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Valvular Heart Disease: Ambulatory Monitoring and Surgical
Referral
Dr. Shane ShaperaPrevious version: Dr. Wassim Saad
for AIMGP October 2006
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Valvular Heart Disease Focus on:
Aortic stenosis Chronic mitral regurgitation Mitral Stenosis (extra slides if time permits)
Who should have an Echo? At first contact? Follow up? How do we interpret the results?
How should we follow patients? How often should they be seen in clinic? Are there options for medical management? When should we refer to a surgeon?
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References New ACC/AHA Practice
Guidelines: ACC/AHA 2006 Practice Guidelines 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 (Committee on Management of Patients With Valvular Heart Disease) JACC. 2006;48(3):598-675.
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Reminder Class I: There is evidence and/or general agreement that
a given procedure or treatment is useful and effective
Class II: There is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
IIa: Weight of evidence/opinion is in favor of usefulness/efficacy
IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: There is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful.
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A new referral 62 year old man RFR: Family MD “heard a murmer” PMH: HTN and obesity Meds: ASA and Norvasc HPI:
Told he has a murmer 2 years ago No symptoms of CVS or respiratory nature Limited physical activity, but no limitations
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A new referral O/E:
HR: 88 BP: 150/85 JVP normal Harsh midsystolic ejection murmer
(3/6) over aortic area – radiates to the clavicle
Normal pulses Remainder of physical exam normal
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Questions to think about: Is a 2D-Echo appropriate in this
patient?
Which patients require an echo?
Are there any symptoms that need to be considered when deciding whether to order an echo?
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Recommendations for Echocardiography in Asymptomatic
Patients With Cardiac Murmurs
Indication Class
Diastolic, Continuous, Holosystolic or late Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to neck or back
I
Murmurs associated with abnormal physical findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or chest x-ray
IIa
≤Grade 2 midsystolic murmur (Innocent)
III
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Recommendations for Echocardiography in Asymptomatic
Patients With Cardiac Murmurs
Indication Class
Diastolic, Continuous, Holosystolic or late Systolic murmurs
I
Grade 3 or greater midsystolic murmurs
I
Murmurs with ejection click or radiation to neck or back
I
Murmurs associated with abnormal physical findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or chest x-ray
IIa
≤Grade 2 midsystolic murmur (Innocent)
III
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Recommendations for Echocardiography in Symptomatic Patients With Cardiac Murmurs
Indication Class
Signs / symptoms of CHF, MI, ischemia or syncope
I
Signs / symptoms of endocarditis I
Signs / symptoms of thromboembolism I
Signs/ symptoms likely due to noncardiac disease but cardiac disease not excluded by standard cardiovascular evaluation
IIa
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Back to the case… CXR: normal ECG: LVH (aVL > 11mm) ECHO:
AVA 1.4cm2 with a mean gradient 30mmHg
Mild concentric LVH Grade I LV Final interpretation: moderate AS
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Aortic Stenosis: Causes Two most common causes of AS:
Calcification of the valve Older patients Very similar to an atherosclerotic process
Bicuspid aortic valve Younger patients Mechanical abnormality leading to
degeneration
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Aortic Stenosis: Natural History
Prognosis mnemonic: A-S-D
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Aortic Stenosis: Classification
AVA Gradient Jet Velocity
Mild AS < 1.5 cm2 < 25 mmHg < 3 m/s
Moderate AS 1.0 – 1.5 cm2
25 – 40 mmHg
3 – 4 m/s
Severe AS < 1.0 cm2 > 40 mmHg > 4 m/s
Critical AS < 0.75 cm2 variable Variable, but often > 5 m/s
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Questions to think about for our patient with moderate AS
What is his expected prognosis?
How should he be followed?
When should we offer a surgical intervention?
Is there medical therapy we can offer?
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Aortic Stenosis: Follow-up Expect prolonged latency period
Low M&M while asymptomatic Progression of stenosis is highly variable
Treatment based largely on symptoms Average survival 2-3 yrs once symptoms Risk of sudden cardiac death once symptoms
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Aortic Stenosis: Follow-up ACC Guidelines suggest “frequent
monitoring” of asymptomatic patients looking for: Symptoms of angina, syncope and
SOB Signs of CHF (raised JVP, SOA,
crackles)
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Aortic Stenosis: Follow-up
When should you repeat an ECHO? Changing signs or symptoms Patient becomes pregnant Routine follow-up
Mild AS: q 3-5 years Moderate AS: q 1-2 years Severe AS: q 1 year
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Aortic Stenosis: When to operate?
