indications for aortic valve replacement
TRANSCRIPT
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Indications for Aortic Valve Replacement
Tim Brinker
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Overview
• Anatomy• Aortic Stenosis and Aortic Insufficiency
-Etiology-Signs/Symptoms-Diagnostic Studies-Indications for Surgical Intervention
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Normal Anatomy
• 3 semilunar valve leaflets (right, left, and posterior)
• Normal Aortic valve has cross sectional area of 2.5 to 3.5 cm2.
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Aortic Stenosis
• Etiology– Degenerative calcific disease– Congenital Stenosis– Bicuspid Aortic Valve– Rheumatic Heart Disease
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Signs and Symptoms
• Most patients remain asymptomatic for years.
• Classic Triad– Angina Pectoris– Syncope– Congestive Heart FailureOther symptoms include hypertension and
dyspnea.
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NYHA Classification
• Class I – Symptomatic only with greater than normal activity.
• Class II – Symptomatic with ordinary activity.
• Class III – Symptomatic with minimal activity.
• Class IV – Symptomatic at rest.
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Physical Exam
• High pitched systolic crescendo-decrescendo murmur at RUSB and radiates to the carotids.
• Decreases with Valsalva maneuver.• Increases with passive leg raise• Ejection click with bicuspid aortic valve
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Diagnostic Studies• CXR – Normal size or cardiomegaly. May see
calcification of the valve in older individuals.• EKG – Demonstrates LVH.• ECHO – Can evaluate calcification and mobility
of aortic valve leaflets, anatomy and aortic valve area, LVH, EF, transvalvular gradients, and aortic regurgitation.
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• Cardiac Catheterization – Reveals coronary anatomy, CO, transvalvular gradients, LV function, presence of other valvular lesions. Indicated in patients suspected of having CAD in preparation for AVR.
• Exercise Testing – May elicit exercise-induced symptoms and abnormal bp responses in asymptomatic patients.
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Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the
management of patients with valvular heart disease). Journal of the American College of Cardiology 2006; 48:e1.
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Low Gradient Aortic Stenosis
• AVA <1.0 cm2 with TVPG <30 mmHg
Dobutamine or Nitroprusside can distinguish between true stenosis and psuedostenosis.
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Operative Indications
• Surgery (Aortic Valve Replacement)– Symptomatic Severe Aortic Stenosis– Asymptomatic severe Aortic Stenosis with
decreased EF (<0.50), AVA <0.6cm2, aortic jet >4m/s, or decreased BP with exercise
– Asymptomatic moderate-severe Aortic Stenosis and undergoing CABG.
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Medical Treatment
Antibiotic prophylaxis for infective endocarditis and recurrent rheumatic fever.
If patient is symptomatic and not an operative candidate– Gentle Diuresis, control of HTN
(ACEI,dig,statin)– Avoid venodilators (nitrates) and neg
ionotropes (BB, CCB) in severe AS
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Prognosis
• Angina – 5 year survival• Syncope – 3 year survival• CHF – 2 year survival
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Aortic Insufficiency
• Etiology– Degenerative diseases– Inflammatory or infectious disease
(endocarditis, rheumatic fever)– Congenital diseases (bicuspid valve)– Aortoannular ectasia– Aneurysm of the aortic root– Aortic dissection
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Signs and Symptoms
• May be asymptomatic• Dyspnea on exertion, decreased exercise
capacity• Palpitations• Angina• Pulmonary edema• Right heart failure
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Physical Exam
• Diastolic decrescendo murmur at LUSB• Severity proportional to duration of
murmur.• Wide pulse pressure (decrease in diastolic
pressure)• Austin Flint murmur – diastolic rumble at
apex
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Diagnostic Studies
• CXR – cardiomegaly ,+/- aortic dilation• EKG – may show LVH or A-fib• ECHO – Measures degree of valvular
insufficiency, LV size and function.• Exercise test – assess functional capacity and
symptomatic response.• May perform aortic root angiography or MRI if
aneurysmal disease is suspected.
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Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Journal of the American College of Cardiology 2006; 48:e1.
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Operative Indications
• Surgery (Aortic Valve Replacement)– Symptomatic severe AI– Asymptomatic severe AI and EF <50% or LV
systolic diameter >55mm or diastolic diameter >75mm
– Asymptomatic severe AI and undergoing CABG.
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Medical Therapy
• Vasodilators (nifidepine, ACEI, hydralazine) if severe AI, HTN, or patient is not an operative candidate.
• Diuretics and Digoxin if patient with CHF.
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Operative Techniques
• Aortic Valve Replacement– Median sternotomy incision– Cardiopulmonary bypass is used.– Aortic valve is excised totally.– Mechanical valves (single tilting or bileaflet
disk). Patients require lifelong anticoagulation.
– Tissue valves (have projected durability of 15 years or longer with no anticoagulation).
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• Ross Procedure– Involves replacement of the aortic valve with
an autograft from the patient’s native pulmonary valve. The pulmonary valve is then replaced with a pulmonary homograft.
– Patients do not require long term anticoagulation.
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Take Home Points• In symptomatic AS patients, AVR improves
symptoms and improves survival• AVR is indicated in virtually all symptomatic
patients with severe AS.• AVR is indicated in patients with symptomatic AI
or with LV dysfunction (EF<0.50 at rest)• AVR is not indicated in asymptomatic patients
with normal LV function (EF>0.50) and LV dilation in AI