1. Some Essentials of Valvular Heart Disease CCU lecture series

3. Case 1 • 56 YO M presents for DOE 6 months • Denies CP, syncope, palpitations • PMH significant for hypercholesterolemia • Had “murmur since I was a child” • Mother died of heart failure in 60s • Non-smoker

4. Case 1 • HR 66 BP 120/85 • Neck: No bruits • Chest: CTA • CVS: RRR, harsh 3/6 SEM radiating to carotids • Abdomen: Soft, NT • Ext: No c/c/e

5. Aortic Stenosis • Obstruction most commonly located at the level of the aortic valve • May be congenital or acquired (most common) • Calcific AS is associated with traditional risk factors for atherosclerosis (smoking, high LDL, HTN) • Also seen in ESRD, Pagets, SLE, alkaptonuria

6. Pathophysiology • Aortic stenosis generally develops gradually, leading to LV hypertrophy • As stenosis progresses, LVEDP begins to increase – LV function usually remains normal until late in disease process • Diastolic dysfunction may also contribute to symptom onset

7. Clinical Features • 3 classic symptoms of severe AS • DOE • Syncope • Angina

11. Physical Exam • Pulse • Heart sounds (second heart sound) • Murmur • Other clinical manifestations (bleeding, embolic events, CAD)

12. Testing • EKG • CXR • Echo • Cardiac catheterization • CT/MRI?

16. Catheterization findings

17. Cardiac MRI and CT

18. Grading Severity of AS

19. Low Gradient AS

20. Indications for Surgery

21. Indications for Surgery

22. Treatment • No effective medical therapy for what is primarily a mechanical obstruction • Aortic valve replacement is standard of care • Mechanical vs. Bioprosthetic valves • The Ross procedure • Aortic root replacement?

24. Balloon Valvuloplasty • 31 patients >90 years old who underwent balloon valvuloplasty from 2003-2006 • Patients all had severe symptomatic AS and were deemed high risk for surgery • Mean STS score was 18.5%

25. Results • 25 patients underwent retrograde BAV, 6 anterograde • Mean AVA increased from 0.52 to 0.92 cm² • Mean NYHA Class increased from 3.4 to 1.8 • 30 day mortality was 9.7%

27. CoreValve • 86 patients with symptomatic severe AS, >80 years old and high risk for cardiac surgery enrolled • Percutaneous AV replacement attempted with 18 and 21 French systems

29. Results • Acute device success was 88% • Successful implantation led to a significant reduction in gradient • Aortic regurgitation remained unchanged • Procedural mortality was 6% • 30 day mortality was 12%

34. The SALTIRE Study • 155 patients with moderate to severe AS enrolled – randomized to 80 mg atorvastatin or placebo • AV stenosis and calcification assessed by echocardiography and cardiac CT • Primary endpoints changes in aortic jet velocity and AV calcium score

35. SALTIRE • LDL decreased to 62 mg/dl in the atorvastatin group, 131 in placebo • No significant change in endpoints

36. The Critically Ill AS patient • Remember… • Atrial fibrillation is bad! • Vasopressor agents are preferable to inotropes for blood pressure support • Think IABP early • Always auscultate before you give NTG for chest pain!

39. Management Recommendations

40. Case Number 2 • 72 YO M in the emergency department has had CP x 5 days • Finally decides to come to the ED • Hypoxic on room air, rales 1/2 way up • Heart sounds difficult to appreciate • Troponin is 44

41. EKG

42. Stat Echo performed…

43. Acute Mitral Regurgitation Three main mechanisms • Flail leaflet due to mitral valve prolapse • Chordae tendinae rupture due to trauma, infective endocarditis or rheumatic fever • Papillary muscle dysfunction due to ischemia/infarction (what kind of infarction will more often present with acute MR?)

44. Mitral Valve Anatomy

45. Pathophysiology • Hemodynamic changes much more pronounced than in chronic MR due to lack of time for adaptation • The abrupt increase in left atrial pressure is transmitted to the pulmonary circulation • Cardiac output falls and systemic vascular resistance increases

46. Clinical Manifestations • Often present in cardiogenic shock and acute pulmonary edema • Physical exam may reveal a hyperdynamic precordium (will the apex be displaced?) • The murmur • Up to 50% of patients will not have an audible murmur at the time of evaluation

47. Testing • Echocardiography mainstay of diagnosis • Cardiac catheterization may be required for determination of the extent and severity of concomitant CAD • Hemodynamics are characteristic

48. Mitral Regurgitation

49. Treatment • Definitive treatment is surgical • Supportive measures include nitroprusside (what is the mechanism?) and possibly dobutamine for low cardiac output • IABP

50. Class I Indications for MV Surgery in Severe MR • Acute symptomatic MR • Chronic severe MR with NYHA class II, III or IV in absence of severe LV dysfunction and/or LVESD>55 mm. • Symptomatic or asymptomatic patients with mild/mod LV dysfunction (EF 30-60%) and end-systolic dimension >40 mm • MV repair recommended over replacement for majority of pts; pts should be referred to experienced surgical center.