Indication for Aortic Valve Repair Class
Severe AS (AVA <1.0cm2) with symptoms I
Severe AS undergoing CABG or CVS surgery I
Severe AS and impaired LV function (LVEF < 50%) I
Moderate AS undergoing CABG or CVS surgery IIa
Asymptomatic patients: - critical AS if operative mortality very low (<1%) - severe AS with exercise induced hemodynamic changes - severe AS and risk of rapid progression (age, calcified, CAD)
IIbIIbIIb
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Aortic Stenosis: Medical Therapy
Baloon Valvotomy Not an alternative to valve replacement Many complications (10%) Most get restenosis in 6 – 12 months Can be used as a bridge to OR Can be used for palliation in non-
operative pts
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Aortic Stenosis: Medical Therapy No medical therapy prolongs life
Theoretical benefit of statins, but trials –ve so far
Treatment of CHF can reduce symptoms Diuretics, ACEi, Digoxin have all been used
Atrial fibrillation worsens symptoms Needs aggressive rate control or cardioversion
All patients should be considered for OR Age is NOT a contraindication to surgery, but
increases risk of complications
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Back to the case… 62M with asymptomatic moderate AS
Annual history and physical exam Repeat Echo q 1-2 years or if symptoms Discuss prognosis and possibility of valve
replacement in future if symptoms develop
Cover with endocarditis prophylaxis for dental and surgical procedures
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Next referral 68 year old woman
RFR: Murmur heard on routine physical exam
PMH: previous smoker x 20 pk yrs
Meds: Vitamin D and Calcium
HPI: Very poor physical fitness Occasional SOB while running for the bus No chest pain or pre-syncope Mild SOA and a couple of episodes of PND
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Next referral O/E:
HR: 92 BP: 138/78 JVP normal Soft S1 with holosystolic murmer at the
apex (2/6) that radiates to the axilla Mild SOA Remainder of physical exam normal
Is a 2D-Echo appropriate in this patient?
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Recommendations for Echocardiography in Asymptomatic
Patients With Cardiac Murmurs
Indication Class
Diastolic, Continuous, Holosystolic or late Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to neck or back
I
Murmurs associated with abnormal physical findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or chest x-ray
IIa
≤Grade 2 midsystolic murmur (Innocent)
III
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Recommendations for Echocardiography in Symptomatic Patients With Cardiac Murmurs
Indication Class
Signs/symptoms of CHF, MI, ischemia or syncope
I
Signs / symptoms of endocarditis I
Signs / symptoms of thromboembolism I
Signs/ symptoms likely due to noncardiac disease but cardiac disease not excluded by standard cardiovascular evaluation
IIa
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Back to the case… CXR normal ECG normal PFT’s normal ECHO
Grade II LV with regional variability Severe MR Slightly dilated LA (42mm) LV end systolic dimension ~42mm RVSP 65mm Hg
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Mitral Regugitation: Natural History
May be asymptomatic for many years Chronic severe MR tends to increase over time
Usually leads to symptoms within 6 – 10 years
Eventually develop overload with LV dysfunction Chronic volume overload state LV dysfunction Increased LV end-systolic volume LV dilatation and higher LV pressures Pulmonary congestion Symptoms of CHF
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Mitral Regurgitation: Classification
No specific numbers to memorize
Multiple components go into determining severity (chamber sizes, LVEF, RVSP, visual assessment, etc…)
Final report: Mild, Moderate or Severe
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Questions to think about for our patient with moderate MR What baseline tests should we do?
How should we follow her up? When should we reassess her symptoms? When should we repeat the Echo?
How can we treat her medically?
When should we refer her for surgery?
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Mitral Regurgitation: Baseline Establish clear exercise tolerance
Be sensitive to subtle changes suggesting CHF
Baseline ECG and CXR Chamber enlargement and complications (Afib)
ECHO Assess severity and look for possible anatomical
causes of MR (Ischemic vs. functional)
Exercise testing Consider exercise measurements of PAP and MR if
exercise capacity can’t be established on history
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Mitral Regurgitation: Follow-up
Asymptomatic mild MR (normal LVEF, chamber sizes & RVSP) Annual history and physical No repeat Echo unless symptoms develop
(Class III)
Asymptomatic moderate MR Annual history and physical Repeat Echo annually (Class I)
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Mitral Regurgitation: Follow-up
Asymptomatic severe MR History and physical q6months
Watch carefully for development of symptoms Repeat Echo q6months (Class I)
Watch for Echo evidence of asymptomatic LV dysfunction which would be an indication for OR
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Mitral Regurgitation: When to operate?
General Principles (Class I evidence)* MV repair is preferred over MV replacement Acute severe symptomatic MR needs surgical repair Chronic severe MR should be referred to CVSx if:
Symptomatic (NYHA≥II) and LV function preserved (LV ≥ Gr3) Symptomatic (NYHA≥II) and LV end-systolic dimension
enlarged Asymptomatic with any of the following: LV dysfunction,
LV dilatation, pulmonary HTN or new-onset atrial fibrillation Isolated MV surgery is not indicated for patients with
mild to moderate MR (Class III)
*please see guidelines for complete list of recommendations
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Mitral Regurgitation: Medical Therapy
Asymptomatic chronic MR No specific therapy recommended No evidence for vasodilators (despite the logical appeal)
Chronic MR secondary to ischemic or dilated CM Preload reduction is beneficial (Lasix)
LV dysfunction present Usual therapies for LV failure (BB, ACEi, Biventricular
Pacing)
Atrial Fibrillation Usual therapy with rate control and anticoagulation
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Back to the case… 68 year old woman
Minimal physical activity, but occasionally SOB on exertion
Severe MR with Grade 2 LV, regional wall motion abnormalities and pulmonary hypertension
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Back to the case… History, physical, ECG and CXR done
Don’t add much to the picture
Further workup? Possible ischemic etiology?
