcalcification: 2. 7%

MSPathophysiology • Progressive. Dyspnea(70): LAdilation  pulmonarycongestion(reducedemptying) – worsewithexercise, fever, tachycardia, andpregnancy • Increased. Transmitral. Pressures:MSPathophysiology • Progressive. Dyspnea(70%): LAdilation pulmonarycongestion(reducedemptying) – worsewithexercise, fever, tachycardia, andpregnancy • Increased. Transmitral. Pressures: Leadstoleft atrialenlargementandatrialfibrillation. • Rightheartfailuresymptoms: dueto Pulmonaryvenous. HTN • Hemoptysis: duetoruptureofbronchialvessels duetoelevatedpulmonarypressure

Natural. Historyof. MS • Diseaseofplateaus: – Mild. MS: 10 yearsafterinitial. RHDinsult – Moderate: 10 yearslater –Natural. Historyof. MS • Diseaseofplateaus: – Mild. MS: 10 yearsafterinitial. RHDinsult – Moderate: 10 yearslater – Severe: 10 yearslater • Mortality: Duetoprogressivepulmonary congestion, infection, andthromboembolism.

Physical. Exam. Findingsof. MS • prominentawaveinjugularvenouspulsations : Duetopulmonaryhypertensionandrightventricular hypertrophy • Signsofrightsidedheartfailure: inadvanced disease • Mitralfacies: When.Physical. Exam. Findingsof. MS • prominent»a»waveinjugularvenouspulsations : Duetopulmonaryhypertensionandrightventricular hypertrophy • Signsofrightsidedheartfailure: inadvanced disease • Mitralfacies: When. MSissevereandthecardiac outputisdiminished, thereisvasoconstriction, resultinginpinkishpurplepatchesonthecheeks

 • Diastolicmurmur:  – Lowpitched diastolicrumble mostprominentat theapex. – Heardbestwiththepatientlyingontheleftside inheldexpiration – Intensityofthediastolicmurmur doesnot correlate • Diastolicmurmur: – Lowpitched diastolicrumble mostprominentat theapex. – Heardbestwiththepatientlyingontheleftside inheldexpiration – Intensityofthediastolicmurmur doesnot correlate withtheseverityofthestenosis. Heart. Soundsin. MS

 • Loud. Opening. S 1 snap: heardattheapexwhen leafletsarestillmobile – Duetotheabrupthaltinleafletmotioninearly diastole, afterrapidinitialrapidopening, dueto fusionattheleaflettips. – • Loud. Opening. S 1 snap: heardattheapexwhen leafletsarestillmobile – Duetotheabrupthaltinleafletmotioninearly diastole, afterrapidinitialrapidopening, dueto fusionattheleaflettips. – Ashorter. S 2 toopeningsnapintervalindicates moreseveredisease. Heart. Soundsin. MS

Evaluationof. MS • ECG : mayshowatrialfibrillationand. LA enlargement • CXR : LAenlargementandpulmonary congestion. Occasionallycalcified. MV •Evaluationof. MS • ECG : mayshowatrialfibrillationand. LA enlargement • CXR : LAenlargementandpulmonary congestion. Occasionallycalcified. MV • ECHO : The GOLDSTANDARD for diagnosis. Assesmitralvalvemobility, gradientandmitralvalvearea

Managementof. MS Serialechocardiography:  – Mild: 35 years – Moderate: 12 years – Severe: yearly •Managementof. MS Serialechocardiography: – Mild: 35 years – Moderate: 12 years – Severe: yearly • Medications: MSlike. ASisamechanicalproblem andmedicaltherapydoesnotpreventprogression blockers, CCBs, Digoxinwhichcontrolheart rateandhenceprolongdiastoleforimproved diastolicfilling – Duireticsforfluidoverload

Managementof. MS • Identifypatientearlywhomightbenefitfrom percutaneousmitralballoonvalvotomy.  • IEprophylaxis: Patientswithprostheticvalvesor a. Hxof. IEfordentalprocedures. Managementof. MS • Identifypatientearlywhomightbenefitfrom percutaneousmitralballoonvalvotomy. • IEprophylaxis: Patientswithprostheticvalvesor a. Hxof. IEfordentalprocedures.

Simplified Indicationsfor. Mitral valvereplacement • ANYSYMPTOMATIC Patientwith NYHAClass. IIIor. IVSymptoms • Asymptomaticmoderateor. Severe. MSwith apliablevalvesuitablefor. PMBVSimplified Indicationsfor. Mitral valvereplacement • ANYSYMPTOMATIC Patientwith NYHAClass. IIIor. IVSymptoms • Asymptomaticmoderateor. Severe. MSwith apliablevalvesuitablefor. PMBV

Aortic. Regurgitation Aortic. Regurgitation

Aortic. Regurgitation. Overview • Definition: Leakageofbloodinto. LVduring diastoleduetoineffectivecoaptationofthe aorticcusps Aortic. Regurgitation. Overview • Definition: Leakageofbloodinto. LVduring diastoleduetoineffectivecoaptationofthe aorticcusps