Exercise tolerance unclear Regional wall motion abnormalities on
Echo
Stress echo MR worse with exercise with reversible
inferior wall motion abnormality
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Back to the case… Management
Pt is a surgical candidate NYHA II with preserved LV function (Class I)
Refer for CVSx opinion, TEE & Cath Treat medically while waiting for OR
Rx for symptoms, underlying CAD and LV dysfunction with ASA, BB, ACEi, Statin & Lasix
Hold ASA 5 days pre-op
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Summary History and physical exam guide decision
to do an Echo during first visit Many patients have valvular lesions for
years before they develop symptoms Patients should be followed clinically and
radiologically at intervals that vary according to the specific valve pathology and severity
Symptomatic or severe asymptomatic valvular lesions requires an early surgical opinion
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Extras… If time permits, continue with
slides on mitral stenosis otherwise they can serve as a reference for residents
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Last referral 57 year old man
RFR: Murmur heard on routine physical exam
PMH: No cardiac risk factors
Meds: None
HPI: Asymptomatic
O/E: Loud S1, Low pitched rumbling diastolic murmur with
pre-systolic accentuation at the apex. No opening snap.
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Does this patient need an Echo?
Indication Class
Diastolic, Continuous, Holosystolic or late Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to neck or back
I
Murmurs associated with abnormal physical findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or chest x-ray
IIa
≤Grade 2 midsystolic murmur (Innocent) III
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Back to the case… The echo shows an MVA of 1.3cm2.
Chamber size and function are normal RVSP and gradient across valve
normal CXR and ECG normal Pt is asymptomatic
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Questions about MS? What should you do at your initial
assessment? How should you follow up this
patient? When would you refer to a surgeon? When would you repeat the Echo? How can you manage these patients
medically?
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Mitral Stenosis: Natural History
Asymptomatic patient with MS 10 yr survival >80% 60% have no progression of
symptoms Significant limiting symptoms
10 yr survival rate of 0-15% If severe pulmonary HTN
Mean survival <3 yr
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Mitral Stenosis: Classification
Mild Moderate Severe
Valve area > 1.5 cm2 1.0 – 1.5 cm2 < 1.0 cm2
PAP < 30 mmHg
30 – 50 mmHg
> 50 mmHg
Mean Gradient
< 5 mmHg 5 – 10 mmHg > 10 mmHg
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Mitral Stenosis: Initial Exam
Hx – dyspnea, hemoptysis, hoarseness, CHF, thromboembolism, endocarditis
P/E – evidence of Afib, pulmonary HTN, CHF
CXR – heart size, pulmonary edema
ECG – rhythm, LAE, RVH due to pulmonary HTN
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Mitral Stenosis: Initial Echo Baseline Echocardiogram
Doppler to assess severity Determines valve area, RVSP and gradient
Visualize leaflets and commissures Determines timing and type of interventions Assesses for other valvular lesions
Chamber size & function Consider exercise Echo if clinical picture
doesn’t fit with Echo findings
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Follow Up - Asymptomatic Mild MS (MVA > 1.5cm2)
Patients remain stable for years Should be seen annually and have CXR,
ECG
Modearte-Severe MS (MVA ≤ 1.5cm2) Initially, assess valve morphology & look
for pulmonary HTN (PAP > 50mmHg) If intervention is not appropriate, then
follow as for mild MS (above)
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Follow up – When to re-Echo?
Repeat any time symptoms change
Routine follow-up Mild MS – repeat Echo q 3-5 years Mod MS – repeat Echo q 1-2 years Severe MS – repeat Echo q 1 year
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Who Should be Referred to a Surgeon?
Indication Class
NYHA ≥ II with moderate or severe MS (MVA≤1.5cm2)
I
Asymptomatic patient with moderate or severe MS (MVA≤1.5cm2) who have pulmonary HTN (PAP>50)
I
Asymptomatic patient with moderate or severe MS (MVA≤1.5cm2) who have new onset atrial fibrillation
IIb
Interventions: balloon valvotomy, repair, replacement
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Medical Management - MS CHF
Salt restriction and intermittent diuretics See MD immediately if sudden onset SOB
May have A-fib with flash pulmonary edema
Exertional symtpoms Consider –ve chonotropic agents (BB,CCB)
Atrial fibrillation Rate control and anticoagulation May consider anticoagulation if stroke w/o
Afib
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Back to the case… 57 year old man Asymptomatic with mild MS (MVA
1.3cm2) Annual history and physical Repeat Echo q3-5yrs or sooner if symptoms Call EMS immediately if acute onset SOB Endocarditis prophylaxis for dental and
surgical procedures
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Questions?