Etiologyof. Acute. AR • Endocarditis • Aortic. Dissection • Physical. Findings: – Widepulsepressure – Diastolicmurmur –Etiologyof. Acute. AR • Endocarditis • Aortic. Dissection • Physical. Findings: – Widepulsepressure – Diastolicmurmur – Floridpulmonaryedema

Treatmentof. Acute. AR • True. Surgical. Emergency:  • Positiveinotrope: (eg, dopamine, dobutamine) • Vasodilators: (eg,Treatmentof. Acute. AR • True. Surgical. Emergency: • Positiveinotrope: (eg, dopamine, dobutamine) • Vasodilators: (eg, nitroprusside) • Avoidbetablockers • Donotevenconsideraballoonpump

Etiologyof. Chronic. AR • Bicuspidaorticvalve • Rheumatic • Infectiveendocarditis Etiologyof. Chronic. AR • Bicuspidaorticvalve • Rheumatic • Infectiveendocarditis

Pathophysiologyof. AR • Combinedpressure. ANDvolumeoverload • Compensatory. Mechanisms: LVdilation, LVH. Progressivedilationleadstoheart failure Pathophysiologyof. AR • Combinedpressure. ANDvolumeoverload • Compensatory. Mechanisms: LVdilation, LVH. Progressivedilationleadstoheart failure

Natural. Historyof. AR • Asymptomaticuntil 4 th or 5 th decade • Rateof. Progression: 46peryear •Natural. Historyof. AR • Asymptomaticuntil 4 th or 5 th decade • Rateof. Progression: 46%peryear • Progressive. Symptomsinclude: Dyspnea: exertional, orthopnea, and paroxsymalnocturnaldyspnea Nocturnalangina: duetoslowingofheartrate andreductionofdiastolicbloodpressure Palpitations: duetoincreasedforceof contraction

Physical. Examfindingsof. AR • Widepulsepressure: mostsensitive • Hyperdynamicanddisplacedapicalimpulse • Auscultation – Diastolicblowingmurmur attheleftsternal border – AustinflintmurmurPhysical. Examfindingsof. AR • Widepulsepressure: mostsensitive • Hyperdynamicanddisplacedapicalimpulse • Auscultation – Diastolicblowingmurmur attheleftsternal border – Austinflintmurmur (apex): Regurgitantjet impingesonanterior. MVLcausingittovibrate – Systolicejectionmurmur : duetoincreasedflow acrosstheaorticvalve

MRIofthe. Heart. Revealinga. Central, High. Velocity. Jet. Projectingintothe. Left. Ventricular. Cavity. Thejetclearlystrikestheanteriormitralvalveleaflet, causingdistortionandprematureclosure duringdiastole. MRIofthe. Heart. Revealinga. Central, High. Velocity. Jet. Projectingintothe. Left. Ventricular. Cavity. Thejetclearlystrikestheanteriormitralvalveleaflet, causingdistortionandprematureclosure duringdiastole.

The. Evaluationof. AR • CXR: enlargedcardiacsilhouetteandaortic rootenlargement • ECHO : Evaluationofthe. AVandaorticroot withmeasurementsof. LVdimensionsand function(cornerstonefordecisionmakingand followupevaluation)The. Evaluationof. AR • CXR: enlargedcardiacsilhouetteandaortic rootenlargement • ECHO : Evaluationofthe. AVandaorticroot withmeasurementsof. LVdimensionsand function(cornerstonefordecisionmakingand followupevaluation) • Aortography: Usedtoconfirmtheseverityof disease

Managementof. AR • General : IEprophylaxisindentalprocedures withaprosthetic. AVorhistoryof endocarditis.  • Medical: Vasodilators(ACEI’s), Nifedipine improvestrokevolumeandreduce regurgitationManagementof. AR • General : IEprophylaxisindentalprocedures withaprosthetic. AVorhistoryof endocarditis. • Medical: Vasodilators(ACEI’s), Nifedipine improvestrokevolumeandreduce regurgitation onlyifptsymptomaticor. HTN. • Serial. Echocardiograms: tomonitor progression. • Surgical. Treatment: Definitive. Tx

Simplified. Indicationsfor. Surgical Treatmentof. AR • ANYSymptomsatrestorexercise • Asymptomatictreatmentif: – EFdropsbelow 50or. LVbecomes dilated Simplified. Indicationsfor. Surgical Treatmentof. AR • ANYSymptomsatrestorexercise • Asymptomatictreatmentif: – EFdropsbelow 50%or. LVbecomes dilated

Mitral. Regurgitation Mitral. Regurgitation

 • Definition: Backflowofbloodfromthe. LV tothe. LAduringsystole • Mild(physiological)MRisseenin 80of normalindividuals. Chronic. Mitral. Regurgitation Overview • Definition: Backflowofbloodfromthe. LV tothe. LAduringsystole • Mild(physiological)MRisseenin 80%of normalindividuals. Chronic. Mitral. Regurgitation Overview

Acute. MR • Endocarditis • Acute. MI:  • Malfunctionordisruptionofprosthetic valve Acute. MR • Endocarditis • Acute. MI: • Malfunctionordisruptionofprosthetic valve

Managementof. Acute. MR • Myocardialinfarction: Cardiaccathor thrombolytics • Mostothercasesofmitralregurgitation isafterloadreduction: – Diureticsandnitrates – nitroprusside, eveninthesettingofa normalbloodpressure.Managementof. Acute. MR • Myocardialinfarction: Cardiaccathor thrombolytics • Mostothercasesofmitralregurgitation isafterloadreduction: – Diureticsandnitrates – nitroprusside, eveninthesettingofa normalbloodpressure.

Managementof. Acute. MR • Donotattempttoalleviatetachycardia withbetablockers. Mildtomoderate tachycardiaisbeneficialinthesepatients becauseitallowslesstimefortheheartto havebackfill, whichlowersregurgitant volume. Managementof. Acute. MR • Donotattempttoalleviatetachycardia withbetablockers. Mildtomoderate tachycardiaisbeneficialinthesepatients becauseitallowslesstimefortheheartto havebackfill, whichlowersregurgitant volume.

Treatmentof. Acute. MR • Balloon. Pump • Nitroprussideevenifhypotensive • Emergent. Surgery Treatmentof. Acute. MR • Balloon. Pump • Nitroprussideevenifhypotensive • Emergent. Surgery

 • Myxomatousdegeneration(MVP) • Ischemic. MR • Rheumaticheartdisease • Infective. Endocarditis Etiologiesof. Chronic. Mitral Regurgitation • Myxomatousdegeneration(MVP) • Ischemic. MR • Rheumaticheartdisease • Infective. Endocarditis Etiologiesof. Chronic. Mitral Regurgitation

Pathophysiologyof. MR • Pure. Volume. Overload • Compensatory. Mechanisms: Leftatrial enlargement, LVHandincreased contractility – Progressiveleftatrialdilationandright ventriculardysfunctionduetopulmonaryPathophysiologyof. MR • Pure. Volume. Overload • Compensatory. Mechanisms: Leftatrial enlargement, LVHandincreased contractility – Progressiveleftatrialdilationandright ventriculardysfunctionduetopulmonary hypertension. – Progressiveleftventricular volumeoverload leadstodilation andprogressiveheartfailure.

Physical. Examfindingsin. MR • Auscultation: soft. S 1 anda holosystolic murmurattheapexradiatingtotheaxilla – S 3(CHF/LAoverload) – Inchronic.Physical. Examfindingsin. MR • Auscultation: soft. S 1 anda holosystolic murmurattheapexradiatingtotheaxilla – S 3(CHF/LAoverload) – Inchronic. MR, theintensityofthemurmur doescorrelate withtheseverity. • Exertion. Dyspnea: (exerciseintolerance) • Heart. Failure: Maycoincidewith increasedhemodynamicburdene. g. , pregnancy, infectionoratrialfibrillation

The. Natural. Historyof. MR • Compensatoryphase: 1015 years • Patientswithasymptomaticsevere. MR havea 5/yearmortalityrate • Oncethepatient’s. EFbecomes60The. Natural. Historyof. MR • Compensatoryphase: 1015 years • Patientswithasymptomaticsevere. MR havea 5%/yearmortalityrate • Oncethepatient’s. EFbecomes<60% and/orbecomessymptomatic, mortality risessharply • Mortality: Fromprogressivedyspneaand heartfailure

Imagingstudiesin. MR • ECG: Mayshow, LAenlargement, atrial fibrillationand. LVhypertrophywithsevere. MR • CXR: LAenlargement, centralpulmonary arteryenlargement. Imagingstudiesin. MR • ECG: Mayshow, LAenlargement, atrial fibrillationand. LVhypertrophywithsevere. MR • CXR: LAenlargement, centralpulmonary arteryenlargement. • ECHO: Estimationof. LA, LVsizeand function. Valvestructureassessment – TEEiftransthoracicechoisinconclusive

Managementof. MR • Medications a) Vasodilatorsuchashydralazine b) Ratecontrolforatrialfibrillationwith blockers, CCB, digoxin c) Anticoagulationinatrialfibrillationandflutter d) Diureticsforfluidoverload Managementof. MR • Medications a) Vasodilatorsuchashydralazine b) Ratecontrolforatrialfibrillationwith blockers, CCB, digoxin c) Anticoagulationinatrialfibrillationandflutter d) Diureticsforfluidoverload

Managementof. MR • Serial. Echocardiography: – Mild: 23 years – Moderate: 12 years – Severe: 612Managementof. MR • Serial. Echocardiography: – Mild: 23 years – Moderate: 12 years – Severe: 612 months • IEprophylaxis: Patientswithprosthetic valvesora. Hxof. IEfordentalprocedures.

Simplified. Indicationsfor. MV Replacementin. Severe. MR • ANYSymptoms atrestorexercisewith (repairiffeasible) • Asymptomatic: – If. EF60 –Simplified. Indicationsfor. MV Replacementin. Severe. MR • ANYSymptoms atrestorexercisewith (repairiffeasible) • Asymptomatic: – If. EF<60% – Ifnewonsetatrialfibrillation

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